Rapid Sequence Intubation in the Prehospital Setting

Securing and maintaining a patent airway are the highest priorities when caring for critically ill patients. When airway intervention is required, it should be performed in an expedient and organized fashion by an experienced individual, with the goal of providing a definitive airway safely, minimizing any possible complications. Rapid sequence induction, or RSI, has this goal in mind. Performing RSI successfully requires experience; a thorough understanding of its indications, contraindications and limitations; and a working knowledge of the pharmacology of agents used to assist in intubation. This article reviews how to recognize airway or ventilatory compromise, manage the problem, and emphasize the proper use of RSI with a focus on clinical skills, and discusses the pharmacology and indications of the various agents employed with this technique.

Brief History

Since its introduction in the late 1970s, there has been a great deal of controversy over RSI within the medical community. This controversy stems partly from individuals who are not familiar with their EMS systems’ competence and feel that this task cannot be safely performed by a nonphysician.

Numerous studies, however, have proven that, in experienced hands, RSI can be safely performed in the prehospital setting. Some studies have tried to demonstrate that nasal intubation is superior to pharmacology-assisted oral intubation. Although nasal intubation may be quicker in some providers’ hands, RSI has a consistently higher initial success rate.

Of utmost importance, there must be a highly organized and structured physician-based quality assurance program behind every EMS system that uses RSI in its airway management protocols. If RSI is to be adopted by an EMS agency, cooperation is necessary from everyone in that system.

For instance, local emergency department directors should be consulted and their concerns and comments addressed regarding medical command and control concerning RSI use by EMS providers. Motivated and cooperative operating room personnel and anesthesiologists are invaluable, for that is where various skills and experience with pharmacologic agents can be obtained during the training process. The OR is also useful for performing monthly and yearly quality skills assessments for every participant practicing this technique.

Airway Anatomy

The airway is divided into upper, middle and lower regions. Each region is comprised of separate structures.

Upper Airway

The upper airway begins with the face and facial skeleton, which includes the mandible and maxilla. This means that facial fractures are airway injuries as well. Also within this region are the nasopharynx and oropharynx, which conduct air to the lower airways, humidify gases and clear debris.

Middle Airway

The middle airway is principally composed of the larynx, located midline in the neck and fairly vulnerable to injury. However, it is relatively well-protected from its two muscular lateral sides and the vertebral column posteriorly. The mandible adds some anterior protection as well. The larynx is comprised of cartilage, of which the thyroid and cricoid are major components. The vocal cords are situated within the larynx. This region is narrow, and edema, secretions or foreign bodies can quickly compromise airway patency.

Lower Airway

The trachea delineates the middle and lower airways as it exits the neck and enters the chest. It is made up of incomplete cartilage rings anteriorly that are open posteriorly and held together by elastic muscle tissue posteriorly. It travels into the chest and ends as the airway divides into the right and left mainstem bronchi. The trachea is relatively well-protected; however, injury can occur from blunt trauma to the chest, primarily decelerating injuries, as well as from penetrating injuries.

Prehospital RSI Airway

Look for signs of airway compromise, which include tachypnea, evidence of increased effort such as use of accessory muscles of respiration (sternal retractions, use of scalene muscles, or diaphragmatic or paradoxical breathing), nasal flaring and difficulty handling oral secretions. Look for agitation. An agitated patient may be hypoxic and should be presumed so until proven otherwise. Remember that not all agitation is due to intoxication. Obtunded or lethargic patients may be so due to CO2 retention. Cyanosis is a very late sign that is indicative of poor oxygenation. Look for cyanosis of the digits and nail beds and around the mouth (circumoral). Observe the neck for evidence of tracheal deviation or subcutaneous emphysema, which may alert to impending airway compromise. Make a quick inspection of the oral cavity for evidence of a foreign body, as well as the presence of impaired airway-protective reflexes.

