RAPID SEQUENCE INTUBATION 主講人 : 黃水元 醫師 此範本可作為群組設定中簡報訓練教材的起始檔案。 章節 在投影片上按一下右鍵以新增章節。 章節可協助您組織投影片，或簡化多個作者之間的共同作業。 備忘稿 使用 [備忘稿] 章節記錄交付備忘稿，或提供其他詳細資料給對象。 於簡報期間在 [簡報檢視] 中檢視這些備忘稿。 請記住字型大小 (對於協助工具、可見度、影片拍攝及線上生產非常重要) 協調的色彩 請特別注意圖形、圖表及文字方塊。 考慮出席者將以黑白或 灰階列印。執行測試列印，以確保在進行純黑白及 灰階列印時色彩正確。 圖形、表格和圖表 保持簡單: 如果可能，使用一致而不令人分心的樣式和色彩。 所有圖表和表格都加上標籤。

Basic Airway Care and Oxygenation Basic airway care begins with assessment. -- look, listen and feel -- upper airway ; lower airway Upper airway obstruction is relieved with head tilt and chin lift, or if neck movement is contraindicated, jaw thrust. Oropharyngeal airway or a nasopharyngeal airway Pre-oxygenation provide a reservoir of oxygen to limit desaturation during drug-induced apnea for intubation

Rapid Sequence Intubation Definition: Administration of a potent induction agent (anaesthetics) followed by a rapidly acting neuromuscular blocking agent (usually suxamethonium) to induce unconsciousness and motor paralysis for tracheal intubation. Assumed that the patient has a full stomach, and is at risk of aspiration of gastric contents. Aim : render the patient unconscious and paralysed so that they can be intubated.

Rapid Sequence Intubation Assessments Anticipate a potentially difficult intubation Steps :

Preparation Environment • Monitoring – ECG monitor, BP, SpO2, capnography • IV access – 2 IV lines • Supine position • Drugs – drawn up in labelled syringes Equipment • Laryngoscopes fitted with appropriate blade. • Endo tracheal tube - test cuff inflation and have smaller sizes ready: - Male, size 6.5 to 8 mm - Female, size 6.0 to 7.5 mm • Stylet • Suction

Preoxygenation High concentration O2 to the patient for ideally 5 minutes prior to the procedure If it is not possible to give 5 minutes of preoxygenation then 8 vital capacity breaths should be taken. Desaturate from 90% to zero is very short : healthy adult : 120 seconds, child : 45 seconds. Desaturation is much more rapid if the lungs are abnormal, (eg pulmonary edema) or if oxygen consumption is increased (eg trauma, burns etc)

Paralysis with Induction Induction agents : -- thiopentone, Etomidate, Propofol Muscle relaxants : -- Succinylcholine, Rocuronium -- Contraindication of succinylcholine • ECG or biochemical evidence of hyperkalemia • Patient ≥24 hours post burn • Patient ≥7 days post crush injury or denervation • Family history of malignant hyperthermia

Protection and Positioning Cricoid Pressure : In-line Stabilisation : -- R/O cervical spine injury

Placement and Proof The endotracheal tube should be placed under visualization of larynx. Tube position is confirmed by a combination of: • visualising the passage of the ET tube between the cords • listening to both sides of the chest and over the stomach • end-tidal CO2 measurement which is the most reliable method Cricoid pressure can be discontinued on instruction from the intubator.

Difficult and failed airway Identification of factors of difficult airway may make the intubator decide that RSI should not be attempted and that other methods of securing the airway should be used. Look externally : -- Body habitus, short neck, mouth (small opening, loose teeth, macroglossia), jaw abnormalities (micrognathia, malocclusion),

Difficult and failed airway Obstruction : -- stridor, inability to swallow secretions or alteration in voice quality -- Upper airway obstruction : epiglottitis, abscess, foreign body, thermal injury, tumor, and trauma. Neck mobility : -- Neck mobility can be significantly reduced in patients with trauma (cervical collar) or in the elderly and in those with arthritis.

Post-Intubation Management After tube placement is confirmed, the ET tube can be tied or taped in place. Vital sign should be monitored. Mechanical ventilation can now be initiated. Standard Post Intubation Care: • ECG • SpO2 • NIBP / A-Line • Capnograph • CXR • Maintenance sedation and NMB