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Pre-Hospital RSI Part II

Part II of a video run-through of pre-hospital care of patient requiring RSI
I’m just going to keep going just right up to the [INAUDIBLE],, if we can. That’s brilliant. And we can put brakes on there. So at this point, we have assessed the patient, we’ve packaged them, and we’ve moved them over to the [INAUDIBLE] area in preparation to RSI them. We’ve got a nice box waveform on there opposite– we’re still sitting nicely. And just a sense check, Kat. So 80 kg, 3, 2, 2. Yep, 80. Yep, that all looks good. [INAUDIBLE], lovely. I’m just thinking, we’ll get the fluids and the drips down there. Yep. Can we get the flush out over to you?
What we need to do now is brief our ambulance colleagues and explain that we’re going to conduct an RSI and that we would need to run through a checklist. Laurie, are you happy to run through the checklist. Yes. So we’re just going to run through a checklist. Obviously, any emergencies, let us know. But otherwise, can we just have quiet while we’re going through this, please. CDM connected to flowing oxygen. Check. Mask on with two hands. Check. Catheter mount. Check. HME. Check. End tidal CO2, good box waveform. Check. Cannula functioning times two. Check. Long line attached with 10 ml flush. Check. IV fluid connected. Check. BP cycling. Check. Sats probe on. Check. ECG on. Check. Drug giver will be Lara.
Drug giver is myself. Check. Fentanyl, 240 mics, 4.8 mls. Fentanyl 240 mics, 4.8 mls. Ketamine, 160 milligrammes, 16 mls. Ketamine, 160 milligrammes, 16 mls. Rock uranium, 160 milligrammes, 16 mls. Rock, 160 milligrammes, 16 mls. Check. Primary blade will be DL Mac 4 Check. Back up blade will be McGrath. It’s available. Close suction. Check. Primary suction. Check. Back up suction. Available. Bougie size 15. Check. Chief size eight ready. Check. Syringe for cuff. Check. Alternative tube size seven ready. It’s available. Tube tie. Check. IDL 4. Check. Surgical airway. Not anticipated but available. Check. Goodell and MPAs. In situ and available. Temperature probe. Check. Thoracostomy not indicated. Agreed. Baseline obs.
OK, so we have a heart rate of 69, a blood pressure of 130 over 80, sats are 98. And we’ve got a good box waveform of an entire left 4.3. Thank you. I’m happy to proceed. Happy for the drugs. OK, so fentanyl at 4.8 mls.
So that’s 0.2 back.
Ketamine, 16 mls. That’s four back. Cricoid on, please out. And rocks, I’ve got the 4-10.
It’s flushing nicely there, Kat.
And another six, so four back to me. I’m just going to give that a nice flush.
OK. I’m just going to have [INAUDIBLE].. What time is it? Start the timer. It’s really important that there’s a shared understanding of what’s going on during the RSI. The operator should verbalise their findings at laryngoscopy. And there should be clear communication around the handling of the bougie and the tube. So cuff is through the cords. OK, so the bougie’s coming out now. The cuff is going up. No herniation. OK. So the suctionless catheter is coming on.
The [INAUDIBLE] is coming. OK, so dispense [INAUDIBLE] there. So I’ve got a good box waveform. End tidal’s 5.1. Sats are 99%. Really easy to ventilate. Got tube misting, got chest rising and falling. I’m happy. Chricoid off. Everything else is really steady, as well, Kat, on the screen there. OK. In the pre-hospital setting, we use a bougie every time. We maintain the view at laryngoscopy during inflation of the cuff and until there is confirmation of a good end tidal CO2 box waveform. So the [INAUDIBLE] to me. Going to tie the tube. [INAUDIBLE] to you there. Thank you. OK, can you hold the angle, please? Yeah, course. So I’ve got the angle. We’re At 22 at the lips.
I’ve got the [INAUDIBLE] and I’ve got the bag. So if you’re happy, I’ll pack up the kit and we can start moving towards the aircraft. Yeah. I’ll do the temperature probe when we get there. And we can do the vent when we get there, as well. Controlled ventilation needs to be established and packaging needs to be finalised before loading the patient onto an ambulance or aircraft. So we did want to move. So we’ll definitely be flying [INAUDIBLE] into the aircraft in that.
OK, we’ve got that, Kat? We’re good. [HELICOPTER BLADES ROTORING]
In this step, we will continue our RSI scenario video. In this part, we will see the RSI checklist in action, a standardised approach to intubation and post-intubation care.

Post-Video Exercise:

Watch the video first and then consider the following scenario challenges.

Scenario Challenges:

How would you manage the RSI differently if:

  • The patient had a BMI of 40?
  • The patient had facial injuries and anticipated difficult intubation?
  • The patient was a 1 year old child

Final challenge – for discussion!

Let’s bring everything together:

  • What if the patient was an obese, paediatric, peri-arrest, poly trauma patient, trapped in the vehicle with leaking fuel and the scene is at night, in the rain, on a live road, with multiple other casualties and drunk relatives threatening the clinical team?

This is not unrealistic and some of you may have faced similar scenarios in the past.

A structured, well-rehearsed, team-based approach is absolutely essential, bolstered by excellent CRM and driven by common goals.

Please discuss your own approach to this final scenario in the discussion board.

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