Policy: Rapid Sequence Intubation (RSI) – Margaretville Hospital Approver(s): Anesthesia Department Chair, Executive Director Nursing (Margaretville) Initiated: 2/2017 Last Approval Date: 2/2017 Reference(s): Nickson, C., MD. (2015, June 18). Rapid Sequence Intubation (RSI). Retrieved from http://lifeinthefastlane.com Lafferty, K., & Dillinger, R. (2016, December). Rapid sequence intubation. Retrieved from http://emedicine.medscape.com Clinical & practice management- Rapid sequence intubation. (2012, April). Retrieved from http://www.acep.org Responsible Departments: Nursing, Anesthesia, Emergency Department Providers ______

1.0 DEFINITIONS: 1.1 Rapid Sequence Intubation (RSI) Rapid sequence intubation is an airway management technique that is accomplished by sedating and paralyzing the patient to allow for endotracheal tube intubation. RSI is the fastest and most effective means of controlling the emergency airway because it involves administration of weight-based doses of an induction agent immediately followed by a paralytic agent to achieve rapid unconsciousness. This is particularly important in patients with an intact gag reflex, a “full” stomach, and a life threatening injury or illness requiring immediate airway control.

1.2 Indications for RSI : The accompanying examples represent possible scenarios and are not an all-inclusive list. 1.2.1 Failure to maintain airway tone:  Swelling of upper airway, facial or neck trauma with oropharyngeal bleeding or hematoma. 1.2.2 Failure to protect airway against aspiration such as:  Decreased consciousness and loss of airway reflexes that leads to regurgitation of vomit, secretions, or blood. 1.2.3 Failure to ventilate  Prolonged respiratory effort that results in fatigue or failure, i.e., status asthmaticus or severe COPD. 1.2.4 Failure to oxygenate  Diffuse pulmonary edema, ARDS, large pneumonia or air space disease, cyanide toxicity, carbon monoxide toxicity. 1.2.5 Anticipated clinical course of deterioration  Uncooperative trauma patient with life-threatening injuries who needs immediate procedures or testing.  Stab wound to neck with expanding hematoma or septic shock with high minute ventilation and poor peripheral perfusion  Intracranial hemorrhage with altered mental status or cervical spine fracture with concern for edema and loss of airway patency.

2.0 POLICY: 2.1 RSI can be performed by physicians and ED mid-level providers, only. 2.2 All credentialed physicians and ED mid-level providers who administer RSI drugs must be ACLS and ATLS certified or equivalent (i.e., board certification in emergency medicine or anesthesia) and meet ongoing bi-annual competency requirements as defined by the Chair of Anesthesia. 2.3 The physician or ED mid-level provider performing RSI including drug administration is responsible for obtaining consent from the patient or a representative. 2.4 Immediately prior to the initiation of RSI, the credentialed physician or mid-level provider and two registered nurses are required to remain in the procedure area. One registered nurse will remain present following completion of the procedure, until transfer. 2.5 RSI is a procedure for patients with a critical disease or traumatic process. The selection of technique and specific agents is determined individually for each patient and situation. 2.6 All patients receiving RSI will be transferred to a tertiary care facility for continuation of care.

3.0 RELATED POLICIES: 3.1 Procedural Sedation and Analgesia

4.0 PROCEDURE: 4.1 Equipment that must be immediately available: 4.1.1 Monitoring devices (see below) 4.1.2 Airway Control Adjunct  Suction and catheters  BVM  Intubation supplies  ACLS crash cart 4.1.3 IV access 4.1.4 Supplemental Oxygen

4.2 Monitoring Devices: All of the following will be used for continuous monitoring from initiation of RSI until the time of to transfer: 4.2.1 Cardiac monitor 4.2.2 Pulse oximetry 4.2.3 Blood Pressure cuff 4.2.4 End Tidal CO2 detector for intubated patients

4.3 Induction drugs and paralytics used to facilitate airway visualization: 4.3.1 Hypnotic/ sedatives  Midazolam  Etomidate  Propofol (to maintain sedation after intubation only) 4.3.1 Paralytics  Vecuronium  Succinylcholine  Rocuronium 4.3.2 Reversal Agents  Flumazenil  Naloxone 4.3.3 Dissociative agents  Ketamine

5.0 DOCUMENTATION: 5.1 Documentation will be completed in the EMR and on the RSI flowsheet as applicable.

6.0 QUALITY REVIEW: 6.1 All cases involving RSI will be reviewed for compliance by the Medical Director of the Emergency Department.