Rapid Sequence Intubation: Who and When
Rapid Sequence Intubation is a series of steps used by trained emergency providers in securing an emergent advanced airway. These situations typically involve a patient who is unable to ventilate or oxygenate, who's airway needs to be secured against the possibility of aspiration or obstruction, or who's medical course is anticipated to deteriorate in the immediate future. Rapid Sequence Intubation was not developed in the ED but it is widely used there. The question is who to use it on and when to use it.
Intubation is indicated in several situations:
- unable to ventilate: the patient cannot move air on their own. This can be due to paralysis of the muscles of respiration, severe illness, trauma
- unable to oxygenate: the patient has some condition that does not allow sufficient oxygenation of the blood. This could be due to pneumonia, pulmonary embolism, COPD exacerbation
- unable to protect their airway due to swelling (burn victim, anaphylaxis) or due to the patient being unconscious (intoxication, drug overdose, head trauma)
- patient in need of significant pain control or sedation (trauma patient with significant injury and pain) which will lead to sedation and poor respiratory drive
- patient requires prolonged transport time and may deteriorate. If this patient is leaving your hospital in a helicopter they would prefer the patient be intubated in the ED rather than in the helicopter. If the patient is being transported by ground there may not be sufficient staff to safely intubate the patient en route without stopping or diverting to another emergency department.
Your first impression is so important in this situation. Initial impression is where you place patients into one of three groups. The patient may go from one group to another as their condition changes.
The first group is the patient in full arrest- they are able to oxygenate or ventilate. This patient is likely unconscious and getting Bag Valve Mask respiration with an oral or nasal airway if they arrive by EMS. If they arrive by car, you are helping lift them out of the car as they are unconscious. This is considered a "Crash Airway" situation. This patient does not need a LEMON mnemonic evaluation! They may not require any medication initially. They ultimately will need a definitive airway, followed by medication for sedation and pain. Initially, however, they may need some temporizing measures to buy time while keeping them safe. An LMA is a great option here. You could take them from BVM ventilation which is likely filling their stomach with air, to LMA ventilation which can reduce stomach distension (reduces the risk of vomiting and aspiration) while also protected the airway a bit from aspiration. This is a situation that you can prepare for in advance by having the BVM and LMA easily available, along with other equipment. EM:RAP had a great article on this. The recommended mnemonic is SOAP-ME, which includes suction, oxygen, airway, positioning, medications and end-tidal CO2. These steps would be performed in this order in a Crash Airway situation- suction and LMA/oxygen initially, set up airway and position the patient who is likely unconscious, intubate the patient and push drugs. Monitor with end-tidal CO2 and set up maintenance medicine. Remember that this patient likely has poor circulation and may need higher drug doses initially, especially for paralytics.
The second group includes patients in respiratory failure but still ventilating. They are likely on the verge of respiratory collapse and need supplemental oxygen, and the timeline appears urgent. This patient is typically hypertensive, tachypneic and agitated. This is not a Crash Airway but could become one if the patient goes unconscious. This patient may benefit from high flow oxygen, BiPap or O2 Rescue as well as nebulizer treatments but typically they are too agitated to accept a mask over their face. Sedation may help here but intubation is pending. Starting with sedation and positioning is a great option. Ketamine has the benefit of maintaining respiratory drive, so it is a good first option at lower dosing than for sedation. This patient also may have poor circulation with peripheral vasospasm. Sedation dose may need to be reduced if their blood pressure is soft but the paralysis dose should be increased to ensure the efficacy. Prepare the staff for the possibility of respiratory arrest and have your next steps laid out for staff so they are ready to help. You may prevent Rapid Sequence Intubation or delay it as you stabilize the patient with interventions such as BiPap, O2 Rescue, high flow oxygen, nebulizer treatments, IV fluids.
The third group is currently stable but will likely need Rapid Sequence Intubation to help with overall medical stability. A few examples would be a stroke patient, a trauma patient needing significant sedation and pain control rendering them unable to ventilate safely, or a septic patient on the verge of going unconscious. Another situation is the transfer patient discussed above. These patients do not need airway or breathing intervention immediately and the LEMON mnemonic is helpful as part of their work up. Talk with your hospitalist or receiving hospital as you likely have time to make a thorough plan with these patients.
As you develop a plan of action for these groups of patients, department planning and Case Review can be very helpful. For a smaller emergency department, Rapid Sequence Intubation is not a daily or even weekly occurrence. Having the tools takes planning and review. The patients are often transferred to a larger facility, so transfer planning is also part of the process. If your Case Review shows that your patients are getting intubated on arrival at the receiving hospital, that tells you something about how other emergency departments see the same patient. Learn from this and re-evaluate your indications for intubation.