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Rapid Sequence Intubation

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Rapid Sequence Intubation Delon F.P. Brennen, MD MPH Pediatric Emergency Medicine Morehouse School of Medicine Nondepolarizing Bind to acetylcholine receptors in a ... – PowerPoint PPT presentation

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Title: Rapid Sequence Intubation


1
Rapid Sequence Intubation
  • Delon F.P. Brennen, MD MPH
  • Pediatric Emergency Medicine
  • Morehouse School of Medicine

2
Outline
  • Definition
  • Indications
  • Method

3
Definition
  • The induction of a state of unconsciousness with
    complete neuromuscular paralysis to achieve
    intubation without interposed mechanical
    ventilation in efforts to facilitate the
    procedure and minimize risks of gastric
    aspiration

4
Indications
  • Failure of airway maintenance/protection
  • - lost or diminished gag reflex
  • Failure of oxygenation/ventilation
  • - asthma, aspiration, pneumonia
  • Anticipated clinical course
  • - multiple trauma, head injured
  • - intoxication, air transport

5
Method (6Ps)
  • Preparation T-10mins
  • Positioning
  • Preoxygenation T-5mins
  • Premedication T-3mins
  • Paralysis T-1min
  • Placement of tube T-0mins
  • Post management

6
Preparation
  • Evaluate
  • LEMON
  • Equipment Check
  • Positioning
  • Drug Selection
  • IVs, monitor, oximetry
  • Ancillary Staff
  • Anticipate alternative airway maneuver

7
LEMON
  • LEMON
  • L-Look
  • E-Evaluate
  • M-Mallampati
  • O-Obstruction
  • N-Neck mobility

8
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9
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10
Preoxygenation
  • 100 O2 for 5 minutes or 5 vital capacity
    breaths can theoretically permit 3-5 minutes of
    apnea before desaturation to less than 90 occurs
  • NOT Positive Pressure Ventilation
  • If possible

11
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12
Premedication
  • Goal
  • blunt the patients physiologic responses to
    intubation
  • Which are ?
  • bradycardia
  • hypoxemia
  • cough/gag reflex
  • increases in intracranial, intraocular, and
    intragastric pressures

13
Premedication
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculating doses priming

14
Lidocaine
  • Thought to blunt the rise in ICP associated with
    airway manipulation and the use of depolarizing
    neuromuscular blocking agents
  • Dose
  • 1.5 - 3 mg/kg (3 mins prior to intubation)

15
Atropine
  • Minimize vagal effects, bradycardia, secretions
  • Infants and children lt 8 yrs may develop profound
    bradycardia during intubation
  • 0.02 mg/kg (minimum 0.1 mg IV, max 1 mg) 3
    minutes prior to intubation

16
Defasciculating Doses
  • Decreases muscle fasiculations caused by the
    depolarizing agents (succinylcholine)
  • Attenuates rise in intracranial pressure
  • Agents - non-depolarizing blocking agents
    (vecuronium, pancuronium, etc.)
  • Usually 1/10 of standard dose

17
Sedation
  • Sedative agents administered at doses capable of
    producing unconsciousness with little or no
    cardiovascular effects
  • No ideal agent exists
  • Sedation should nearly always be used when
    paralyzing the patient

18
Sedation
  • Barbiturates/hypnotics
  • Non-barbiturate
  • Neuroleptics
  • Opiates
  • Benzodiazepines

19
Barbiturates/Hypnotics
  • Thiopental (Pentothal), Methohexital (Brevital)
  • Short onset - 10-20secs,
  • Duration - 5-10 mins
  • May reduce ICP, cerebro-protective
  • Histamine release, hypotension, bronchospasm

20
Barbiturates/Hypnotics
  • Etomidate (Amidate)
  • nonbarbiturate hypnotic
  • Rapid onset, short duration
  • Decreases ICP/IOP
  • Minimal hemodynamic effects
  • No histamine release
  • Increases seizure threshold

21
Etomidate
  • No malignant hyperthermia reported
  • Watch for myoclonus, vomiting
  • May decrease cortisol synthesis (adrenal
    insufficiency)
  • Dose 0.3 mg/kg IV

22
Barbiturates/Hypnotics
  • Propofol (Diprivan)
  • sedative hypnotic
  • Extremely rapid onset (10 sec),
  • Duration of 10-15 minutes
  • Decreases ICP, Can cause profound hypotension
  • Dose 1-3 mg/kg IV for induction
  • Dose 100-200 mcg/kg/min for maintenance

23
Ketamine
  • Ketamine
  • dissociative anesthetic, not a sedative
  • Rapid onset (1-2mins), short duration (15mins)
  • Potent bronchodilator, useful in asthmatics
  • Increases ICP, IOP, IGP, (beware in head
    injuries)
  • Increases bronchial secretions
  • Emergence phenomenon
  • rarely in children lt10 yrs , common in adults
  • Dose 1-2 mg/kg

24
Opiates
25
Fentanyl
  • Rapid onset (lt1 min), long duration - 30 min
  • Does not release histamine
  • May decrease tachycardia and hypertension
    associated with intubation
  • Seizures and chest wall rigidity
  • Can be reversed with Naloxone
  • Dose 2-10 mcg/kg IV

26
Morphine Sulfate
  • Longer onset (3-5) minutes and duration (2-6)
    hours
  • May not blunt the rise in ICP, hypertension and
    tachycardia as well as fentanyl
  • Histamine release
  • Dose 0.1-0.2 mg/kg IV

27
Benzodiazepines
28
Benzodiazepines
  • Midazolam, Diazepam, Lorazepam
  • Provide excellent amnesia and sedation
  • Broad dose-response relationship
  • Reversed with Flumazenil
  • Doses required are higher for RSI than for
    general sedation

29
Midazolam
  • Slower onset (3-5) min than the
    barbiturate/hypnotic agents
  • Considered short-acting (30-60 min)
  • Does not increase ICP
  • Causes respiratory and cardiovascular depression
  • Dose 0.1-0.4mg/kg IV

30
Diazepam and Lorazepam
  • