Identification and Patient Introduction
Introduce Yourself: State your name and role clearly.
Verify Patient Identity: Confirm the patient's full name and date of birth.
Consent: Explain the procedure and gain informed consent if possible, considering the urgency.
Indications for Intubation
Failure to maintain/protect airway.
Failure to oxygenate or ventilate.
Anticipated clinical course deterioration.
Complications and Risk Disclosure
Trauma Risks:
Oral, nasal, or pharyngeal injuries.
Fractured teeth.
Tracheal or esophageal damage from excessive stylet or force.
Physiological Risks:
Hypoxia during prolonged attempts.
Aspiration of gastric contents.
Cardiovascular instability.
Contraindications
Near-death scenarios where intubation is non-beneficial.
Difficult airway assessment:
L: Look externally for predictors (facial trauma, small mouth).
E: Evaluate 3-3-2 rule (mouth opening, thyromental distance).
M: Mallampati score.
O: Obstruction or obesity.
N: Neck mobility limitations.
Steps of RSI ("7 Ps")
Preparation:
Ensure suction, oxygen, airway equipment, pharmacology, and monitoring devices are ready.
Check laryngoscope (Macintosh/Miller), endotracheal tubes (ETT 7.0-8.0 mm), syringes, and backups (e.g., video laryngoscope).
Preoxygenation:
100% oxygen for 3 minutes or 8 deep breaths with high-flow O2.
Consider bag-mask ventilation if SpO2 < 90%.
Pretreatment:
Lidocaine: 1.5-2 mg/kg (blunts cough reflex).
Fentanyl: 2-3 mcg/kg (reduces sympathetic response).
Atropine: 0.01 mg/kg in pediatric cases.
Defasciculating agent for succinylcholine use.
Paralysis and Induction:
Sedative: Etomidate (0.3 mg/kg), Ketamine (1-2 mg/kg), or Propofol (2 mg/kg).
Neuromuscular blocker: Succinylcholine (1.5 mg/kg) or Rocuronium (1.2 mg/kg).
Positioning:
Sniffing position for standard cases.
RAMP position for obese patients.
Placement:
Crossed-finger technique for mouth opening.
Insert laryngoscope, visualize glottis, and advance ETT 3-4 cm past vocal cords.
Confirm placement with capnography (EtCO2), bilateral chest auscultation, and chest rise.
Postintubation Management:
Inflate cuff, secure ETT, confirm placement with imaging (CXR).
Initiate ventilation settings and monitor continuously.
Post-Procedure Management
Secure Tube:
Confirm tube depth (e.g., 21-24 cm at the lips).
Secure with tape or commercial holder.
Monitor:
Continuous pulse oximetry and EtCO2.
Regular chest auscultation.
Documentation:
Record medications, doses, time of intubation, and complications.
Checklist Summary
This checklist ensures adherence to protocols and structured documentation of the RSI process. Modify per institutional guidelines and patient-specific conditions for the best outcomes.
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