Medical Facility Education Tracking and Reporting Software



Tulare Local HealthCare District

dba Tulare Regional Medical Center

Educational Services

For: ED, ICU, & OR- RN’s

and RT’s

Rapid Sequence Intubation

Rapid Sequence Intubation (RSI)

Introduction:

Welcome to the learning module on Rapid Sequence Intubation. This module is a review of the sequence for rapid intubation on a conscious patient. It is not intended for “crash” intubations. The module will review the process and medications that are generally used.

Description:

This brief online module discusses the patient safety aspect of Rapid Sequence Intubation and the current recommendations/ practice of our Emergency Department Physician group. This module references TRMC Policy #12-1054 Policy and Procedure for Procedural Sedation-Analgesia and includes a ‘Top Tips’ document and a post test.

Objectives:

By completion of this module, the employee will:

1. Utilize the module to review the indications, contraindications, and process for RSI.

2. Describe the different medications and dosages recommended for RSI.

3. Recognize the adverse reactions if the process is not correctly performed.

Target Group:

RN nursing staff – ED, ICU, OR RN’s and RT staff

Continuing Education Credit/In-service Credit: In-service only

Reviewed by: TRMC Staff Educator and ED Director

Course Sequence:

A. Review the Sedation Policy

B. Read the Top Tips document

C. Take the online Post-test. Must pass with at least 85% or better.

TOP TIPS

Rapid Sequence Intubation (RSI) is a process that allows the provider to secure an airway in an acutely unstable patient. The process has medications administered in a specific sequence

RSI is not indicated for a patient who is unconscious and apneic – this is a “crash” intubation where pretreatment, induction and paralysis is not used.

RSI incorporates a regime of medication administration in 3 phases – pretreatment, rapidly acting sedative (induction) agent and a neuromuscular blocking agent.

RSI is the standard of care for emergency management for intubations that are not anticipated to be difficult because most of the patients have not fasted and are at increased risk of aspiration

RSI is administration of a sedative and a neuromuscular blocking agent to render the patient unconscious and flaccid in order to facilitate emergent endotracheal intubation and minimize the risk of aspiration. This unconscious paralyzed state should occur within 1 minute

Indications for RSI include: inability to maintain airway, inability to protect airway, ventilatory compromise, failure to adequately oxygenate, anticipation of a deteriorating course that will lead to inability to maintain or protect airway

Patient preparation

1. Place patient on cardiac monitor or telemetry

2. Place patient on SpO2 monitor

3. Place BP monitor on patient to be checked frequently during and after administration of medication

4. Ensure that patient has an intact IV line with fluids infusing

Preoxygenation

5. Preoxygenate patient with high flow oxygen via non-rebreathing mask for minimum of 3 – 5 minutes prior to procedure. Preoxygenation causes the alveoli to be supersaturated by displacing nitrogen which allows the patient to maintain blood oxygen saturation during the apneic period of paralysis

6. The least resistance necessary to adequately preoxygenate the patient should be used. Assistance with bag valve mask should only be done if absolutely necessary. Providing positive pressure can potentiate aspiration during intubation

Pretreatment

Pretreatment agents are used to mitigate the physiological response to laryngoscopy and induction and paralysis. These medications are typically administered 2 – 3 minutes before induction and paralysis

7. Lidocaine (1.5 mg/kg) suppresses the cough and gag reflex and is thought to play a role in blunting increases in MAP, Heart Rate and ICP

8. Opioid (fentanyl 3 mcg/kg) blunts increases in BP, Heart Rate, MAP and ICP. It prevents blood pressure spikes which could have adverse effects in certain clinical conditions (e.g. aortic aneurysm)

9. Atropine is no longer given routinely but should be available in the event of bradycardia

Induction Agents

Induction agents are used to provide a rapid loss of consciousness that facilitates ease of intubation as well as causing an amnesic state for the patient

10. Etomidate – 0.3 mg/kg IV push – provides no analgesic effect, therefore opioid analgesic such as fentanyl is recommended. This is the most rapid and short acting product available. It also has minimal hemodynamic affects

11. Midazolam – 0.1-0.3 mg/kg if benzodiazepine is required. It is slower onset and longer lasting than Etomidate. Requires a large dose if used for induction and this larger dose has been associated with hypotension

12. Propofol – 1.5 – 3 mg/kg for induction – provides no analgesic effect therefore opioid analgesic is recommended. Propofol is cerebral protective but is a myocardial depressant and decreases systemic vascular resistance, therefore may be contraindicated in some clinical situation.

