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Rapid Sequence Intubation

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Title: PowerPoint Presentation Author: Justin Onzuka Last modified by: AAA Created Date: 7/9/2002 3:56:18 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Rapid Sequence Intubation


1
Rapid Sequence Intubation What Every Emergency
physician Must Know
Abdullah ALsakka EM Consultant KKUH
2
What do the following have in common?
  • 37 year old asthmatic man in extremis
  • 22 year old overdose patient - barely arouses to
    pain
  • 30 year old multiple trauma patient
  • 67 year old man in cardiogenic shock
  • 80 year old woman in refractory pulmonary edema

3
Key Questions Objectives
  • What exactly is RSI?
  • Why use drugs?
  • Can I mitigate adverse effects?
  • What induction agent do I use?
  • What NMBA do I use?

4
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5
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6
Key Questions
  • What exactly is RSI?
  • Why use drugs?
  • Can I mitigate adverse effects?
  • What induction agent do I use?
  • What NMBA do I use?

7
Rapid Sequence Intubation
Definition
The virtually simultaneous administration of a
potent sedative agent and a neuromuscular
blocking agent to induce unconsciousness and
motor paralysis for tracheal intubation.
8
History
  • 1979 first series of ED intubations Taryle,
    1979
  • 1982 first series of intubations using
    succinylcholine in the ED Thompson, 1982

9
History
  • 1997 ACEP RSI policy statement
  • physicians performing RSI should possess
    training, knowledge, and experience in the
    techniques and pharmacologic agents used to
    perform RSI
  • NMBA and appropriate sedative and induction
    agents should be immediately available in the ED
    and accessible to all physicians who perform RSI
    in the ED

Reaffirmed, 2000
10
Rapid Sequence Intubation
Definition Incorporates
  • Patient has a full stomach
  • Preoxygenation
  • No interposed ventilation
  • Sellicks maneuver

11
Rapid Sequence Intubation
Advantages of RSI
  • Rapid control of the airway
  • Minimizes risk of aspiration
  • Highest success rates
  • Lowest complication rates
  • Optimal intubating conditions
  • Adaptable to patient condition

12
The Evidence
  • Prospective observational and retrospective
    studies
  • National Emergency Airway Registry (NEAR)
  • Series of gt 6000 ED intubations
  • 26 teaching hospitals
  • 88.1 adult and 81.1 pediatric intubations
    performed by the EP

13
The Evidence
NEAR data
METHOD FEQUENCY () SUCCESS ()
RSI 69.5 98.7
NO MEDS PRE/FULL ARREST 17.3 94.9
SEDATION 6.8 90.2
NASAL 5.1 87.2
Walls et. al., 1999-2000 ABSTRACT
14
The Evidence
Sakles et. al. , 1998
EXPERIENCE PGY 3 PGY 2 PGY 1 STAFF
INTUBATIONS 73.5 17.8 2.6 6.2
½ RESIDENT FAILURE
Success rate 99.4 with RSI vs. 91.4 with
Sedation
15
The Evidence
  • 1999 Li et. al. prospective airway data
  • 3 months prior and 6 months post implementation
    of an RSI protocol
  • Results

METHOD COMPLICATIONS
RSI n166 28
WITHOUT PARALYSIS n67 78
15 aspiration, 28 airway trauma, 3 death
NOT SEEN IN THE RSI GROUP
16
RSI
  • What are the contraindications to RSI?

17
RSI
  • The predicted difficult airway
  • Inexperience
  • Inadequate difficult airway tools and techniques

18
Rapid Sequence Intubation
The Seven Ps of RSI
Preparation Preoxygenation Pretreatment Paralysis
with induction Positioning Placement with
proof Post-Intubation Management
19
Rapid Sequence Intubation
The Sequence
Zero the time of administration of
succinylcholine.
20
Rapid Sequence Intubation
The Sequence
Zero - 10 minutes
Preparation
  • Assess airway difficulty (LEMON)
  • Plan approach
  • Assemble drugs and equipment
  • Establish access
  • Establish monitoring

21
Rapid Sequence Intubation
The Difficult Airway Rule
L ook externally E valuate 3-3-2 M allampati O
bstruction? N eck mobility
22
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23
Airway Anatomy
24
Airway Anatomy
25
Pediatric Airway
  • Occipital prominence
  • Nasal vs muoth breathing
  • Dentition
  • Adenoid tissue and friable mucosa
  • Aryepiglottic folds more midline
  • Epiglottic shape (longer, narrower, stiffer)
  • Laryngeal position (anterior)
  • Vocal cords (anterior angle)
  • Epiglottic vagal innervation
  • Lung compliance
  • Diaphragmatic muscle fibre type
  • Increased metabolic rate
  • Narrowest point is at cricoid

