Rapid Sequence Induction

[antidote]

Working in the ICU, I've seen this done many times... only on my floor however. Normally a nurse or whoever will call the code, prepare for intubation, explain to the patient if he/she is still aware what is going to happen and wait on the resp. tech or MD to come down and get it done.

However, I'm not sure if it works like this on other floors. I've heard of nurses (in some rural hospitals) administering the eto and paralytic's and then starting the pre-oxygenation before the intubation can be done. But then, I've heard nurses can't do anything (not even administer the meds) without a doctors order.

Can someone tell me more about how this is done in your hospital?

[EDValerieRN, ASN, RN]

I figure a nurse could get into a whole lot of problems administering meds w/o an order... plus, why would you want to paralyze someone when you don't have anyone there to manage an advanced airway? Paralyzing someone before an airway can be managed seems like trouble to me.. order or no order.

[kmoonshine, RN]

Administering meds would further compromise the person's abiliity to maintain their airway. I dont think it is wise to administer RSI meds w/o an order. Plus, meds can get really complicated (no sux for renal failure patients, etc).

RSI meds are not in the ACLS medication protocol. I could see a nurse pushing ACLS meds, but not RSI meds w/o an order.

[ERRNTraveler, RN]

RSI meds shouldn't be given until the doctor is there and ready to intubate. What if it takes the doc longer than you thought to get there??? Then you would have a paralyzed non-intubated patient! Yikes!!!

[getoverit, BSN, RN, EMT-P]

If there's a RT (or RN if allowed) present who can intubate then the airway compromise isn't that much of an issue, but absolutely don't give the paralytics until you're ready to tube. As far as doing it without an order, I don't think it'd go over well in the ICU at all. But in pre-hospital/flight medicine it's a different story. I've probably RSI'd 100+ cases, vast majority were trauma and it was done on standing orders from the medical director. Just tell them what you did after it's over.

but in my hospital the RT or MD will pass the tube and call for the medications. As an RN I can voice my opinion about how much etomidate, sux, vec, etc. and depending on the doctor, I could pass the tube if their attempts weren't successful.

The important thing is to know when to do it. I've never wished that I had intubated someone, but there've been a few times where I wished I hadn't.

[skipaway]

RSI meds shouldn't be given until the doctor is there and ready to intubate.

Or a CRNA

[Rio, ASN, RN]

Antidote,

Granted there are exceptions, but if you’re explaining the procedure to the patient then you have time for the credentialed provider to get there. There is nothing rapid in the RSI process. It should be methodical: plan (assess the airway, gather all equipment), position, preoxygenate, premedicate, paralyze, intubate and verify placement and post procedure sedation. Learn good cricoid pressure, BURP, effective ventilations without filling the belly with air. Have the bougie and your back up airway device out. Learn the medications: dosing, sequence, indications, contraindications, management considerations vs. absolute contraindications. Make absolutely sure you have patent IV access.

Hope this helps… and keep a cool head… most important. Good luck.

[Rio, ASN, RN]

but in my hospital the RT or MD will pass the tube and call for the medications. As an RN I can voice my opinion about how much etomidate, sux, vec, etc. and depending on the doctor, I could pass the tube if their attempts weren't successful.

RNREMT-P,

My advice, and I don't mean to offend you, is not to intubate in a facility that you are NOT credentialed to do so. You are putting yourself in a situation where if something goes wrong, whether or not you are directly responsible, if you attempted laryngoscopy then you won't have any defense, if or when it should go to court. In fact, all it would take would be for someone observing to say something to someone or have you get reported to the state BON and likely you will be out of a career. This is different where you are functioning as a FN/FP and under the license of your flight program's medical director.

Take care of yourself,

[BrnEyedGirl, BSN, MSN, RN, APRN]

rnremt-p "the important thing is to know when to do it. i've never wished that i had intubated someone, but there've been a few times where i wished i hadn't. "

i'm assuming you meant "i've never wished that i hadn't intubated ,.but a few times i wished i had" i can always take that tube out,.sometimes though getting it in isn't possible.

[getoverit, BSN, RN, EMT-P]

rnremt-p "the important thing is to know when to do it. i've never wished that i had intubated someone, but there've been a few times where i wished i hadn't. "

i'm assuming you meant "i've never wished that i hadn't intubated ,.but a few times i wished i had" i can always take that tube out,.sometimes though getting it in isn't possible.

no, you read it right the first time. i've been fortunate with intubations. there has never been a patient that i did not intubate and later regretted not doing it, but there have been patients that i intubated (successfully) but ended up wishing that i hadn't as they just wasted away slowly, never getting off a ventilator. or even worse, during a sedation vacation indicated that they were angry at being put on the vent and wrote "i want to die" over and over again. clinically they were about to code when i induced and intubated them. no dni order, etc...what else can you do?

and rio, no offense taken, that's good advice. thanks.

[twinmommy+2, ADN, BSN, MSN]

In the Er where I work we give the drugs, but only when everyone is present and ready, and only when the dr gives the order for what and how much. No way would any of us give that stuff without an order.