Paralytic Agents

Paralyzing agents provide neuromuscular blockade. They do not provide sedation, analgesia or amnesia and therefore must not be used alone

13. Succinylcholine – 1.5 mg/kg is rapid onset and short duration. Succinylcholine should be used with caution in patients with hyperkalemia. It may cause bradycardia and fasciculations. It also has been associated with malignant hypothermia.

14. Rocuronium – 1 mg/kg is a rapid onset and slightly longer acting drug. This drug does not result in muscular defasciculation and does not exacerbate hyperkalemia. This is a newer agent that is rapidly becoming the standard of practice agent

15. Vecuronium –0.1 mg/kg is rapid onset with longer duration than succinylcholine. Used with caution in patients with hyperkalemia but less effects than succinylcholine.

Post – Intubation Management

15. Secure endotracheal tube

16. Attach end tidal CO2 detector and monitor

17. Ensure order for Chest x-ray for tube placement

18. Mechanical ventilation orders

19. Ensure Continuous Sedation orders

TULARE LOCAL HEALTH CARE DISTRICT

dba TULARE REGIONAL MEDICAL CENTER

POLICY/GUIDELINE MANUAL

TO: All Departments

FROM: Administration

SUBJECT: Policy and Procedure for Procedural/Moderate Sedation-Analgesia

I. Purpose:

The purpose of this policy is to provide a consistent standard that ensures continuity of care and safety during procedural/moderate sedation. This includes the administration of medications that produce moderate sedation, monitoring, emergency interventions and discharge criteria of patients undergoing a procedure with moderate sedation.

II. Definition:

A. Local Anesthesia:

1. Elimination of pain and other sensations in one body location utilizing the topical application or regional injection of a drug.

2. No modification of memory or affect and no alteration or loss of consciousness occurs.

B. Minimal Sedation (Anxiolysis):

1. A drug-induced state during which patients respond normally to verbal commands.

2. Cognitive function and coordination may be impaired; ventilator and cardiovascular functions are unaffected.

3. Light sedation occurs following the administration of medication for reduction of anxiety or pain and allows the patient to maintain normal respiration, eye movements, and protective reflexes.

NOTE: Medication used for this purpose and for sedation of mechanically ventilated patients or for urgent/emergent endotracheal intubation is not covered by this policy.

C. Procedural/Moderate Sedation:

1. A state of altered consciousness resulting in relaxation, euphoria, and amnesia.

2. Procedural/Moderate sedation/analgesia (previously called conscious sedation) is a state of depressed consciousness, controlled by drugs, allowing protection reflexes to be maintained.

3. Patient independently maintains a patent airway and appropriately responds to physical stimulation and/or verbal command. The patient’s cardiovascular system is not usually impaired.

4. Procedural/Moderate sedation is not the use of IV analgesics for pain control when no procedure is being conducted.

NOTE: Procedural/Moderate sedation is not the use of IM sedatives with or without IM analgesics even if an invasive procedure is performed.

D. Deep Sedation/Analgesia:

1. A state of depressed consciousness or unconsciousness controlled by drugs, which may result in the partial or complete loss of proactive reflexes.

2. Patient’s ability to independently maintain a patent airway frequently requires airway and ventilatory support while cardiovascular function is usually intact.

3. The patient ability to respond purposefully to physical stimulation or verbal command is compromised.

E. Anesthesia:

1. Consists of general anesthesia, as well as spinal or major regional anesthesia, but no local anesthesia.

2. General anesthesia is a state of unconsciousness, controlled by drugs, resulting in the complete loss of protective reflexes.

3. Patient’s ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command is absent.

4. Cardiovascular function may be affected.

F. Loss of Protective Reflexes:

1. Absence of gag reflex and/or ability to maintain a patent airway.

III. Policy:

A. It is the policy of Tulare Regional Medical Center to provide safe, standard and consistent procedural sedation/analgesia.

B. Procedural/Moderate sedation outside the Operating Room (OR) may be administered in but not limited to the following locations:

1. Emergency Department (ED)

2. Intensive Care Unit (ICU)

3. Post Intensive Care Unit (PICU)

4. Endoscopy

5. Medical Imaging

6. Cardiac Catherization/Vascular Lab (CCVL)

7. Bronchoscopy Lab

8. Pediatrics

C. Scope of Practice:

1. Physicians:

a. Procedural/Moderate sedation shall be prescribed, selected, ordered and supervised by a physician credentialed for the administration of sedation according to the guidelines established and approved by the medical staff.

b. The physician must be able to manage complications that may occur.

c. Physician credentialing and competency requirements (available on the TRMC Intranet).