Listen for evidence of airway compromise and for harsh, crowing respiratory efforts, also known as stridor. If the patient can speak, listen to the voice quality: Is it clear and understandable? Garbled or hoarse? These sounds may indicate partial upper airway obstruction or the presence of a laryngeal injury. A patient who can speak normally has a patent airway.

Ventilation

Look for signs of ventilatory impairment. Ventilation involves the airways and muscles of respiration, as well as a functioning central nervous system. Therefore, an unobstructed airway will be of little benefit if proper ventilation is not taking place.

Observing for symmetrical rise and fall of the chest helps assume adequate ventilation. Paradoxical movement, as in a flail chest or sternum, will compromise both oxygenation and ventilation. Abdominal or diaphragmatic breathing, as seen in cervical spinal cord injury, also affects both ventilation and oxygenation.

Labored respirations are another sign of possible impending failure. Agitation, somnolence or unresponsiveness may be caused by CO2 retention secondary to impaired ventilation.

Listen to the chest bilaterally for proper air exchange. Symmetrical, equal breath sounds aid in reassuring adequate ventilation. Absent or diminished breath sounds may indicate a pneumothorax, fluid collection or other thoracic conditions that impair adequate gas exchange. The quality of breath sounds may also aid in diagnosis. Wheezing, primarily on exhalation, may represent bronchospasm, as seen in asthma. Upper airway obstruction secondary to foreign body or excessive secretions/blood will also affect ventilation and should be actively sought. Remember the old adage: “All that wheezes is not asthma.” The wide use of pulse oximetry also aids in rapidly determining adequate oxygenation.

Patient Management

The basic tenet in airway management is quick and accurate determination of adequate airway patency and ventilation. Management should be performed in the same fashion. Place supplemental oxygen on all patients. Have proper equipment readily available and functioning correctly. This includes: suction apparatus, full oxygen canister, bag-valve-mask, various-sized oral and nasal airways, endotracheal tubes, laryngoscope with various-sized blades and functioning lights, as well as a backup means for securing the airway. Management techniques can be divided into methods that improve oxygenation and ventilation, maintain airway patency and ultimately provide a definitive airway.

Oxygenation and Ventilation

The importance of proper oxygenation cannot be overemphasized. In order for tissues to function correctly, they require an oxygen-rich environment. Oxygen is supplied by either nonrebreather mask or bag-valve-mask at a concentration of 100%. When administered by face mask, the flow rate should be high enough to maintain a filled reservoir, usually 10–15 liters/minute. Face masks should be tight-fitting to ensure proper delivery and to minimize leaks. While pulse oximetry aids in determining adequate oxygenation, it is limited in certain situations (hypothermia, excessive movement, ambient light interference, anemia, etc.).

Providing adequate ventilation is the most important intervention to be mastered by prehospital providers. This can be accomplished by one person or two via bag-valve-mask. With one person providing ventilation, maintaining a tight fit may be difficult to accomplish. When another rescuer is available, consider two-person ventilation, where one rescuer holds the mask in place with two hands while the other maintains the bag. Apply gentle, even pressure to the bag when ventilating and observe symmetrical chest wall movement. Avoid using excessive force when ventilating to protect against gastric distention and subsequent regurgitation.

Aspiration of stomach contents or oral secretions and/or blood poses a risk to the patient with impaired airway-protective reflexes (head-injured, intoxicated, etc.). To help protect against this, use cricoid pressure (Sellick’s maneuver) whenever ventilating a nonintubated patient. This involves identifying the cricoid cartilage and applying firm, continuous downward pressure to help occlude the esophageal lumen and impede regurgitation of stomach contents and/or aspiration of pooled oral secretions.

Airway Maintenance

Maintaining a patent airway is critical for adequate oxygenation and ventilation. There are many alternatives to accomplish this.

