**3. Rapid sequence induction**

**Size:** The size can be estimated by measuring from the tip of the nose to the tip of the earlobe. An appropriate size of the NPA in adults is 6 mm internal diameter of an average female and

**Technique:** It is very simple. The airway should be lubricated first and then inserted gently into the nostril that looks wider and advanced it posteriorly with slight rotational movement.

**Complications:** It may cause hemorrhage, nasal trauma, and laryngospasm and vomiting in

**Limitations:** It is contraindicated to use NPA when there is a basal skull fracture or cribriform plate injury. These injuries might lead to intracranial placement of the airway. It is usually rare, and when there is life-threatening hypoxemia and where insertion of an OPA is not

The effectiveness of any airway maneuver or adjunct must always be assessed after it has been

The oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) are basic airway adjuncts. They are used to secure and open the airway, once it has been opened by either a head-tilt, chin-lift, or jaw-thrust maneuver and any objects or secretions have been removed

The guidelines recommend that for most acutely ill patients, oxygen should be given to achieve a target saturation of 94–98% or 88–92% of those at risk of hypercapnic respiratory failure. Give all critically ill patients high flow oxygen 15 L/min until they are stable, and then reduce it to achieve the target saturation. These targets can be achieved by the use of nasal cannula, face mask with reservoir, or noninvasive ventilation (NIV) together with airway maneuver and adjuncts [2].

To improve the airflow, another airway can be inserted into the other side.

7 mm internal diameter for an average male [2, 3].

62 Essentials of Accident and Emergency Medicine

a conscious patient with sensitive oropharynx [6].

**Figure 3.** A-oropharyngeal airway, B- nasopharyngeal airway.

completed.

by suctioning (**Figure 3**).

**2.10. Oxygenation**

possible, careful insertion of NPA may be lifesaving [2].

Rapid sequence induction (RSI) is a guided protocol of steps to reduce complications and boost success. The protocol of RSI entails the administration of anesthetic induction drug, followed by muscle-relaxing drugs (neuromuscular blockade drug) to achieve complete paralysis.

RSI is the preferred method to secure an airway on an emergent basis and where there is a risk of aspiration of gastric contents. In experienced hands, it is a relatively safe procedure with few complications. The choice of pharmacologic agents used will vary by physician experience, physician preference, the clinical condition of the patient, and the pharmacology of the agents [4].

#### **3.1. Indication for intubation**

There are four clinical situations in which intubation may be indicated:


#### **3.2. Contraindications**

RSI has just few contraindications. Firstly, inexperienced intubator should not perform RSI. Secondly, when the physician is not sure of his capability to intubate a patient with difficult airway, then he has to perform awake intubation. There are also other contraindications to RSI such as the contraindications of the muscle relaxants and absence of required equipment.

#### **3.3. Preparation for RSI**

Once the decision for intubation is taken, preparation for RSI should be started. The first attempt is always the best chance, so all efforts to make it successful should be done this by a systematic approach, maximizing the preintubation physiologic parameters of the patient and good teamwork which will all increase the success rate for intubation.

#### **3.4. Assessment for difficult airway**

Before proceeding with preparations for RSI, assessment of patient for difficult airway should be done using the LEMON mnemonic which can be done easily on any critically ill patient; this is done by:

**L**-looking externally for any anatomic or external characteristics that predict difficult intubation, such as facial hair, obesity, short neck, prominent upper incisors, receding mandible, edentulous, facial trauma, and airway deformity.

**E**-evaluate the 3-3-2 rule to evaluate the airway and predict the poor visibility of the posterior pharynx.

Starting with mouth opening should be at least 4 cm which is around three fingerbreadths. If it is less than this, it predicts difficult intubation and difficult visualization on laryngoscopy.

Thyromental distance is from the top of the thyroid cartilage to the mentum with fully extended neck. It should be 3–4 fingerbreadths, and when it is less than 3, this predicts difficult view on laryngoscopy.

The final part of the 3-3-2 rule is two fingers from the floor of the mouth to the laryngeal prominence (Adam's apple).

**M**-Mallampati score is used to assess oral access for laryngoscopy by viewing patients tongue, uvula, faucial pillars, and posterior pharynx (**Figure 4**).

**O-**obesity or obstruction obesity in addition to certain infections or swelling involving the upper airways or tumors like patients with chemical or thermal burns, infections of the larynx and pharynx, epiglottis and glottic polyps, laryngeal mass, angioedema, and neck hematoma all will affect laryngoscopy view.

**N**-neck mobility: any condition that limits neck mobility will impair the view on laryngoscopy, for example, patients with arthritis affecting cervical spine, e.g., ankylosing spondylitis, rheumatoid arthritis, and elderly [2, 7].

Once a difficult airway is predicted, EP should be prepared for it before proceeding with RSI by having other devices ready like video laryngoscopy, bougie tube, stylets, laryngeal mask

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 65

The most experienced EP should do the first trial and call for help early, predicting the

airway (LMA), or a surgical airway kit, e.g., cricothyrotomy set, or awake intubation.

• Nonrebreather face masks (different sizes) and oxygen supply and connectors.

) monitor/device.

• Failed intubation equipment or backup equipment should be prepared in case intubation failed. This can be a laryngeal mask airway (LMA), a cricothyroidotomy tray, and video

There are three major qualities of RSI; these are preoxygenation, application of cricoid pressure, and the avoidance of positive pressure ventilation before securing the airway with endo-

using a bag-valve-mask device. This leads to enhance oxygen reserve and prevent hypoxemia

using a nonrebreather mask or assisted ventilation

• Monitor pulse oximetry, ECG, and noninvasive blood pressure (NIBP).

tracheal tube [4, 9]. Steps for performing RSI from start to finish:

The patient is preoxygenated with 100% O<sup>2</sup>

• Laryngoscope blades and handle of different sizes with extra batteries.

difficulty [4, 5].

*3.4.1. Equipment*

• Nasal cannula for oxygenation.

• Stylet and boogie tube.

• Alternative airway devices. • Yankauer suction catheter.

• Medications drawn and labeled.

• End-tidal carbon dioxide (CO<sup>2</sup>

• Resuscitation medications.

• Syringes, 10 and 20 ml.

• Crash cart.

laryngoscopy.

during induction [2, 4, 8].

*3.4.2. Technique*

• Bag-valve-mask devices, different sizes.

• Endotracheal tubes (ETT), different sizes.

• Oropharyngeal airways, different sizes. • Nasopharyngeal airways, different sizes.

**Figure 4.** Mallampati score.

Once a difficult airway is predicted, EP should be prepared for it before proceeding with RSI by having other devices ready like video laryngoscopy, bougie tube, stylets, laryngeal mask airway (LMA), or a surgical airway kit, e.g., cricothyrotomy set, or awake intubation.

The most experienced EP should do the first trial and call for help early, predicting the difficulty [4, 5].

#### *3.4.1. Equipment*


#### *3.4.2. Technique*

**Figure 4.** Mallampati score.

**L**-looking externally for any anatomic or external characteristics that predict difficult intubation, such as facial hair, obesity, short neck, prominent upper incisors, receding mandible,

**E**-evaluate the 3-3-2 rule to evaluate the airway and predict the poor visibility of the posterior

Starting with mouth opening should be at least 4 cm which is around three fingerbreadths. If it is less than this, it predicts difficult intubation and difficult visualization on laryngoscopy. Thyromental distance is from the top of the thyroid cartilage to the mentum with fully extended neck. It should be 3–4 fingerbreadths, and when it is less than 3, this predicts dif-

The final part of the 3-3-2 rule is two fingers from the floor of the mouth to the laryngeal

**M**-Mallampati score is used to assess oral access for laryngoscopy by viewing patients tongue,

**O-**obesity or obstruction obesity in addition to certain infections or swelling involving the upper airways or tumors like patients with chemical or thermal burns, infections of the larynx and pharynx, epiglottis and glottic polyps, laryngeal mass, angioedema, and neck hematoma

**N**-neck mobility: any condition that limits neck mobility will impair the view on laryngoscopy, for example, patients with arthritis affecting cervical spine, e.g., ankylosing spondylitis,

edentulous, facial trauma, and airway deformity.

uvula, faucial pillars, and posterior pharynx (**Figure 4**).

pharynx.

ficult view on laryngoscopy.

