Emergency Rapid Sequence Intubation: A

1
Emergency Rapid Sequence IntubationA How and
When To Guide

• Pat Melanson, MD, FRCPC
• Department of Emergency Medicine
• Division of Critical Care Medicine
• Royal Victoria Hospital

2
Rapid Sequence Intubation Definition

• The near simultaneous administration of a
  sedative-hypnotic agent and a neuromuscular
  blocker in the presence of continuous cricoid
  pressure to facilitate endotracheal intubation
  and minimize risk of aspiration
• modifications are made depending upon the
  clinical scenario

3
A Brief History of Emergency RSI

• intubation of the newly/nearly dead (prehistoric)
• techniques adapted from anesthetists in Case Room
  and crash full-stomach induction's
  (exploration)
• rapid dissemination of RSI teaching to emergency
  physicians (proselytism)
• evidence-based research supporting safety and
  advantages of emergency RSI (enlightenment)
• increasingly sophisticated techniques and
  methodology critically evaluated (postmodern)

4
Intubation Dilemmas

• Intubate Awake or Asleep
• Oral or Nasal
• Laryngoscopy or Blind Intubation
• To Paralyze or Not

5
Oral Intubation Without Drugs

• Reserved for the completely unconscious,
  unresponsive, pulseless and apneic
• Arrest situations only
• The CRASH AIRWAY

6
Oral Intubation with Sedation

• proponents argue use of BZ or opioids
• improves airway access
• decreases patient resistance
• avoids risks of NMB
• Generally obtunds patient to point of loss of
  protective reflexes and respiratory drive
• lower success rate, higher complications compared
  with RSI

7
Oral Intubation with Sedation

• In general, the technique of administering a
  potent sedative agent to obtund the patients
  responses and permit intubation in the absence of
  NMB is hazardous and to be discouraged is not an
  appropriate alternative to properly conducted RSI
  and affords neither the success rate or the
  minimal complication rate of RSI.
• RM Walls, page 4, Chapter 1, Rosen

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Oral Intubation with Sedation

• The avoidance of NMB actually creates a more
  hazardous situation for the patient and this
  practice should no longer be considered an
  appropriate method for emergency department ET
  intubation.
• RM Walls, page 8, Chapter 1, Rosen

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Oral Intubation with SedationUse for the
Anticipated Difficult Airway

• if time permits
• topical anesthesia
• careful titrated sedation
• avoid obtundation
• Awake intubation technique

10
Blind Nasal Intubation

• success rates 65 - 80 in most series
• high complication rates
• epistaxis
• pharyngeal/ esophageal perforations
• increased incidence of O2 desats
• Considered second line approach only
• reserved for when RSI contraindicated
• The DIFFICULT AIRWAY

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Approach to Airway Management Algorithms

• Is intubation indicated ?
• Is this a Crash Airway situation ?
• Is this a potentially Difficult Airway?
• Difficult laryngoscopy ?
• Difficult Bag -Mask Ventilation?
• Is RSI appropriate ?
• Is this a Failed Airway?

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Emergency Airway Concerns

• full stomach
• minimal respiratory reserve
• hemodynamic instability
• acute myocardial ischemia
• increased intracranial pressure
• C-spine injury
• The Difficult Airway
• Laryngoscopy
• bag-mask difficulty

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Advantages of RSI

• facilitates and expedites endotracheal intubation
• increased success rate
• decreased time to intubation
• minimizes trauma during laryngoscopy
• minimizes hypoxia and hypercapnia
• minimizes risk of aspiration
• minimizes hemodynamic effects of intubation

14
Disadvantages of RSI

• operator assumes complete responsibility for
  oxygenation, ventilation and airway patency
• irreversible commitment
• (burnt bridges)
• adverse effects of medications
• ?? increases surgical airway rate
• no evidence

15
Rapid Sequence Intubation Principles

• Emergency intubation is indicated
• The patient has a full stomach
• Intubation is predicted to be successful
• If intubation fails, ventilation is predicted to
  be successful
• Consists of a series of planned discrete steps

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Principles of RSI

• Competing demands
• Minimizing risk of aspiration vs. risk of hypoxia
• Preoxygenation
• ideally avoid BMV-PPV to minimize aspiration
• adequate N2 washout (5 min 100 O2 ) gives oxygen
  reservoir providing several minutes of O2 supply
  despite apnea
• 4 assisted PPV breaths prior to paralysis
• pulse oximetry essential
• ANTICIPATE the O2 trend!