Chin Lift/Jaw Thrust

This maneuver helps alleviate the common occurrence of a prolapsed tongue that is displaced backward and obstructs the upper airway. The chin is displaced forward by placing the fingers of one hand under the mandible while gently lifting up and using the thumb of the same hand to open the patient’s mouth. It is important not to place the fingers on the chin itself, as this could close a partially open airway.

The jaw thrust is performed using both hands. Place your fingers behind the angles of the mandible, one hand on each side, and lift the mandible forward. These techniques allow the tongue to be displaced anteriorly along with the mandible to which it is attached. Promptly remove any foreign bodies.

Nasal or Oropharyngeal Airway

Use of these airways aids rescuers in providing airway patency in both the spontaneously breathing patient and the assisted patient. Nasal airways are preferred in the responsive patient with intact airway reflexes, as they are less stimulating and less likely to induce vomiting. They should be lubricated prior to insertion in the most patent nostril and must never be forced. The oropharyngeal airway is used as a means to displace the tongue anteriorly and remove it from obstructing the pharynx, primarily in the unresponsive patient. Place with its concavity directed toward the palate and rotate carefully 180º as the soft palate is encountered. Using a tongue depressor to facilitate placement is another alternative. Be careful to not push the tongue backward and further occlude the airway.

Laryngeal Mask Airway

The laryngeal mask airway (LMA) is primarily used in controlled settings, such as for outpatient surgery in the operating room, but has recognized utility in providing an airway in many difficult situations.

The LMA is composed of a silicone rubber mask with an inflatable outer rim and an opening at its distal end covered by a grille. It is reusable, requiring steam sterilization. The mask is connected to a plastic tube with a standard 15 mm adaptor for attaching an AMBU bag or breathing circuit.

Prior to insertion, completely remove the air from the cuff of the mask and lubricate its posterior surface. The LMA is inserted blindly, most commonly using a tongue blade for assistance. Insert with the opening or grille side facing the tongue and the black indicator line of the plastic tubing toward the teeth or palate. Advance until resistance is felt; the mask is then inflated.

Once the mask is inflated, a characteristic elevation or slight protrusion of the tubing from the mouth is usually seen, as well as fullness in the neck. These findings, as well as auscultation of breath sounds, rise and fall of the chest with ventilation, and appearance of confirmable end tidal CO2 waves, are used to confirm correct placement of the LMA, or any airway.

When properly placed, the LMA forms a seal around the glottic opening, with its tip at the upper esophagus. This is a relatively noninvasive means of providing ventilation.

The LMA helps establish an airway and enable effective oxygenation and ventilation; however, it does little or nothing to guard against pulmonary aspiration of gastric contents. This can have devastating complications if it occurs, especially in the emergency patient population. Therefore, an attempt should be made to establish a definitive airway.

Esophageal-Tracheal Combitube

The esophageal-tracheal Combitube is a modification and advancement of the older esophageal obturator airway, or EOA. The Combitube is comprised of two separate, clear polyvinyl chloride tubes fused together longitudinally. One tube is patent while the other is blind. The blind tube is longer than the patent tube and is color-coded blue on its more proximal end, as is its pilot balloon.

Two inflatable balloons are located on the tube: one proximal latex 100 cc balloon that functions as the oropharyngeal balloon, and a more distal conventional 15 cc PVC balloon. Between the balloons, on the blind- ended tube, are eight small perforations.

Each tube has a standard 15 mm connector on its proximal end for connection to a breathing apparatus. Like the LMA, the Combitube is placed blindly. It can be lubricated prior to insertion, avoiding occluding the perforations; however, this is not mandatory.

Check both balloons for any defects and then deflate. Gently grasp the patient’s tongue and mandible with the thumb and forefinger and pull forward. A laryngoscope may be used solely to aid in retracting the tongue.

Insert the Combitube until the teeth are located between two black lines located on the proximal portion of the tube. Once inserted, inflate the proximal oropharyngeal balloon with approximately 100 cc of air from the 140 cc syringe supplied. The Combitube may protrude slightly at this point. This oropharyngeal balloon functions as an anchor and occludes the proximal airway by forming a “seal” between the palate and tongue. Next, inflate the distal balloon with 10–15 cc of air.

