Rapid Sequence Intubation

Putting It All Together

New Hampshire
Division of Fire Standards & Training and
Emergency Medical Services
“One pound of knowledge takes ten
pounds of common sense to apply it.”
“To Intubate or not to Intubate?”
6 questions to ask:
 Can the patient maintain an airway?
 Can the patient protect this airway?
 Is the patient appropriately ventilating?
 Is the patient appropriately oxygenating?
 Is the patient’s condition likely to
deteriorate?
 Is the scene appropriate: safety, moving
the patient while apneic
Purpose of this Presentation:
 FAMILIARIZE
 Medications used for RSI
 RSI Procedure
 RECOGNIZE
 RSI: “When” and “When not” to perform
 ANTICIPATE
 Back-up plan
 “Murphy’s Law”
What is “RSI” ?
 “RSI is the near-simultaneous administration of
neuromuscular blocking agents and sedative-
hypnotic drugs in order to facilitate oral intubation of
a patient with the least likelihood of trauma,
aspiration, hypoxia and other physiologic
complications.”
Why use RSI?
 Maximize probability of a successful intubation
 RSI:
 84.2-100% success rate
(US Air Medical Programs, Sand Diego CA (Ochs, Ann. Emerg. Med, 2002) and Washington state trial (Wayen &
Friedland, Prehospital Emerg. Care, 1999)

 Blind NTI:
 72.2% success rate (medical)
 66.7% success rate (trauma)
 Minimize adverse physiologic effects
Indication
 “Immediate severe airway compromise in
the context of trauma, drug overdose,
status epilepticus, etc. where respiratory
arrest is imminent.”
Examples of RSI Indications
 Conditions requiring oxygenation/ventilation
control or positive pressure ventilation:
 Traumatic brain injury with ALOC
 Severe thoracic trauma (flail chest, pulmonary
contusions with hypoxemia)
 Clinical condition expected to deteriorate
 Unconscious or ALOC with potential for or actual
airway compromise or vomiting
 And patient has……
 A clenched jaw
 An active gag reflex
Contraindication
 “Extensive burns or crush injuries greater than
24 hours old.”
Other situations where RSI may not be the
best choice:
 Spontaneous breathing with adequate
ventilation and oxygenation
 i.e. Ability to maintain an effective airway by less
invasive means
 Operator concern that both intubation and BVM
ventilation may not be successful due to:
 Major laryngeal trauma
 Upper airway obstruction
 Distorted facial or airway anatomy
 Operator unfamiliarity with the medications used
 The patient is a candidate for CPAP
Complications
 Increased intracranial pressure
 Increased intraocular pressure
 Increased intragastric pressure
 Aspiration due to decreased gag reflex
 Malignant hyperthermia
 Dysrythmias
 Hypoxemia
 Airway trauma
 Failure to intubate / failure to ventilate
 DEATH
3 Major Assumptions of RSI
1. The patient has a full stomach
2. The operator can secure an airway
Failure = DEATH for the patient
DO NOT take away what you cannot give back!
3. The operator can resuscitate the
patient
Equipment & Knowledge readily available
Preparation is the KEY
for an organized,
smooth intubation

Remember the 7 P’s!!

 IF
Endotracheal Intubation fails, you
must have a back-up plan...
RSI Procedure: The Seven P’s
1. Preparation
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
1. Preparation
 A two-part process:
 Assess the risks

 Prepare the equipment

Assess the Risks
Difficult Airways - Assess the
Risks
“The difficult airway is something one anticipates;
the failed airway is something one experiences.”