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Principles of RSI (cont)

• Minimizing gastric distention
• avoidance of BMV-PPV
• cricoid pressure
• caudal to thyroid cartilage
• complete ring esophageal occlusion
• release if vomiting occurs
• maintain until ETT position confirmed
• minimize peak pressures if BMV-PPV
• immediate ID of esophageal intubation

18
Typical Emergency RSI Time Course

• 100 O2, iv access, monitor, oximetry
• assemble equipment, meds and team
• thiopental 3mg/kg iv
• succinylcholine 1.5mg/kg iv
• cricoid pressure with LOC no bagging
• laryngoscopy after fasciculations
• tube position confirmed and secured
• positive pressure ventilation begins
• To CT/lavage/OR/etc.
• O2 sat 100 throughout

• time 000
• 200
• 215
• 300
• 320
• 500

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Drugs used for RSI Overview

• Essential
• Paralytic
• Sedative/ Induction agent
• Optional
• Defasciculant
• Modulators of hemodynamics/ICP/etc.

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Emergency RSI Selecting the Patient

• Is RSI contraindicated?
• Absolute
• Cardiopulmonary arrest present/imminent
• Operator inexperience
• Relative
• Anticipated technical difficulties with
  laryngoscopy and/or intubation
• Anticipated difficulty with BVM

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Emergency RSI Selecting the Paralytic

• Neuromuscular blocking agents
• Depolarizing
• Succinylcholine
• Non-depolarizing
• Vecuronium
• Rocuronium

22
Emergency RSI Selecting the Paralytic

• Is succinylcholine contraindicated?
• NO choose succinylcholine
• YES choose rocuronium (or vecuronium)
• If using SUX, is atropine needed?
• atropine 0.02mg/kg (.15mg-.5mg) 2min before
• If using SUX, is a defasciculant desired?
• 10 dose of non-depolarizing agent 2 min prior

23
Succinylcholine ( Anectine)

• dose 1.5 mg/kg
• onset 45 - 60 seconds
• duration 6 to 10 min (3 to 15)
• disadvantages
• ACh analog - bradycardia
• fasciculations
• hyperkalemia ( K release)
• malignant hyperthermia

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Succinylcholine Contraindications

• Hyperkalemia - renal failure
• Active neuromuscular disease with functional
  denervation
• ( 6 days to 6 months)
• Extensive burns, crush injuries
• Malignant hyperthermia
• Pseudocholinesterase deficiency
• Organophosphate poisoning

25
Succinylcholine Complications

• Inability to secure airway
• Increased vagal tone ( second dose )
• Histamine release ( rare )
• Increased ICP/ IOP/ gastric pressure
• Myalgias
• Hyperkalemia with burns, NM disease
• Malignant hyperthermia

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Vecuronium ( Norcuron )

• dose 0.1 - 0.2 mg/kg
• action 120 secs to 60 minutes
• prime with 1/10 dose 2 min prior
• onset in 90 secs
• advantages
• non-depolarizing
• neutral hemodynamics
• hepatic clearance

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Rocuronium ( Zemuron )

• dose 0.6 - 1.2 mg/kg
• onset 60 -90 secs
• advantages
• almost as rapid as SUX
• disadvantages
• less rapid in elderly
• long duration

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Emergency RSI Selecting the Sedative
?