Since the Combitube is placed in the esophagus approximately 95% of the time, ventilate the “blue” or blind lumen first. This lumen is blocked distally, which forces air out of the perforations and against the oropharyngeal balloon.

If the tube is placed in the esophagus, the distal cuff seals the esophagus and air travels down the trachea, so breath sounds should be heard over the chest, not the stomach, when this lumen is ventilated. If no breath sounds are detected and there is no chest expansion with ventilation via the blind lumen, assume tracheal placement, the less likely occurrence, and switch ventilation to the patent, shorter lumen.

If placed in this fashion, the Combitube functions as a standard endotracheal tube. If it’s placed in the more common esophageal position, the stomach and its contents can be evacuated with the supplied suction catheter.

The Combitube is designed for patients five feet tall or larger, and, until recently, only came in one size. Its use is contraindicated in patients with an intact gag reflex, known esophageal disease, history of caustic material ingestion, or presence of upper airway obstruction.

As with the LMA, the Combitube will help establish an airway and enable effective oxygenation and ventilation; however, it does little or nothing to guard against pulmonary aspiration of gastric contents, which can have devastating complications. Therefore, an attempt should be made to establish a definitive airway.

Gum Elastic Bougie (GEB)

The gum elastic bougie (GEB), or Eschmann catheter, is a flexible piece of plastic about two feet long with a slight 45° angle on its end. This device is helpful when an anterior larynx is encountered and there’s difficulty in visualizing and/or intubating the larynx. The GEB can be placed through the vocal cords with the use of laryngoscopy and an ETT “railroaded” over it, thus using it as a guidewire or stylet.

When the GEB is properly placed in the trachea, a characteristic “clicking” sensation is felt as it advances over the anterior tracheal cartilaginous rings. Its use is becoming more common in prehospital airway protocols for difficult airway encounters. It is simple to use, doesn’t require any additional training, and can quickly turn a potential disaster into a success.

Definitive Airway

The decision to place a definitive airway is based on clinical judgment and the understanding that a stable patient may deteriorate rapidly, requiring frequent reassessment of their airway, ventilatory and neurologic status, as well as vital signs. Common indications for intubation include:

• Decreased level of consciousness (Glasgow Coma Score <8)—at risk for increased intracranial pressure and need for hyperventilation
• Patients at risk for aspiration secondary to impaired airway-protective reflexes
• Massive facial fractures/injuries, burn patients with risk or evidence of inhalation injury
• Apnea
• Failure to maintain a patent airway and oxygenation by other means.

A definitive airway is meant to represent an endotracheal tube (ETT) that is placed in the trachea, past the vocal cords. A balloon, located distally, serves to protect against aspiration when inflated. The airway can be placed orally, nasally or surgically in the form of a cricothyroidotomy or tracheostomy.

Airway Assessment

Prior to placing a definitive airway, attempt to determine the likelihood of a potential difficult airway with inability to ventilate. There have been numerous methods used to assess this potential; however, they are directed at the more controlled environment and may be difficult, if not impossible, to use in the field. Nonetheless, an attempt should be made.

If possible, have the patient open his mouth as wide as he can and stick out his tongue. The view of the pharyngeal structures seen is classified as class I to IV. Class I is the best view, and class IV is the worst view. It has been proposed that this indicates how easy or difficult intubation may be, but realize that there is great variability.

The actual view seen on laryngoscopy is graded I to IV as to the extent of laryngeal structures seen. This is important to note and communicate to other healthcare professionals regarding the degree of ease or difficulty to be expected if future airway interventions are needed.