1. The physician supervising the administration of or administering procedural/moderate sedation will have privileges to do so.

2. Included in the qualifications of this individual are competency-based education, training and experience.

3. Specifically, practitioners who have appropriate credentials and are permitted to administer moderate sedation are qualified to rescue patients from deep sedation.

4. Competency requirements for Applicants:

• Completion of moderate sedation module post-test with a passing score of 85% or above

• ACLS certification for adult sedation (age >13 years)

• PALS certification for pediatric sedation (age10 years of age refer to adult dosage. Safety and |Neuromuscular: transient skeletal movements, | |insufficiency, which may contribute to |

| |efficacy have not been established in children < 10 years of age.|uncontrolled eye movements. | |increased hospital stay and increased |

| | | | |ventilator days; avoid administration into|

| |Administer I.V. push over 30-60 seconds, very irritating. | | |small vessels on the dorsum of the head or|

| | | | |hand; pre-administration of Lidocaine may |

| | | | |be beneficial |

|Fentanyl (SublimazeR) |Adult: |Respiratory depression, chest rigidity |Naloxone (NarcanR) |Enhanced effects with sedatives |

| |1 mcg/kg | |IV/IM/SQ: 0.1-0.4mg at 2-3 minute intervals| |

| |Pediatric: | |until desired response is achieved. | |

| |IV/IM: 1 mcg/kg, then 0.5 mcg/kg q 5 min | | | |

| |PO: 5-15 mcg/kg (max 400mcg) | | | |

|Ketamine |Adult: NOT recommended |Emergence delirium, tachycardia, salivation, | |Contraindicated in hypertension, CAD, CHF,|

|(KetalarR) |Pediatric: |increased blood pressure, increased | |head trauma, resp infection, psych disease|

| |0.5-1mg/kg IV |intracranial pressure, laryngospasm, myocardial| | |

| |2-3mg/kg IM |ischemia, increased intraocular pressure | | |

| |3-4mg/kg PO | | | |

ATTACHMENT A

|DRUG |DOSAGE/SPECIAL INFO |ADVERSE REACTIONS |REVERSAL AGENT |WARNINGS |

|Meperidine (DemerolR) |Adult: |Respiratory depression, |Naloxone (NarcanR) |Enhanced effects with sedatives, DO NOT |

|NOT RECOMMENDED TO BE USED|50-100mg IM/IV |Seizures (due to metabolite) |IV/IM/SQ: 0.1-0.4mg at 2-3 min intervals |give to patients on MAOs or renal failure|

|ROUTINELY |Pediatric: | |until desired response is achieved. |USE IS DISCOURAGED |

| |1-2mg/kg ( up to 15mg) IM/IV/SQ | | | |

|Midazolam IV (VersedR) |Adult: 0.5-2mg/ dose over 2 min. Repeat in 2-3 min intervals |Respiratory depression, paradoxical agitation,|Romazicon (FlumazenilR) |Use lower doses in combination with |

| |until desired effect. Usual total dose 2.5-5mg. Max dose 10mg. |hypotension, bradycardia |IV: 0.2mg over 15 seconds. May repeat |narcotics |

| |Pediatric: | |every 60 seconds until desired response is | |

| |6mo-5yr—0.05-0.1mg/kg over 2-3 min every 2-3 min to max dose of | |achieved. | |

| |6mg | |Max dose of 1mg. | |

| |6yr-12yr—0.025-0.05mg/kg over 2-3 min every 2-3 min to max dose | | | |

| |of 10mg | | | |

| |Maintenance: 25% of initial dose used to achieve desired | | | |

| |sedation may be given to maintain sedation | | | |

|Midazolam PO (VersedR) |Adult: 7.5-15mg |Respiratory depression, paradoxical agitation,|Romazicon (FlumazenilR) |Use lower doses in combination with |

| |Pediatric: 0.3mg-0.6mg/ kg |hypotension, bradycardia |IV: 0.2mg over 15 seconds. May repeat |narcotics |