• Thiopental
• Ketamine
• Midazolam
• Propofol
• Etomidate
• (nothing)

?
?
?
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Thiopental ( Pentothal )

• dose 1- 5 mg/kg
• action 20 sec to 5 minutes
• advantages
• ultrafast, short duration
• neuroprotective, anticonvulsant
• familiar
• disadvantages
• hypotension ( myocardial depression, vd)
• ultrashort duration ( 3 - 5 minutes )
• demyelination in porphyria
• chemical endarteritis, thrombosis

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Midazolam ( Versed )

• dose 0.1 - 0.4 mg/kg
• action 2 min to 120 minutes
• advantages
• wide therapeutic index
• amnesia
• disadvantages
• variable dose response
• slower onset
• suboptimal effect at lower doses
• negative inotrope, vasodilation

31
Ketamine ( Ketalar )

• dose 1 - 2 mg/kg
• action 30 secs to 15 minutes
• advantages
• bronchodilation
• supports BP
• disadvantages
• increases ICP and IOP
• salivation
• emergence reactions

32
Propofol ( Diprivan )

• dose 0.5 - 2.5 mg/kg (20-40mg q10 s)
• action 20 sec to 5 minutes
• advantages
• ultrarapid
• neuroprotective
• disadvantages
• hypotension, bradycardia
• ultrashort duration

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Etomidate ( Amidate )

• dose 0.3 mg/kg
• action 1 minute to 10 minutes
• advantages
• hemodynamically neutral
• neuroprotective
• disadvantages
• unfamiliar
• vomiting
• cortisol suppression

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Emergency RSI Selecting the Sedative

• Identify Primary Concern
• Hemodynamics fentanyl, ketamine, etomidate
• Neuroprotection thiopental, propofol
  (midazolam)
• Bronchodilation ketamine
• Speed thiopental, propofol (ketamine)

35
Emergency RSI Selecting the Sedative

• Identify any Secondary Concerns
• Hemodynamics beware thiopental, propofol
  (midazolam)
• Neuroprotection avoid ketamine (??)
• Speed beware midazolam
• Patient given naloxone avoid fentanyl
• Specific contraindications (e.g. porphyria)
  avoid drug

36
The Intubation Reflex

• Catecholamine release in response to laryngeal
  manipulation
• Tachycardia, hypertension, raised ICP
• Attenuated by beta-blockers, fentanyl
• ICP rise possibly attenuated by lidocaine
• Midazolam and thiopental have no effect

37
Emergency RSI Selecting optional medications

• Increased ICP Lidocaine
• Bronchospasm Lidocaine
• Tachycardia harmful fentanyl (esmolol) 3 min
  before
• atropine if child receiving Sux
• defasciculant
• priming dose of neuromuscular blocking agent
• topical/regional anesthetics

38
Emergency RSI Checklist Flight planning

• Move patient to resuscitation suite
• Assemble personnel
• 100 O2
• Patient too unstable for RSI gt intubate ASAP
• Inadequate ventilation/sat lt90 gt BMV
• Select drugs and doses, delegate Drug Nurse
• Cardiac monitor, BP cuff, O2 sat continuously
• IV running in limb contralateral to BP cuff
• Cleared to taxi

39
Emergency RSI Checklist Taxiing

• C-Spine? OK pillow/folded sheet under head
• ? designate assistant in-line stabilization
• Check ETT and lubricate (/- stylet)
• Check laryngoscope (and other airway device prn)
• Yankauer suction on and under mattress (to right)
• Final neuro assessment (AVPU, posturing, pupils)
• Baseline HR, BP, O2 sat
• Review drugs, doses and sequence with Drug Nurse
• Cleared for take-off

40
Emergency RSI Checklist Take-off

• administer optional drugs
• administer sedative
• administer paralytic
• cricoid pressure with loss of ciliary reflex
• BMV if hypercapnia deleterious/sat lt90
• laryngoscopy once fully relaxed
• BURP to visualize larynx
• Confirm ETT placement and secure
• Ventilator settings
• Treat fluctuations in VS as indicated
• CXR

• 000
• 300
• 315
• 400
• 430
• 500-1500

time (mmss)
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Rapid Sequence Intubation Procedure

• Pre-intubation assessment
• Pre-oxygenate
• Prepare
• Premedicate
• Paralyze with Induction
• Pressure on cricoid
• Place the tube
• Post intubation assessment

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Pre-oxygenate ( Time
- 5 Minutes)

