If that fails release cricoid force and try ventilation again through the laryngeal mask.Attempt to ventilate with 100% oxygen via laryngeal mask with cricoid force.Release cricoid force as laryngeal mask is inserted and reapply when inserted. If facemask inflation not possible, maintain 30 N cricoid force and insert laryngeal mask.If necessary use two hands to hold facemask and ask responder to squeeze bag.Insert oral airway and attempt facemask ventilation with 100% oxygen.Call for assistance and keep first responder.The only task now is to move to Plan C - the maintenance of oxygenation whilst the induction agent and muscle relaxation wear off and the patient awakens. There is no intubation Plan B because the patient is going to be woken up without any other attempts at intubation. Announce 'Failed intubation' to stop yourself carrying on with further attempts and to alert assistant that Plan A has failed.If intubation unsuccessful - stop further attempts.If difficult try alternative blade (long, straight, McCoy etc), bougie, and the limited amount of external laryngeal manipulation possible with cricoid force.30 N cricoid force (equivalent to registering 3 kg on a weighing machine) after loss of consciousness.Light pressure (no more than 10 N force) on the cricoid cartilage prior to loss of consciousness.Cricoid cartilage identified before induction by assistant.Adjust head/neck position prior to starting.(Please note that the quality of guideline image is low to aid fast loading. The scenario of a rapid sequence induction when surgery is immediately urgent (for example in extremis aortic aneurysm rupture) is not considered here in detail. ![]() In this case scenario, the urgency of the surgery is not immediate and failure of intubation activates a plan of 'wake-up' Airway evaluation is imperfect and so airway strategy must deal with unexpected difficult direct laryngoscopy and difficult facemask ventilation. Preoperative airway evaluation has not predicted any problem with airway management. The anaesthetic technique includes optimal preoxygenation, the use of an induction agent and suxamethonium, with the application of 30 N cricoid force at the onset of unconsciousness. This is a common anaesthetic technique in the UK when there is a risk of gastro-oesophageal reflux. ![]() This case scenario is of an adult, non-pregnant patient undergoing a rapid sequence induction. All rights reserved.This guideline has now been superseeded by the 2015 intubation guidelines click here Rapid sequence induction, non-pregnant adult patient, no predicted difficulty © American Society of Health-System Pharmacists 2022. Oxygenation paralysis pharmacist rapid sequence intubation sedation. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data. While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. ![]() It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. ![]() Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP).
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