Pre-treating patients with a number of agents to counteract the potential adverse effects of intubulation is also adopted. The basic tenet behind application of RSI is the assumption that the patient has a full stomach and therefore would face dangers from aspiration. In the case cited, the patient is being wheeled in for readmission due to bleeding after tonsillectomy.
When applied by skilled technicians RSI shows an intubation success rate of 98% and reduces complications. Schwartz et al report that 3% of intubation in the critically ill are fatal within30 minutes and as high as 8%-18%intubations get misplaced in the esophagus. About 4%-5% result in incidents of aspiration. This data highlights the importance of assessment prior to intubation and the importance of correct pharmacological interventions before RSI. While assessments are important it has been highlighted by studies that in 70% of situations it practically impossible to conduct assessments in the critically ill.
There can be anatomical and functional impediments for placing a face mask. Anatomical barriers include abnormal anatomy of the face upper or lower airways, compliance of the thoracic and abdominal cavities and so on. Functional problems include obesity, chest and diaphragm restriction, decreased respiratory compliance and the like. During RSI, the soft palate tissue rather than the tongue offer the most resistance. This phenomenon is further enhanced by relaxation of this tissue by the agents used in RSI. The excess secretion like saliva and in this case the blood may be aspirated.
"Ventilation is assisted by a jaw thrust or head tilt, the placement of either a nasopharyngeal or oropharyngeal airway, and the application of positive-pressure assisted ventilation." (Stuart. F. Raynolds, John Heffner.2003)
Visual Indicators of a difficult tubulation are:
Short, fat neck
Small, receding chin
Presence of a beard
Poor mouth opening, and/or neck mobility
Facial injury with excess oral secretions
Facial and/or neck burns
(Robert M Pousman, DO.2000)
Patient Assenssment: Forms an important component in the success of the procedure. The Mallampati system is the usual assessment system for menatlly alert patients requiring elective