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JOSEPHINE G PATERSON
Abstract
In the management of critically ill patients in
emergency departments, rapid sequence induction
(RSI) of anaesthesia is often required. This article
examines the elements of RSI that are necessray
before before endotracheal tube placement and
reviews the findings of a national audit project,
conducted by Royal College of Anaesthetists and
Difficult Airway Society. It also considers the role
ofnurses in RSI procedures.
Keywords
Anaesthesia, airway, crew resource management
EMERGENCY DEPARTMENT (ED) staff undertake
rapid sequence induction (RSI) of anaesthesia
to ensure that definitive airways can be secured
in critically ill patients. A definitive airway has
been defined as a cuffed tube in the trachea
(Kummer et al 2007) and most frequently involves
the drug-assisted passing of an oral endotracheal
tube. Some patients can be intubated without drugs
but some have a degree of remaining airway reflex,
which requires pharmacological adjuncts to support
tracheal intubation (Carley et al 2002).
Rapid sequence induction was originally
undertaken in patients if they had eaten shortly
before surgery to ensure that they did not aspirate
their stomach contents. Specialised equipment, and
trained and experienced staff, are needed before
the procedure can be undertaken in EDs (Reid et al
2004), where the clinical conditions of patients can
make the procedure especially difficult.
Class 2
Class 3
Class 4
Peter Lamb
Class 1
1
3
Equipment
Patient
EMERGENCY NURSE
80 70 60 50 -
Patient is
hypoxaemic
40 -
Patient is
at high risk
Patient is
at low risk
30 20 10 0
10 20 30 40 50 60 70 80 90 100
Partial pressure of oxygen in the blood (%)
Patient
breathingair
450mL
3,000mL
1,000-1,500mL
3,500-4,000mL
250mL/minute
250mL/minute
1 minute
8 minutes
EMERGENCY NURSE
Drug
Syringe Concentration
size (mL)
(mg/mL)
Dosage (mg/kg)
If patient
is stable
Duration
Indications
Cautions
If patient
Of onset Of action
is unstable (seconds) (minutes)
Ischaemic heart
disease.
Hypertensive
emergencies.
Ketamine
20
10
60-120
5-15
Hypotension.
Asthma.
Chronic obstructive
pulmonary disease.
Thiopental
20
25
1.5
30-60
5-30
Hypotension.
Normotensive.
Status epilepticus.
Isolated head injury.
Table 3
Drug
Syringe Concentration
size (mL)
(mg/mL)
Dosage (mg/kg)
If patient
is stable
Duration
Indications
Cautions
If patient
Of onset Of action
is unstable (seconds) (minutes)
Rocuronium
10
10
45-60
45-70
Difficult intubation.
Suxamethonium
50
1.5
1.5
30-60
5-15
Hyperkalaemia.
Myopathy.
Neuropathy or stroke.
Denervation illness.
Ear-to-sternal notch
horizontal plane
Peter Lamb
EMERGENCY NURSE
30
Cricoid:
posterior
aspect
Oesophagus
March 2014 | Volume 21 | Number 10 21
Prepare equipment
Prepare team
Intubator................................
Airway assistant .....................
W
ho should be contacted ifmore
help is needed?
Bleep number............................
Are specific
complications
anticipated?
EMERGENCY NURSE
Grade 1
Grade 2
Grade 3
Grade 4
Laryngeal
mask airway
urgica
n iq u e
l te c h
Endotracheal
tube
Face
mask
Conclusion
As the NAP4 study demonstrates, there is a need for
improvements in RSI conducted outside operating
theatres (Cook et al 2011). Patient safety can be
improved if team members are trained appropriately
and if methods that are proven to reduce errors,
such as the use of checklists and other cognitive
aids, are adopted by teams managing critically
ill patients. Above all, RSI procedures should be
planned and prepared meticulously: failing to plan
is planning to fail.
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Conflict of interest
None declared
References
Association of Anaesthetists of Great Britain
and Ireland (2007) Recommendations for
Standards of Monitoring During Anaesthesia
and Recovery. Fourth edition. AAGBI, London.
EMERGENCY NURSE
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