#3 Rapid Sequence Intubation (RSI)

For this episode I interviewed Dr. Cyrus Shariat, who is an intensivist, about rapid sequence intubation (RSI).  We talked about what happens during RSI and, specifically, how nurses can help facilitate this high stakes procedure.

During the pre-intubation period, look around the room and make sure it has the following equipment:

1. A nonrebreather mask and nasal cannula. If time permits, get a BiPAP machine. These items will be critical for pre-oxygenating the patient
2. An O2 monitor. Check to make sure it’s working.
3. Suction canisters with Yankaurs. Working suction is critical for reducing the risk of aspiration during intubation. This is a big one that can easily be overlooked on a med/surg floor
4. Blood pressure cuff set to cycle every 3 minutes
5. Med room supplies: IV pumps, IV tubing, a bag of NS or LR, syringes, and blunt needles
6. It wouldn’t be a bad idea to get restraints ready in case the patient gets feisty

Some things to consider

1. Has the patient been NPO? Does he or she have gastric distension? Communicate this with the doctor. If there is a high risk of aspiration, be prepared to drop in an NG tube.
2. Does the patient have good IV access? If not, get one (or actually at least two) in STAT or tell the doctor performing the procedure that a femoral line may needed
3. Place the patient with the HOB 20-30 degrees until the physician tells you otherwise. 
4. Assume that the patient will become hypotensive due to the reasons Dr. Shariat gave:
   • Intubation meds can cause hypotension through a combination of direct vasodilation and cardiac depression as well as shutting off the intrinsic adrenergic drive (your body’s very own epinephrine and norepinephrine).
   • The second point he made was about the switch from negative to positive pressure ventilation. With positive pressure ventilation, there is an increase in intrathoracic pressure, and thus a decrease in right ventricular preload and afterload. These two effects ultimately decrease stroke volume and blood pressure.
   • To counteract the drop in BP, anticipate bolusing the patient and either starting the patient on or increasing the dose of vasopressors.
5. Be nice to your patient and make sure that a sedative drip is ordered. Conscious paralysis is just mean.
6. If you are not totally familiar with the medications used during RSI, please let your pharmacist or fellow nurse grab these from the code cart and administer them. As always, stay within your scope of practice.

Check out Yun Cee Dirsa’s Nursing Intubation Checklist to get a more comprehensive look at intubation from an emergency nurse’s point of view.

Other helpful resources for RSI:

• Life in the Fast Lane: Rapid Sequence Intubation (RSI)
• Up to Date: Induction agents for rapid sequence intubation in adults outside the operating room

I would love to hear from nurses about their experiences with RSI! What do you do to ensure safety and success?

Episode image from http://www.cprcertification.com