26
Rapid Sequence Intubation
The Difficult Airway Rule
L ook externally E valuate 3-3-2 M allampati O
bstruction? N eck mobility
27
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28
Airway Assessment
29
Airway Assessment
30
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31
Airway Assessment
32
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33
Rapid Sequence Intubation
The Sequence
Zero - 5 minutes
Preoxygenation
  • 100 oxygen for five minutes
  • 8 vital capacity breaths
  • Provides essential apnea time
  • Apnea time varies

34
Rapid Sequence Intubation
Time to Desaturation
From Benumoff
35
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36
Rapid Sequence Intubation
The Sequence
Zero - 3 minutes
Pretreatment
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculation

LOAD the patient before intubation.
37
Rapid Sequence Intubation
The Sequence
Zero!!
Paralysis with induction
  • Induction agent IV push
  • Neuromuscular blocking agent IV push

38
Rapid Sequence Intubation
INTUBATION
39
Rapid Sequence Intubation
The Sequence
Zero 30 seconds
Protection
  • Sellicks Maneuver
  • Position patient
  • Do not bag unless S O lt 90

p
2
40
Sellick Maneuver
41
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42
  • CRICOID PRESSURE IN EMERGENCY RAPID SEQUENCE
    INTUBATION
  • CONCLUSIONS Although application of cricoid
    pressure has been described as the "linchpin of
    RSI" and has come to be a widely accepted
    practice, there is no clear evidence to suggest
    that it reduces the risk of aspiration during
    RSI.
  • Butler, J., Emerg Med J 22815, November 2005

43
  • LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED
    TRIAL COMPARING CRICOID PRESSURE,
    BACKWARD-UPWARD-RIGHTWARD PRESSURE, AND BIMANUAL
    LARYNGOSCOPY
  • CONCLUSIONS bimanual laryngoscopy was more
    effective than cricoid pressure or the BURP
    maneuver in improving laryngoscopic visualization
    for intubation
  • Levitan, R.M., et al, Ann Emerg Med 27(6)548,
    June 2006

CONCLUSIONS In this cadaver
44
Rapid Sequence Intubation
The Sequence
Zero 45 seconds
Placement
  • Check mandible for flaccidity
  • Intubate, remove stylet
  • Confirm tube placement - ET CO2
  • Release Sellicks maneuver

45
  • BURP
  • Technique
  • Blade (type, size, placement)

46
Confirmation of Tube Position
  • Visualize through cords
  • ETCO2
  • Listen over stomach
  • Compliance with bagging
  • B/S over chest
  • Esophageal detector device
  • Bilateral chest rise
  • Tube condensation
  • Sats improve
  • Bronchoscope
  • CXR (lateral)

47
Rapid Sequence Intubation
The Sequence
Zero 90 seconds
Post-intubation Management
  • Secure tube
  • Chest x-ray
  • Long acting sedation/paralysis
  • Establish ventilator parameters

48
Rapid Sequence Intubation
Summary
The Seven Ps of RSI
Preparation Preoxygenation Pretreatment Paralysis
with induction Protection Placement Post-Intubatio
n Management
49
Rapid Sequence Intubation
Failed Attempt
Rescue Maneuvers
  • The first rescue from failed intubation is
    bagging
  • The first rescue from failed bagging is better
    bagging

50
Key Questions
  • What exactly is RSI?
  • Why use drugs?
  • Can I mitigate adverse effects?
  • What induction agent do I use?
  • What NMBA do I use?

51
Why use drugs?
  • Blunt perception and recall
  • Make intubation easier
  • Mitigate adverse responses
  • Improve patient condition

52
Key Questions
  • What exactly is RSI?
  • Why use drugs?
  • Can I mitigate adverse effects?
  • What induction agent do I use?
  • What NMBA do I use?

53
WHAT CAUSES THE RESPONSE?
  • Laryngoscopy and intubation cause
  • bronchospasm
  • ICP
  • catecholamines
  • Succinylcholine causes ICP

54
PATIENTS AT RISK
  • Intracranial pathology
  • tight brain
  • Cardiovascular disease
  • tight heart
  • floppy heart
  • Reactive airways disease
  • tight lungs

55
ATTENUATING THE RESPONSE
  • Pretreatment L.O.A.D.
  • Induction agents

56
L.O.A.D.
  • L idocaine
  • O pioid
  • A tropine no longer use
  • D efasciculation no

The Pretreatment drugs for RSI Give 3 minutes
before SCh
57
LIDOCAINE
1.5 mg/kg
  • Increased intracranial pressure
  • Bronchospasm

58
OPIOID
Fentanyl 3 mg/kg May give slowly over 3 minutes
  • Cardiovascular disease
  • Intracranial hypertension

Caution if dependent on sympathetic drive
59
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60
Atropine
  • No longer recommended

61
DEFASCICULATION
  • No longer recommended

62
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63
Key Questions
  • What exactly is RSI?
  • Why use drugs?
  • Can I mitigate adverse effects?
  • What induction agent do I use?
  • What NMBA do I use?