| | | |every 60 seconds until desired response is | |

| | | |achieved. | |

| | | |Max dose of 1mg. | |

|Morphine |Adult: |Respiratory depression, N/V, urinary |Naloxone (NarcanR) |Enhanced effects with sedatives |

| |IM: 5-20mg |retention, constipation, hypotension, |IV/IM/SQ: 0.1-0.4mg at 2-3 minute | |

| |IV: 2-15mg |bradycardia, increased intracranial pressure, |intervals until desired response is | |

| |Pediatric: 0.1-0.2mg/kg (up to 15mg) |biliary spasm |achieved. | |

|Propofol |Adult: |Pain at injection site, hypotension, |None Available |Intra lipid allergy |

|(DiprivanR) |IV: 100-150 mcg/kg/min load over 3-5 minutes, followed by 25-75|bradycardia, apnea | |MUST BE ADMINISTERED BY A PHYSICIAN WHEN |

| |mcg/kg/min | | |PT. NOT INTUBATED |

| |Pediatric: NOT recommended | | | |

1. Micromedex Inc. Healthcare Series 2004, and Harriet Lane Handbook 16th ed. 2. LexiComp Online 2012.

ATTACHMENT B: ASA Classification

Class I Normal healthy patient

Class II Patient with mild systemic disease

None or only slightly limiting organic heart disease

Mild diabetes controlled with oral medication

Essential hypertension medication

Anemia

Chronic bronchitis

Class III Patient with severe systemic disease

Diabetes, well controlled with insulin hose restoration of normal diet will aid in diabetic control

Immunosuppressed

Moderate degree of pulmonary insufficiency

Stable coronary artery disease

Asthma under treatment

Extreme obesity

Class IV Patient with severe systemic disease that is constant threat to his or her life

Organic heart disease showing marked signs of cardiac insufficiency

Persistent anginal syndrome

Active myocarditis

Advanced degrees of pulmonary, hepatic, renal, or endocrine insufficiency

No class 4 shall be done on an outpatient basis

Class V Moribund patient not expected to survive 24 hours

Class VI Patient declared brain dead whose organs are being removed for donation.

E Emergency

Attachment C: Discharge Criteria

Reference: Standardized Procedure – Discharge of Patients from Ambulatory Care Unit by an RN. #20-20,002

Obtain order from attending physician to discharge per criteria. The patient must meet all discharge criteria:

Aldrete Score ≥ 8, or at pre-procedure level (criteria immediately below

meet Aldrete criteria):

1. Documented BP is within 20mm/hg of the admitting BP

2. Respirations unlabored and patient able to deep breath and cough

freely or at pre-procedure levels.

3. Absence of respiratory distress.

4. Alert and oriented or LOC returned to pre-procedure level.

Tolerates fluids with minimal nausea and vomiting. (The physician must be notified if the patient is actively vomiting).

Pain is adequately managed, and pain is appropriate for procedure (if applicable).

Swallow, cough and gag reflex present, protective reflexes are intact.

Dressing (if applicable) dry and intact or with minimal drainage appropriate for procedure.

Post procedure education completed with questions answered. Patient/Responsible Party can verbalize discharge instructions.

Attachment D: Pediatric Sedation

This attachment is to be used in conjunction with Moderate Sedation Policy

12-3027, (it is not a “stand alone” attachment)

Pediatric patients consist of children 2-3 days through the age of 13 yrs. (See pediatric Scope of Service)

The goal for the pediatric patient receiving sedation is to maintain safety /comfort, control anxiety/stress, modify behavior/movement, minimize psychological trauma, and maximize the potential for amnesia.

Patients admitted to the pediatric department requiring sedation for a procedure will fall within the requirements of policy 12-3027 with the following exceptions:

1. Continuous blood pressure monitoring may be altered or suspended during the child’s procedure. Reason for omitting B/P needs to be documented in the patient record. However, continuous heart rate, respiratory rate, and pulse oximetry will not be interrupted. (B/P monitoring will resume post procedure as outlined in the post procedure section of policy.)

2. Patients receiving oral medication for sedation purposes and have no prior cardiac history may be monitored with continuous pulse oximetry and heart rate only. EKG monitoring may or may not be used according to patient’s tolerance and risk of procedure.

3. Orally sedated out-patients in the Pediatric Unit may or may not have IV access, dependent on physician orders, assessment risk, and risk of procedure.

4. ER pediatric patients receiving moderate sedation will have IV access established.

5. The physician/pediatrician must be present for oral sedation procedures. (TJC 2010 standard)

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