- Email: [email protected]
The ED rapid sequence intubation drug organizer
TheEDrapidsequence intubation drugorganizer Authors:
Shanda
Zaharako,
RN, BSN, and Rafael
F. CIUZ, MD, Xenia,
Ohio, and Newport
News, Va
A
- s emergency nurses well know, rapid sequence intubation (RSI) can be a somewhat unorganized, cumbersome procedure that is surrounded by confusion even in the best of emergency departments. The RSI procddure is a technique in which a potent sedative or induction agent is administered virtually simultaneously with a paralyzing dose of a neuromuscular blocking agent to facilitate rapid sequence endotracheal intubation. The technique includes prevention of gastric distention. It provides excellent access to the airway for intubation and permits pharmacologic control of adverse responses to illness, injury, and the intubation itself. The nurse in charge of the patient provides the physician with frequent updates about vital signs, especially oxygen saturation readings, during the procedure. Obtaining the different medications used in RSI is a time-consuming process. The medications are kept in variety of places: the medication room, the refrigerator, and in a locked cabinet. If you have a Pyxis machine, many drawers need to be accessed to obtain the necessary medications and supplies. Some departments may have what they consider to be RSI kits, which usually consist of a bag with scattered supplies (needles, syringes, saline solution and some, but not all, medications). This lack of organization inspired an emergency physician (RFC) and I to consider other alternatives. Because two of the medications used in RSI need to be refrigerated, we thought, why not refrigerate all of them? Our research revealed that all of the other medications would remain stable and effective when refrigerated. Next, we decided to develop a compact organizer that would hold all the necessary medications and supplies in a way that would allow everything to be clearly visible, secure, and easily accessible. With the help of a small company, the RSI Organizer was born (Figure 1). The RSI Organizer (a product of MDSCo-RSIO, Toledo, Ohio) completely zips open on 3 sides and can be placed near (or on) the patient (Figure 2). The medications required for Shanda Zaharako is Director of Emergency Services, Greene Memorial Hospital, Emergency Center, Xenia, Ohio. Rafael F. Cruz is Emergency Physician, Riverside Regional Medical Center, Newport News, Va. For reprints, write: Shanda Zaharako, RN, BSN, 529 Leslie Dr, Xenia, OH 45385. J Emerg Nurs 2000;26:42-4. Copyright 0 2000 by the Emergency Nurses Association. 0099-1767/2000$12.00+0 18/g/104827
42 Volume 26. Number 1
Figure 1 conveThe RSI Organizer, kept in the ED refrigerator, niently arranges all the medications needed for the procedure. After use, the Organizer is exchanged in the pharmacy. RSI are arranged in elastic banded compartments, allowing them to be clearly visible and organized. The zipper is then locked with a small numbered plastic lock. We developed an RSI quick reference card that would facilitate use of this procedure (Figure 3). Finally, we developed an RSI education program for the staff. The RSI Organizer is kept in the refrigerator, and costs of using it are charged to the patient after each use. A charge sheet/inventory list is placed in each Organizer by pharmacy personnel (Figure 4). An additional Organizer is kept in the pharmacy for rapid exchange. The Organizer is made of completely washable material and has a clear vinyl pocket on the outside for clear identification. As mentioned previously, it includes a quick-look reference card that summarizes the RSI procedure and medication administration (Figure 3). A removable pouch that contains surgical airway supplies is included on the inside of the Organizer in case they are needed. This pouch includes needles, syringes, a No. 10 gauge angiocatheter, a No. 15 scalpel with handle, a Shiley tracheostomy tube, and a tracheal hook. The emergency physicians, critical care specialists, and emergency medicine residents have been extremely pleased with the Organizer and no longer have to wait while the proper medications and equipment are assembled. In fact, the residents have be-
The RSI Organizer is kept in the refrigerator, and costs of using it are charged to the patient after each use. A charge sheet/inventory list is placed in each Organizer by pharmacy personnel. An additional Organizer is kept in the pharmacy for rapid exchange.
Figure 2 Another
l
view of the RSI Organizer.
RSI 4 P’s SUCTION, C-Spine, SELLICK-prevent
1. Prepare:
2. Pretreat/Preoxygenate: 1) Lido 2) Norcuron 3) Atropine 3. Paralyze/Sedation l * 1) Etomidate OR 2) Versed 3) Ketamine 4) Fentanyl l * 1) Succinyl 2) Norcuron 4. Placement:
IV, Monitor,
ET, Blade,* Stylet, ETCO,, 1 If age <8 yo, no ET cuff Peds ET Tube depth = (3x ET size)
(l-l.5 mg/kg) 100 mg if CHI/CVA (O.Ol/kg) or 1 (0.01-0.02 mg/kg) minimum 0.5 mg if age <5 yo (First) (0.3 mg/kg) 20 onset 20-40 set (less JBP, JP) (0.1-0.2 mg/kg) 5-7 mg onset 1 min (1.5 mg/kg) 100 mq onset 1 min (asthmatics) (1.5-2 pg/kg) (1.5 mg/kg) 100 mq onset 1 min (1 mg/kg) 7-10 mq onset 2-3 min (remember to sedate
Pass ET, confirm
IMPORTANT-READ
O,, BVM, distention
these
(listen,
ETCO,
paralyzed
patients)
and CXR)
statements
This document is distributed without warranties of any kind. The producers of any liability, loss or damage caused by contents. It should be clearly understood should serve as guidelines. Only those with clinical expertise should be using tions. If you do not accept the above statements, you should discontinue use of
this that this this
product disclaim this information product/medicareference card.
RSI quick reference card This card can be laminated and attached to the “D” ring on the outside of the organizer. Bl? Blood pressure; BVM, bag valve mask; CWCVA. closed head injury/cerebrovascular accident; CO, carbon dioxide; C-spine, cervical spine, CXR, chest x-ray; ET endotracheal tube; ETCO, end tidal carbon detector; IV, intravenous; 0,. oxygen; P, pulse. *Blade = laryngoscope
February
2000
43
IOURNM OF EMERGENCY NURSING/Zaharako and Cniz
I
I
I
I
Witness: Figure 4 RSI Organizer pharmacy charge sheet/drug list. After each use, the nurse completes this form, which Organizer, and returns it with the organizer to the pharmacy for exchange. A photograph of medication is kept in the Organizer to facilitate the replacement of medication in a consistent arrangement.
come so accustomed to the Organizer in the emergency department that it is now also used in our ICU. The standard intubation equipment (bag valve mask, laryngoscope, endotracheal tubes, suction, suction, and more suction) is located in its usual place in the department and is not included in the RSI Organizer. Our nursing staff, who have had educational training and experience with the RSI Organizer, believe that it has made RSI a smooth procedure. Medications included in the organizer are listed in Figure 4. Efficiency is essential in any type of critical care situation, but especially in this one. If you have any
44
Volume 26, Number
1
is kept in the arrangement
questions about the RSI Organizer, contact Shanda Zaharako via E-mail at szaharakoQaol.com. To obtain an RSI Organizer for your institution, send an E-mail message to RSlkitQaol.com.
Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, RN, EdD, c/o Managing Editor: ENA, 935 Lee St, Des Plaines, IL GO01G;phone (84 7) 4604044; E-mail: [email protected].
Shanda
Zaharako,
RN, BSN, and Rafael
F. CIUZ, MD, Xenia,
Ohio, and Newport
News, Va
A
- s emergency nurses well know, rapid sequence intubation (RSI) can be a somewhat unorganized, cumbersome procedure that is surrounded by confusion even in the best of emergency departments. The RSI procddure is a technique in which a potent sedative or induction agent is administered virtually simultaneously with a paralyzing dose of a neuromuscular blocking agent to facilitate rapid sequence endotracheal intubation. The technique includes prevention of gastric distention. It provides excellent access to the airway for intubation and permits pharmacologic control of adverse responses to illness, injury, and the intubation itself. The nurse in charge of the patient provides the physician with frequent updates about vital signs, especially oxygen saturation readings, during the procedure. Obtaining the different medications used in RSI is a time-consuming process. The medications are kept in variety of places: the medication room, the refrigerator, and in a locked cabinet. If you have a Pyxis machine, many drawers need to be accessed to obtain the necessary medications and supplies. Some departments may have what they consider to be RSI kits, which usually consist of a bag with scattered supplies (needles, syringes, saline solution and some, but not all, medications). This lack of organization inspired an emergency physician (RFC) and I to consider other alternatives. Because two of the medications used in RSI need to be refrigerated, we thought, why not refrigerate all of them? Our research revealed that all of the other medications would remain stable and effective when refrigerated. Next, we decided to develop a compact organizer that would hold all the necessary medications and supplies in a way that would allow everything to be clearly visible, secure, and easily accessible. With the help of a small company, the RSI Organizer was born (Figure 1). The RSI Organizer (a product of MDSCo-RSIO, Toledo, Ohio) completely zips open on 3 sides and can be placed near (or on) the patient (Figure 2). The medications required for Shanda Zaharako is Director of Emergency Services, Greene Memorial Hospital, Emergency Center, Xenia, Ohio. Rafael F. Cruz is Emergency Physician, Riverside Regional Medical Center, Newport News, Va. For reprints, write: Shanda Zaharako, RN, BSN, 529 Leslie Dr, Xenia, OH 45385. J Emerg Nurs 2000;26:42-4. Copyright 0 2000 by the Emergency Nurses Association. 0099-1767/2000$12.00+0 18/g/104827
42 Volume 26. Number 1