-Walls 2002
How do you know if your
patient is going to be difficult to
intubate…
…and does it really matter?
 Identifying a
potentially difficult
airway is essential to
preparing and
developing a strategy
for successful ETI and
also preparing an
alternate plan in the
event of a failed ETI.
Some Predictors of a Difficult
Airway
 C-spine immobilized  Dentures
trauma patient  Limited jaw opening
 Protruding tongue  Limited cervical mobility
 Short, thick neck  Upper airway conditions
 Prominent upper  Face, neck, or oral trauma
incisors (“buckteeth”)  Laryngeal trauma
 Receding mandible  Airway edema or
 High, arched palate obstruction
 Beard or facial hair  Morbidly obese
Additional Predictors:
Medical History
 Joint disease  Previous problems
 Acromegaly in surgery
 Thyroid or major neck  Diabetes
surgeries  Pregnancy
 Tumors, known  Obesity
abnormal structures
 Pain issues
 Genetic anomalies
 Epiglottitis
Objectives
 Identify 4 areas of airway difficulty
 Difficult to ventilate with a BVM
 Difficult laryngoscopy
 Difficult to intubate
 Difficult to perform cricothyrotomy
 Predict a difficult airway using the following
mnemonics:
 MOANS
 LEMONS
 DOA
Difficult to Bag (MOANS)
 Mask Seal
 Obesity or Obstruction
 Age > 55
 No Teeth
 Stiff
Difficult Laryngoscopy & Intubation
 LEMONS
 Look Externally
 Evaluate 3-3-2
 Mallampati Score
 Obstruction
 Neck Mobility
 Scene and Situation
Difficult Cricothyrotomy
 DOA
 Disruption or Distortion
 Obstruction
 Access Problems

 If you can’t bag and can’t cric, they’re

DOA
Disruption / Distortion
 Distortion
 Surgeries
 Radiation Therapy
 Scarring
 Burns
Disruption / Distortion
 Disruption
 Hanging
 Crush Injuries
 Penetrating Trauma
 Other Soft Tissue Trauma
 Burns
 Laceration
Obstructions
 Hematoma
 Abscess
 Tumor
 Tumors can also create distortions & extra
bleeding
Access Issues
 Obesity
 Halo
 Short neck
 SC Emphysema
 Bushy beard
 Flexion deformity of the spine
So, give me some good news:
The 3-3-2 Rule
 Bottom of Jaw/Chin to Neck >
3 fingers
 Jaw/Palate > 3 fingers wide
 Mouth opens > 2 fingers wide

Any single indicator has poor specificity

Mallampati Classification

Increased success/ease Decreased success/ease

Cormack & Lehane Grading

Grade I = 
success & ease
10-30%
of intubation

<5% <1%

% listed = incidence
Always have a back-up plan.
 Plans “A”, “B”, and “C”
 Know the answers before you begin
Plan “A”: (ALTERNATIVES)
 Different:
 Size of blade
 Type of blade
 Miller
 Macintosh
 Specialty
 Position (patient & provider)
 Hockey stick bend in ETT or Directional tip ETT
 Gum Elastic Bougie or Flex-guide Endotracheal Tube
Introducer
 Remove the stylette as you pass through the cords
 “BURP”
 2-person technique
 “cowboy” or “skyhook”
 Have someone else try

The assistant should be able to identify and prepare the

devices for the advanced provider, if asked.
“BURP”
 Backward, Upward,
Rightward Pressure:
manipulation of the
trachea
 90% of the time the
best view will be
obtained by pressing
over the thyroid
cartilage

Differs from the Sellick Maneuver

Plan “B”: (BVM and BACKUP AIRWAY
Techniques )

 Can you ventilate with a BVM?

 (Consider two NPA’s and an OPA, + Cricoid pressure w/
gentle ventilation)
 Gum Elastic Bougie
 Combitube
 KING – LT-D
 LMA?
What do we do when faced with a “Can’t
Intubate Can’t Ventilate” situation?

 Plan “C”: (CRIC) Needle, Surgical

 Last resort…

The assistant should be able to identify and prepare the cricothyrotomy

devices for the advanced provider, if asked.
Always expect the unexpected!
RSI Procedure: The Seven P’s
1. Preparation - CONTINUED
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
1. Preparation
 A two-part process:
 Assess the risks

 Prepare the equipment

Prepare the Equipment
Prepare the Equipment
 Adequate Ambu-mask/oxygen sources/suction
 2 laryngoscope handles
 Assortment of blades
 Assortment of ET tubes, stylette, syringe
 Two assistants familiar with the procedure
 1-2 secure IV lines
 All pharmaceutical agents needed for the
procedure
 Back-up plan and rescue airway devices
 Oximetry and capnography monitoring
 Bulb-style tube checker
Monitor the Patient
 Cardiac monitor
 Monitor for dysrythmias
 bradycardia, tachycardia, ectopy
 Blood Pressure monitoring (manual or NIBP)
 Monitor for hypo- or hypertension
 Pulse oximetry
 Monitor for hypoxia
 Capnography
 Monitor for hypo- or hypercarbia
RSI Procedure: The Seven P’s
1. Preparation - CONTINUED
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
2. Preoxygenation
 Pre-oxygenate with 100% O2 via non-
rebreather mask for at least 3-5 minutes
 Replaces the patient’s functional residual capacity (FRC)
of the lung with oxygen
 “Nitrogen Washout”
 If done properly, this will permit as much as 3-4
minutes of apnea before hypoxia develops

In emergent cases, three mask breaths with 100% oxygen may have
to suffice.

Assistant: Will most likely be responsible for the preoxygenation of your

patient.
2. Preoxygenation
 Resist the use of positive pressure
ventilation (PPV). Use only if the patient is
not ventilating adequately.
 PPV leads to gastric distention  regurgitation 
aspiration
 If PPV is necessary, utilize cricoid pressure
 Place NG/OG if prolonged use of BVM
Rapid Sequence
Intubation
Medications
Note about Medications
 Medications are ONLY to be drawn,
prepared, and administered by
paramedics.

 The Basic or Intermediate Assistance

cannot prepare RSI Medications, as they
are not protocoled for their use.
RSI Procedure: The Seven P’s
1. Preparation - CONTINUED
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
3. Premedication
 These medications are given 2 minutes prior to
intubation to reduce/blunt the patient’s physiologic
responses to the subsequent intubation
 Possible physiologic responses include:
 Bradycardia
 Tachycardia
 Hypertension
 Hypoxia
 Increased intracranial and intraocular pressures
 Cough and gag reflexes
Lidocaine
 Dose: 1.5 mg/kg IVP
 When: At least 2 minutes
prior to intubation
 Why: May prevent a rise in
ICP in TBI patients

Assistant: Will not see any major

change in patient.
Lidocaine

 Lidocaine for head injuries, non-traumatic

head bleeds and asthma patients (Tight
head, tight chest)
 Takes 3 minutes to work, so may not be
worthwhile if time is critical……..
 Use your judgment
Atropine
 Dose: 0.5 mg IVP
 When: Prior to intubation
for bradycardic adults
 Why: Given to prevent
worsening bradycardia
 From Succs, vagal
stimulation during direct
visualization, and hypoxia

Assistant: Will not see any major

change in patient.
RSI Procedure: The Seven P’s
1. Preparation - CONTINUED
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
4. Paralyze

 A three step process:

 Induction

 Cricoid Pressure

 Paralytic
Induction with Etomidate
 Hypnotic induction agent
 No analgesic properties
 Dose: 0.3 mg/kg IV
 Onset: 30-60 seconds
 Duration: 3-5 minutes
 Should always be given prior to paralytic

Assistant: Will see the patient become less responsive; more

relaxed.
Cricoid Pressure
 Also known as “Sellick’s Maneuver”
 Should be automatic
 Begin just as Etomidate is administered
 Maintained until ETT placement is confirmed and tube is
secure (cuff inflated)
 Used to occlude the esophagus and prevent passive
regurgitation common with Succs
 If patient starts to actively vomit – RELEASE!
and suction oropharnyx.
 Otherwise, can lead to esophageal rupture

Assistant: This an important role for you!

Cricoid Pressure

Use thumb and forefinger

to apply pressure directly
backward/posterior over
the cricoid cartilage.
Cricoid Pressure
 The patient MAY become apneic shortly
after receiving Etomidate, and will be
completely paralyzed 30-60 seconds
after Succinylcholine

 An assistant MUST perform cricoid

pressure at the first sign of sedation
and continue until the airway is secure
Anectine (Succinylcholine)
SCh or “Succs”
 The only depolarizing paralytic in clinical
use
 Benefits:
 Rapid onset
 Short duration

Will cause “fasciculations”

Fasciculations
 Muscular twitching involving the
simultaneous contraction of contiguous
groups of muscle fibers

Merriam-Webster
Dictionary
 Succinylcholine
 Dose: 1.5mg/kg IV
 When: Immediately after
Etomidate
 Onset: rapid, usually 30-90
secs
 Duration: short acting, 3-5
mins

Assistant: You will likely see the patient go through a brief period of
fasciculations followed by complete flaccidity,as the patient become paralyzed.
Contraindications
 Severe burns
 > 24 hours old
 Massive crush injuries
 >8 hours old
 Spinal cord injury
 >3 days old
 Penetrating eye injuries
 Narrow angle glaucoma
 Hx of malignant
hyperthermia
 patient or family
 Pseudocholinesterase
deficiency
 Neuromuscular disease
 patient or family
 Hyperkalemia
 May precipitate fatal
hyperkalemia!
Complications
 Cardiovascular Effects
 Minimal in adults
 Muscle Pain
 From the fasciculations
 Hyperkalemia
 Not a significant issue in the acute period
 Should be considered in patients with known
hyperkalemia, acute renal failure
Complications
 Increased intraocular pressure
 May be a concern for those with penetrating
globe injuries – theoretically can lead to
expulsion of intraocular contents
 No documented cases found
 Defasciculating dose of a non-depolarizing
neuromuscular blocker and lidocaine
pretreatment may abolish this complication
Complications
 Increased intracranial pressure
 Controversial
 May be a concern for those with suspected
traumatic brain injury
 Lidocaine administration is thought to blunt the
ICP spike
Complications
 Increased intragastric pressure
 Passive regurgitation from fasciculations
 Importance of Cricoid Pressure / Sellick’s
maneuver
Complications
 Malignant Hyperthermia
 Very rare condition – 1:15,000
 Patient experiences a rapid increase of
temperature, metabolic acidosis,
rhabdomyolysis, and DIC
 Treatment includes administration of
Dantrolene and external means of temp.
reduction
Complications
 Prolonged paralysis
 In patients with:
 A deficiency of pseudocholinesterase
 Certain meds: magnesium, lithium, quinidine
 Cocaine
 Masseter muscle rigidity
RSI Procedure: The Seven P’s
1. Preparation - CONTINUED
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
5. Pass the Tube
 Intubation is performed when there is full
relaxation of the airway muscles
 About 90 seconds after Succs
 If intubation fails, maintain cricoid
pressure and ventilate with BVM
 After patient is reoxygenated, reattempt
or move to a different airway adjunct

Assistant: You are still performing the cricoid pressure at this point.
Direct Visualization…
Suspected Cervical Injury?

Hold manual
in-line axial
stabilization
(MIAS)
Pass the Tube

 COMPLICATIONS:
 If you miss or are unable to intubate after 30
seconds……
 Ventilate with BVM / high flow O2 with cricoid
pressure maintained
 Make ONE more attempt to intubate
 If still unsuccessful – continue BVM / Cricoid pressure
 Secure Airway with backup device (CombiTube, LMA
or King-LT-D)

Assistant: The advanced provider may ask you to perform the “BURP”
maneuver to better visualize the cord.
If Unable

 If unable to intubate, unable to secure the

airway with backup device, and unable to
maintain an SpO2 of >90% with a BVM
 Contact Med Control
 Consider surgical airway:
 Surgical Cric
 Commercial Cric. Device
 Needle Cric
RSI Procedure: The Seven P’s
1. Preparation - CONTINUED
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
6. Proof of Placement
OBJECTIVE SUBJECTIVE
 Direct visualization  Absence of abdominal
 BEST sounds while ambu-
 CXR (in hospital) bagged
 Pulse oximetry  Mist in the tube
 Capnography  Bilateral breath sounds
 CO2 detectors  Rise/fall in chest
 Easy Cap - colormetric
 Self-inflating bulb
Confirm placement using at least 3 methods, including
capnography waveform.

Assistant: Be familiar with the set-up and/or assembly of the various confirmation
devices as you will likely be called upon to connect them.
SpO2 (Pulse Oximetry)
 Provides quick
estimate of PaO2
 Often referred to as
an additional vital
sign
 Non-invasive
Waveform Capnometry
 Number of important applications
 Monitor & Confirm ETT placement
 Useful to document adequacy of ventilation
during mechanical ventilation
 Limitations:
 For patients with impaired pulmonary function
or hemodynamic instability

Assistant: Become familiar with the appropriate waveform for a properly

ventilated patient.
The Capnogram
 Represents the
Respiratory Cycle
 Exhalation
 A to D
 Inhalation
 D to E
Waveform Capnometry
 Prerequisite
Requirement
 Becoming a
standard of care
 Easy to Use
 Good measure of
Pulmonary
Perfusion
 Relates well to
PaCO2
 Does have
limitations
After confirming placement:
 Secure airway device
 Immobilize the head
 Verify correct placement each time the
patient is moved
 Document appropriately

Assistant: Again, be familiar with these steps and be able to perform.

RSI Procedure: The Seven P’s
1. Preparation - CONTINUED
2. Preoxygenation
3. Premedication
4. Paralyze
5. Pass the tube
6. Proof of placement
7. Post intubation care
7. Post Intubation Care
 Medicate:
 Sedation
 midazolam (0.05-0.1 mg/kg IVP) or
 lorazepam (1-2 mg IV)
 fentanyl (25-100 mcg may be considered prn)
 Paralysis (with online medical control)
 vecuronium (0.1 mg/kg IVP) or
 rocuronium (1 mg/kg IVP)
 Consider wrist restraints
Midazolam & Lorazepam
 Benzodiazepines
 Provide sedation, amnesia, and
anticonvulsant properties
 No analgesia
Midazolam: Faster onset, shorter duration than lorazepam
Lorazepam: may be the preferred agent due to its longer action duration

Pay close attention to the patient’s level of consciousness. Should the

patient at anytime show any signs/symptoms of discomfort (movement,
increase heart rate, increased blood pressure) consider further sedation.
Sedation Assessment
 Sign/symptoms
 Movement
 Increase in heart rate
 Increase in blood pressure
 Decrease in SpO2
 Changes in muscle tone
 Facial muscle tension
Midazolam (Versed)

 Dose: 0.05-0.1 mg/kg IVP

 Rapid onset – 1-2 minutes
 Single dose duration: 15-20 minutes
Midazolam
 Duration: 1-4 hours
 Hepatic clearance
 Decreased dose needed (longer half life)
 Obese
 Geriatric
 CHF
 Hepatic or renal insufficiency
Lorazepam (Ativan)

 Post-RSI sedation:
 Lorazepam 1-2 mg IV push q 5 min prn
 Titrate to keep patient sedated and SBP >90
 Onset: 5 minutes
 Duration: 6-8 hours, dose dependant
Fentanyl
 Class
 Anesthetic Induction /
Maintenance
 Narcotic
 25-100 mcg may be
considered prn
Fentanyl
 Opioid agonist
 Dampens sympathetic (catecholamine)
response
 Does not release histamine
 May cause stiff chest in doses >500mcg
 Caution in hypotension / hypovolemia
Vecuronium & Rocuronium
 Non-Depolarizing
Paralytics
 Provide paralysis, but
NO sedation, amnesia,
or analgesia properties
Vecuronium (Norcuron)
 Considered safe without
many contraindications
 May be used in most
patients including
cardiovascular,
pulmonary, and
neurological emergencies
 Must be reconstituted
from powdered form
Vecuronium
 Dose: 0.1mg/kg IVP
 Repeat/maintenance dose: 0.01 mg/kg
 Onset: 2-3 minutes
 Duration: approx. 20-30 minutes
Vecuronium
 Metabolized by the liver and kidneys
 Use with caution in patients with liver
failure
 May have 2x the recovery time
 Patients with renal or hepatic failure will
need less medication to maintain paralysis
 Does not cause hypotension or tachycardia
Rocuronium (Zemuron)
 Very similar properties to
Vecuronium
 Does not need to be mixed,
can be stored at room temp
for 60 days
 Less vagolytic properties
Rocuronium
 Onset: 30-60 seconds
 Fastest onset of all non-depolarizing NMBs
 Dose related
 Dose: 1 mg/kg IVP
 Duration: 20-75 minutes
 Repeat/maintenance dose is the same as
the initial dose
Review:
Sequence of Administration
 Time -5 minutes Preoxygenation
 Time -2 minutes Premedication
 Time -0 minutes Sellick Maneuver,
Induction Agent,
Paralytic
 Time +1 minutes Intubation
Medication Sequence
 Oxygen
 Lidocaine and/or Atropine if indicated
 Etomidate
 Cricoid Pressure
 Succinylcholine
 INTUBATION
 Lorazepam / Fentanyl prn
 Rocuronium or Vecuronium prn
IMPORTANT REMINDERS!!
 Always remember (and suggest) the use
of sedatives before giving paralytics, and
allow them to take effect
 Sedatives and paralytics do not have any
analgesic properties, evaluate patient
response and possible need for analgesia
 vital signs, skin signs
 R a p id S e q u e n c e In tu b a tio n

P re -o x yg e n a te p a tie n t
1 0 0 % O 2 fo r 5 m in u te s
N R M ask or B VM

L id o c a in e IV if in d ic a te d

E to m id a te IV

S e llic k s M a n e u v e r - B U R P

S u c c in ylc h o lin e

IN T U B A T E !

L o ra z e p a m IV F e n ta n y l IV
“Failed Airway”
Worst case scenario:
Know Your Options!!!
& Don’t hesitate to use them!
Failed Airway
Unable to intubate
(including blind
devices) and unable to
ventilate with a BVM
and maintain an Sp02
> 90 %.
Rescue Airway Management
 Have a back-up plan
 Algorithmic approach
 BVM
 Gum Elastic Bougie
 Laryngeal Mask Airway (LMA)
 Esophageal Tracheal Combitube
 King-LT-D

Assistant: Be familiar with the set-up and/or assembly of the various

backup devices as you will likely be called upon to assist with them.
BVM
 Can you obtain a good mask seal?
 Adequate chest rise & fall?
 Adequate oxygenation & ventilation?

Assistant: You will most likely be performing this skill.

Gum Elastic Bougie (GEB) or Flex-guide
(FG) Endotracheal Tube Introducer
 First introduced in 1949
 Useful in failed intubation with Grade III or Grade IV
laryngoscopic view
 Might be helpful in the immobilized trauma patient
 Has been found to reduce the incidence of failed intubation
 96% success rate
 On average, use if an FG instead of a stylet only requires
10 seconds longer to perform intubation
 Providers must receive training in the use if the FG
LMA
 Good temporizing
measure
 Multiple sizes
 Aspiration likely if
vomiting occurs
 Pre-Hospital use
unproven/unpublished
 Risk of aspiration
Combitube
 Especially suited for…
 Patients with difficult anatomy
 Reduced access spaces
 Reduced illumination (bright light)
King-LT-D
Failed Airway Management
Cricothyrotomy

 Airway of last resort

 Low frequency/high
risk skill
 Can be complex and
confound decisions
Cricothyrotomy
 Relatively contraindicated by
anatomic disruption of the
cricothyroid region of the airway
(Lack of landmarks)
Final Thoughts on the
“Failed Airway”
 In all cases of a failed airway, the
operator must continually assess the
adequacy of oxygenation and
ventilation
 7% of all trauma patients will require
intubation
Additional Documentation Items
 Why was the decision made to RSI
 Pre & Post O2 and CO2 levels
 Airway Grading/scales
 Unsuccessful Attempts
Case Studies
Case 1
 67 y/o female “code blue” – in asystole.
PLAN?
Case 2
 72 y/o female with Hx fever, productive
cough and progressive dyspnea. Lethargic,
perioral cyanosis. RR 34 and labored, HR
114, BP 117/76. Lung sounds equal with
scattered rhonchi. PLAN?
Case 3
 41 y/o female with c/o “asthma attacks”
x20 minutes. Severe respiratory distress.
RR 32, HR 127, BP 160/92. Bilateral I/E
wheezes. Within 10 minutes, she becomes
lethargic and her RR slows. PLAN?
Case 4
 46 y/o male with a Hx of EtOH and drug abuse.
Presents with “had a seizure” per bystanders. Pt
is responsive to pain, but does not follow
commands or answer questions. RR 18, HR 109,
BP 120/80. Within minutes, he has 2 episodes
of vomiting and “gurgling respirations”. PLAN?
Case 5
 25 y/o male with GSW to abdomen. Pt is
intoxicated, decreased LOC, minimal gag reflex.
RR 8-10, HR 120, BP 100/80. PLAN?
Case 6
 87 y/o male MVC, high-speed,
unrestrained. Patient gasping for air, able
to talk, c/o right side CP. RR 32, HR 120,
BP 186/92. Multiple deformities to face and
chin. Ecchymosis and swelling to neck and
anterior chest. Large flail segment to
ant/lat chest. Decreased BS on the right.
No stridor, but some gurgling in throat.
PLAN?
References
 Marx: Rosen's Emergency Medicine:
Concepts and Clinical Practice, 5th
ed., Copyright © 2002 Mosby, Inc.
 Miller: Miller's Anesthesia, 6th ed.,
Copyright © 2005 Elsevier
 Roberts: Clinical Procedures in
Emergency Medicine, 4th ed.,
Copyright © 2004 Elsevier