64 Essentials of Accident and Emergency Medicine

prominence (Adam's apple).

all will affect laryngoscopy view.

rheumatoid arthritis, and elderly [2, 7].

There are three major qualities of RSI; these are preoxygenation, application of cricoid pressure, and the avoidance of positive pressure ventilation before securing the airway with endotracheal tube [4, 9]. Steps for performing RSI from start to finish:

The patient is preoxygenated with 100% O<sup>2</sup> using a nonrebreather mask or assisted ventilation using a bag-valve-mask device. This leads to enhance oxygen reserve and prevent hypoxemia during induction [2, 4, 8].

The routine practice is to preoxygenate the patient for 5 minutes. If it is not possible, then preoxygenate for 3 minutes. However, four maximal inspirations are equally effective in the cooperative patient [4, 8]. Administering oxygen using noninvasive positive pressure ventilation has the ability to improve the process of oxygenation much faster than by using the face mask.

**4. Needle decompression**

to cardiac arrest [4, 11] (**Figure 5**).

Indication for emergent needle decompression. Traumatic cardiac arrest with chest involvement

**Figure 5.** Radiograph of a patient with a large spontaneous tension pneumothorax.

**4.1. Basic principle**

management [14].

• Tension pneumothorax

increased percussion note.

Needle decompression is a lifesaving procedure used to decompress the chest when there is tension pneumothorax. Tension pneumothorax is the accumulation of air in the pleural cavity under pressure. Progressive buildup of pressure in the pleural space leads to mediastinum shift to the opposite side, lung collapse, and tracheal deviation to the unaffected side and obstructs venous return to the heart. This results in a hemodynamic instability and can lead

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 67

The main idea is to insert a catheter into the pleural space, thus creating a pathway for the air to escape and release the built-up pressure. It is an emergency procedure when there is tension pneumothorax and should be followed by the chest tube insertion as a definitive

That is evident clinically in patients with tachypnea, hypoxia, tachycardia, hypotension, tracheal deviation to the unaffected side, diminished breath sound, hyperresonance chest, and

All the equipment should be prepared before the intubation and should be checked. The laryngoscope handles and light should be checked if they are working or not. ETT cough should be checked for any air leaks. Connect the patient at the same time to a monitor including pulse oximetry, cardiac monitor, and NIBP. The nurse at the same time should prepare the required medication and label them and get an intravenous access. Record and observe patient physiologic parameters.

The patient should be positioned in the sniffing position if no cervical spine injury is suspected. If cervical spine injury is suspected, manual in-line immobilization should be maintained during the intubation.

Premedicate the patient as indicated by the condition. Lidocaine (1.0–1.5 mg/kg) or fentanyl (2–3 μg/kg) both can be given to blunt the intracranial pressure response, transient hypertension, bronchospasm, and tachycardia associated with intubation. Phenylephrine (50 μg) can be used to lessen the hypotensive effect of intubation. Administer an appropriate induction agent as indicated by the clinical setting and patient's hemodynamic status followed by a non-depolarizing agent, if no contraindication. Flush the intravenous line after each drug to ensure delivery [10].

A cricoid pressure (the Sellick maneuver) should be applied immediately and maintained till oral endotracheal intubation is completed.

Intubate the patient after administration of succinylcholine (or rocuronium) and the patient's muscles are relaxed. Confirm the correct placement of the ETT by visualizing the tube passing through the vocal cords, monitoring continuous end-tidal CO<sup>2</sup> wave on the capnography, and auscultating breath sounds at the midaxillary lines and epigastric area. Release cricoid pressure. After successful intubation, secure the tube and connect to a ventilator and adjust the sitting according to patient condition. Administer additional sedative hypnotics and analgesics as indicated by clinical scenario. Obtain a chest radiograph to confirm proper placement of the endotracheal tube [2, 4, 6, 7, 9, 10].

#### *3.4.3. Complications of RSI*