• 100 oxygen for 5 minutes
• 4 conscious deep breaths of 100 O2
• Fill FRC with reservoir of 100 O2
• Allows 3 to 5 minutes of apnea
• Essential to allow avoidance of bagging
• If necessary bag with cricoid pressure

43
Preparation (
Time - 5 Minutes )

• ETT, stylet, blades, suction, BVM
• Cardiac monitor, pulse oximeter, ETCO2
• One ( preferably two ) iv lines
• Drugs
• Difficult airway kit including cric kit
• Patient positioning

44
Pre-treatment/ Prime ( Time
- 2 Minutes )

• Lidocaine 1.5 mg/kg iv
• Defasciculating dose of non-depolarizing NMB
• Fentanyl 3- 5 mcg/kg
• Atropine 0.02 mg/kg
• ( The above agents are optional and given if
  there is a specific indication and time permits)

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Induction agent

• Thiopental 3 - 5 mg/kg
• Midazolam 0.1 - 0.4mg/kg
• Ketamine 1.5 - 2.0 mg/kg
• Propafol 0.5 - 2.0 mg/kg
• Etomidate 0.2 - 0.3 mg/kg

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Paralyze ( Time Zero )

• Succinylcholine 1.5 mg/kg iv
• Allow 45 - 60 seconds for complete muscle
  relaxation
• Alternatives
• Vecuromium 0.1 - 0.2 mg/kg
• Rocuronium 0.6 - 1.2 mg/kg

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Pressure

• Sellick maneuver
• initiate upon loss of consciousness
• continue until ETT balloon inflation
• release if active vomiting

48
Place the Tube (
Time Zero 45 Secs )

• Wait for optimal paralysis
• Confirm tube placement with ETCO2

49
Post-intubation Hypotension

• Loss of sympathetic drive
• Myocardial infarction
• Tension pneumothorax
• Auto-peep

50
Difficult Airway Kit

• Multiple blades and ETTs
• ETT guides ( stylets, bougé, light wand)
• Emergency nonsurgical ventilation
  ( LMA, Combitube, TTJV )
• Emergency surgical airway access (
  cricothyroidotomy kit, cricotomes )
• ETT placement verification
• Fiberoptic and retrograde intubation

51
Amitriptyline tripper

• 27 year old overdose benzos TCAs 1 hour PTA.
• Decreasing LOC (?ciliary reflex). HR 140
  wide-complex regular, BP 90/50, RR 24,
• O2 sat 99 on O2.

52
Walking at the scene

• 22 yr old multiple abdominal stab wounds 6
  knife.
• Evisceration, agitation and uncooperative.
• HR 140, BP 90/50, RR 22,
• O2 sat 99 on O2.

53
Status asthmaticus severus

• 50 yr old asthmatic x years, never admitted O/N.
  SOB x 2d despite prednisone, antibiotics, and
  salbutamol q1h. Despite continuous salbutamol,
  epi s/c x 2, and SoluMedrol iv, begins to
  fatigue.
• pH 7.22, pCO2 70, pO2 140.

54
Collapse at bank

• 38 year old male, standing in line at bank,
  complained of sudden severe HA and collapsed.
• On arrival, HR 55 BP 170/100 RR 12 decorticate
  posturing.

55
NOT renal colic

• 68 year old male, hypertensive, no past history
  of urolithiasis, presents with R flank pain and
  hematuria. While you are booking the spiral CT,
  he complains of increasing back pain, then
  vomits. HR 140 BP 85/palp diaphoretic .
• And then he gets worse.

56
Overdue for dialysis

• 68 yr old hemodialysis-dependent pt in florid
  pulmonary edema and decreasing LOC.
• HR 120 reg, BP 220/120,
• O2 sat 85 on non-rebreather 15L/min.

57
Too much Nintendo

• 14 year old known epileptic on multiple meds,
  still seizing after diazepam, phenobarb and over
  30 minutes in the ED.
• 160 100/50 37.2 99 sat.
• Small jaw.

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I would especially commend the physician who,
in acute diseases, by which the bulk of mankind
are cutoff, conducts the treatment better than
others. Hippocrates