Other indicators of a difficult airway and/or mask ventilation include:

• Short, fat neck
• Small, receding chin
• Presence of a beard
• Large tongue
• Poor mouth opening and/or neck mobility
• Facial injury with excess oral secretions
• Facial and/or neck burns
• Fractured mandible
• Laryngeal injury.

Route of Intubation

Oral Intubation

This is by far the route of choice. There are few, if any, contraindications for placing an orotracheal ETT. This can be performed safely in the patient with confirmed or suspected cervical spine fracture. Combative patients or patients who won’t open their mouths, however, make this route difficult, if not impossible. Use of pharmacologic agents greatly aids in its success.

Nasal Intubation

Though the blind nasal route requires a spontaneously breathing patient, this is not required for nasal intubation, where visualization of the cords is performed via laryngoscopy. This can be accomplished quickly and rapidly in most cases, but has contraindications such as the presence of or suspected basilar skull fracture or facial fractures. The most common complication is epistaxis. Use in the head-injured patient with increased intracranial pressure or the combative patient with possible cervical spine injury may be detrimental to the patient. Nasal tubes also increase the occurrence of sinusitis.

Surgical Airway

Use of a surgical technique, limited to cricothyroidotomy for prehospital providers, is indicated in severe facial injuries, such as crush or burns that make nasal or oral intubation virtually impossible or unsafe; when oral or nasal intubation has failed to provide a definitive airway, such as in severe laryngeal edema or crush injuries; as well as in a failed rapid sequence intubation attempt with inability to provide oxygenation/ventilation by less invasive means.

This is accomplished by locating the thyroid cartilage and sliding a finger inferiorly until the depression of the cricothyroid membrane is felt. Hold the larynx in place with the nondominant hand and make a small vertical incision in the membrane with a #11 scalpel blade.

Insert and rotate the end of the scalpel handle in the incision to allow entry of a 6.0 mm ETT. Secure after placement is confirmed with end tidal CO2 and bilateral breath sounds, as with any airway. A cricothyroidotomy is contraindicated in children under 12 years old.

Rapid Sequence Induction

Rapid sequence induction (RSI) is the use of pharmacologic agents to aid in establishing a definitive airway. More than 90% of in-hospital intubations use RSI, with the other 10% being “crash intubations” or those where the obtunded patient does not require initial sedation or neuromuscular blocking agents (NMBAs). It is intended for patients who are considered at risk of aspirating stomach contents—the so-called “full-stomach” patients—as an effort to decrease the potential occurrence of pulmonary aspiration.

In the prehospital setting, any patient should be considered a “full-stomach” patient, thus at risk of aspiration. RSI has been made popular by anesthesiologists in the OR, where the normal sequence is done in a more rapid fashion.

What exactly is meant by “rapid sequence induction”? Before we describe the technique, some terms need to be defined:

Induction: Use of pharmacologic agents, whether intravenous solutions or inhaled gases, that act on the brain to quickly move from consciousness to unconsciousness, to create a plane or level of anesthesia.

Pre-oxygenation: Application of oxygen prior to attempting intubation.

Premedication: Administration of medications prior to induction of anesthesia; usually chosen with a particular purpose in mind.

Cricoid pressure: Use of gentle, continuous downward pressure on the cricoid cartilage of the larynx; intended to prevent aspiration by compressing the larynx against the posteriorly located esophagus.

Neuromuscular blocking agents: Drugs that produce chemical paralysis of skeletal muscle. It must always be remembered that these agents only paralyze skeletal muscle; they offer no benefit of sedation or analgesia. These are also referred to as paralytics or paralytic agents.

RSI Technique

In non-emergent situations, the patient is normally given an induction agent, which rapidly produces unconsciousness and apnea. At this point, there is a period of assisted ventilation and oxygenation via bag-valve-mask ventilation to establish the presence of a patent airway, as well as to determine the ability to oxygenate. This is performed before administering the neuromuscular blocking agent. Once the presence of an airway is established and ventilation can be easily performed, the neuromuscular blocking agent is given and tracheal intubation follows shortly after.