Figure 1 conveThe RSI Organizer, kept in the ED refrigerator, niently arranges all the medications needed for the procedure. After use, the Organizer is exchanged in the pharmacy. RSI are arranged in elastic banded compartments, allowing them to be clearly visible and organized. The zipper is then locked with a small numbered plastic lock. We developed an RSI quick reference card that would facilitate use of this procedure (Figure 3). Finally, we developed an RSI education program for the staff. The RSI Organizer is kept in the refrigerator, and costs of using it are charged to the patient after each use. A charge sheet/inventory list is placed in each Organizer by pharmacy personnel (Figure 4). An additional Organizer is kept in the pharmacy for rapid exchange. The Organizer is made of completely washable material and has a clear vinyl pocket on the outside for clear identification. As mentioned previously, it includes a quick-look reference card that summarizes the RSI procedure and medication administration (Figure 3). A removable pouch that contains surgical airway supplies is included on the inside of the Organizer in case they are needed. This pouch includes needles, syringes, a No. 10 gauge angiocatheter, a No. 15 scalpel with handle, a Shiley tracheostomy tube, and a tracheal hook. The emergency physicians, critical care specialists, and emergency medicine residents have been extremely pleased with the Organizer and no longer have to wait while the proper medications and equipment are assembled. In fact, the residents have be-
The RSI Organizer is kept in the refrigerator, and costs of using it are charged to the patient after each use. A charge sheet/inventory list is placed in each Organizer by pharmacy personnel. An additional Organizer is kept in the pharmacy for rapid exchange.
Figure 2 Another
l
view of the RSI Organizer.
RSI 4 P’s SUCTION, C-Spine, SELLICK-prevent
1. Prepare:
2. Pretreat/Preoxygenate: 1) Lido 2) Norcuron 3) Atropine 3. Paralyze/Sedation l * 1) Etomidate OR 2) Versed 3) Ketamine 4) Fentanyl l * 1) Succinyl 2) Norcuron 4. Placement:
IV, Monitor,
ET, Blade,* Stylet, ETCO,, 1 If age <8 yo, no ET cuff Peds ET Tube depth = (3x ET size)
(l-l.5 mg/kg) 100 mg if CHI/CVA (O.Ol/kg) or 1 (0.01-0.02 mg/kg) minimum 0.5 mg if age <5 yo (First) (0.3 mg/kg) 20 onset 20-40 set (less JBP, JP) (0.1-0.2 mg/kg) 5-7 mg onset 1 min (1.5 mg/kg) 100 mq onset 1 min (asthmatics) (1.5-2 pg/kg) (1.5 mg/kg) 100 mq onset 1 min (1 mg/kg) 7-10 mq onset 2-3 min (remember to sedate
Pass ET, confirm
IMPORTANT-READ
O,, BVM, distention
these
(listen,
ETCO,
paralyzed
patients)
and CXR)
statements
This document is distributed without warranties of any kind. The producers of any liability, loss or damage caused by contents. It should be clearly understood should serve as guidelines. Only those with clinical expertise should be using tions. If you do not accept the above statements, you should discontinue use of
this that this this
product disclaim this information product/medicareference card.
RSI quick reference card This card can be laminated and attached to the “D” ring on the outside of the organizer. Bl? Blood pressure; BVM, bag valve mask; CWCVA. closed head injury/cerebrovascular accident; CO, carbon dioxide; C-spine, cervical spine, CXR, chest x-ray; ET endotracheal tube; ETCO, end tidal carbon detector; IV, intravenous; 0,. oxygen; P, pulse. *Blade = laryngoscope
February
2000
43
IOURNM OF EMERGENCY NURSING/Zaharako and Cniz
I
I
I
I
Witness: Figure 4 RSI Organizer pharmacy charge sheet/drug list. After each use, the nurse completes this form, which Organizer, and returns it with the organizer to the pharmacy for exchange. A photograph of medication is kept in the Organizer to facilitate the replacement of medication in a consistent arrangement.
come so accustomed to the Organizer in the emergency department that it is now also used in our ICU. The standard intubation equipment (bag valve mask, laryngoscope, endotracheal tubes, suction, suction, and more suction) is located in its usual place in the department and is not included in the RSI Organizer. Our nursing staff, who have had educational training and experience with the RSI Organizer, believe that it has made RSI a smooth procedure. Medications included in the organizer are listed in Figure 4. Efficiency is essential in any type of critical care situation, but especially in this one. If you have any
44
Volume 26, Number
1
is kept in the arrangement
questions about the RSI Organizer, contact Shanda Zaharako via E-mail at szaharakoQaol.com. To obtain an RSI Organizer for your institution, send an E-mail message to RSlkitQaol.com.
Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, RN, EdD, c/o Managing Editor: ENA, 935 Lee St, Des Plaines, IL GO01G;phone (84 7) 4604044; E-mail: [email protected].