64
PHARMACOLOGIC INDUCTION
  • GOAL INDUCTION OF UNCONSCIOUSNESS
  • Doses dependent on
  • Weight
  • Hemodynamics
  • Level of consciousness
  • age

65
Etomidate
  • Imidazole derivative
  • ACTION
  • Sedative-hypnotic
  • INDICATION
  • Hemodynamic instability
  • Respiratory compromise
  • increased ICP
  • DOSE
  • 0.3 mg/kg iv
  • ADVERSE EFFECTS
  • Adrenal suppression
  • No analgesia property
  • Pain on injection
  • Etomidate does cause adrenal insufficiency?
  • Not clear this affects overall survival

66
Barbiturates
  • Sodium thiopental
  • ACTION
  • GABAergic
  • INDICATION
  • Increased ICP
  • DOSE
  • 3-5 mg/kg
  • ADVERSE EFFECT
  • Negative inotrope and venodialtor
  • () histamine release
  • Apnea
  • No analgesic property

67
Benzodiazepines
  • Midazolam
  • ACTION
  • GABAergic
  • INDICATIONS
  • Cerebroprotective
  • Amnesia
  • Anxiolysis
  • Muscle relaxation
  • DOSE
  • 0.1 - 0.3 mg/kg (induction)
  • ADVERSE EFFECT
  • Negative inotrope
  • No analgesia property

68
Ketamine
  • Phencyclidine derivative
  • ACTION
  • Induces a cataleptic state
  • INDICATION
  • Obstructive airway disease
  • Hemodynamic instability
  • Analgesia
  • DOSE
  • 1-2 mg/kg
  • ADVERSE EFFECTS
  • Myocardial depressant, induces tachycardia (via
    SNS)
  • Unpleasant emergence

69
  • Ketamine in Head Injury
  • Can you use ketamine in head injured patients?
  • Critical review of literature
  • Included 79 studies
  • May improve cerebral perfusion
  • Neuroprotective
  • No negative effects, possibly beneficial
  • Himmelseher S, et al. Anesth Analg
    2005101524

70
Propofol
  • Alkylphenol
  • ACTION
  • Hypnotic, mechanism unknown (GABA)
  • INDICATION
  • Increased ICP or IOP
  • Amnesia
  • Status epilepticus
  • DOSE
  • 1-3 mg/kg
  • ADVERSE EFFECT
  • Decreases cerebral perfusion
  • myocardial and respiratory depression
  • Venodilation
  • Pain on injection
  • No analgesic property

71
INDUCTION AGENTS HEALTHY, STABLE PATIENTS
  • Etomidate 0.3 mg/kg
  • Midazolam 0.2-0.3 mg/kg
  • Ketamine 1.5 mg/kg
  • Propofol 1-3 mg/kg
  • Pentothal 3 mg/kg

IV Push
72

INDUCTION AGENTS COMPROMISED, UNSTABLE PATIENTS
  • Etomidate 0.15 mg/kg
  • Midazolam 0.1 mg/kg
  • Ketamine 1 mg/kg
  • Propofol 0.5 mg/kg
  • Pentothal 1.5 mg/kg

73
INDUCTION AGENTS Special Circumstances
  • Reactive airways ketamine
  • ICP etomidate/pentothal
  • Hypotensive ketamine/etomidate
  • Operator preference

74
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75
Key Questions
  • What exactly is RSI?
  • Why use drugs?
  • Can I mitigate adverse effects?
  • What induction agent do I use?
  • What NMBA do I use?

76
NEUROMUSCULAR BLOCKING AGENTS
  • Depolarizing - succinylcholine
  • Competitive (nondepolarizing)
  • Aminosteroids
  • Rocuronium, vecuronium
  • Benzylisoquinolines
  • Curare
  • Benzylisoquinoliniums
  • Atracurium, mivacurium

77
SUCCINYLCHOLINE
  • Rapid onset / brief duration
  • May ICP
  • Fatal hyperkalemia
  • burns beyond day one
  • active neuromuscular disease
  • crush injuries
  • intra-abdominal sepsis

78
USE OF NONDEPOLARIZERS
  • Pretreatment no more use
  • Rapid sequence intubation
  • rocuronium
  • Maintaining paralysis for ventilation

79
What do the following have in common?
  • 37 year old asthmatic man in extremis
  • 22 year old overdose patient - barely arouses to
    pain
  • 30 year old multiple trauma patient
  • 67 year old man in cardiogenic shock
  • 80 year old woman in refractory pulmonary edema

80
What do the following have in common?
  • All should be intubated with RSI in the absence
    of identified difficult airway attributes

81
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83
Rapid Sequence Intubation
Questions ?
  • Walls RM, et al Manual of Emergency
  • Airway Management, LWW, 2004
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