The difference in RSI performance is exclusion of assisted ventilation once the patient is induced. The induction agent is immediately followed by administration of the paralytic agent, thus the name “rapid sequence induction.”

Pre-oxygenation is done prior to administering any agents, and cricoid pressure is applied until airway establishment has been confirmed. A sample sequence follows:

• All equipment is available and functional: laryngoscopes, ETT, suction, #11 scalpel, pulse oximeter/end tidal CO2 monitor, ECG and BP monitor.
• IV access is established.
• Pre-oxygenation with nonrebreather mask or AMBU bag; valve-assisted ventilations with application of cricoid pressure.
• Premedications, if any, are administered.
• Induction agent is administered.
• Neuromuscular blocking agent is given immediately following induction.
• Laryngoscopy and intubation are performed.
• Endotracheal tube placement is confirmed (listening for bilateral equal breath sounds, absence of breath sounds over the stomach, esophageal detector, presence of appropriate end tidal CO2 waves on monitor, observing symmetrical chest expansion).
• Cricoid pressure is released.
• Tube is secured.
• Patient is ventilated with additional paralysis and sedation, as needed.

RSI is indicated for any patient at risk of aspiration: patients with full stomach (any emergent case or trauma patient); pregnant patients; patients with known reflux, hiatal hernia or delayed gastric emptying.

The true contraindication to RSI is any patient on whom you may not be able to intubate or perform a cricothyroidotomy.

Cervical Spine Injury (CSI)

The presence or suspicion of cervical spine injury is not a contraindication to RSI. The technique can be performed safely if patients at risk of such injury are identified and appropriate precautions are taken. When a patient at risk of CSI is in need of airway management and RSI is to be performed, an extra person is needed to stabilize the neck in the following fashion:

Manual in-line axial stabilization (MIAS) is used to add protection against creating or causing further damage to the spinal cord. This is accomplished with the help of another provider who stabilizes the neck in a neutral position.

Using both hands, grasp the mastoid processes and maintain the head and neck in a neutral position. Three providers are needed to perform MIAS: one for cricoid pressure, one for laryngoscopy and intubation, and another for MIAS.

It is important to realize that the intent of MIAS is to provide stabilization, not traction of the cervical spine. Traction may cause distraction of any ligamentous injury and further damage an already compromised spinal cord.

Failed Intubation

In the event an intubation attempt fails, have a backup plan ready. If the patient has been induced and given paralytics, this could be a true emergency. If this scenario occurs, it is important to maintain oxygenation via bag-valve ventilation using constant cricoid pressure.

Another attempt at laryngoscopy and intubation may be made if mask ventilation is possible and oxygenation, as measured by pulse oximetry, is adequate. A sample algorithm follows:

• Cannot intubate
• Maintain cricoid and MIAS (if cervical spine injury suspected)
• Bag-valve ventilation with 100% oxygen
• Reposition patient; attempt to optimize view, use gum elastic bougie (GEB) or Eschmann catheter
• Re-attempt laryngoscopy and intubation
• If unable to reintubate, but can bag-valve ventilate, maintain cricoid pressure and continue with bag-valve ventilation.
• If unable to bag-valve ventilate, go to surgical airway or airway adjunct (LMA, Combitube), if protocol allows.

Conclusion

The use of RSI is intended to allow rapid, safe airway management and protection while minimizing periods of hypoxia. Protection against aspiration of gastric contents is crucial in performing this technique, and it is prudent to understand the patients at risk for such a complication. This technique has been used extensively in operating rooms and is also gaining popularity in the emergency department.

It should be noted that poor outcomes following the use of prehospital RSI have been documented, but poor outcomes are noted for in-hospital RSI as well.

Despite controversy regarding the safety of RSI in the hands of prehospital providers, it has been shown that with proper training, routine skills assessment, and close medical supervision and cooperation, RSI can be accomplished with great success. ?

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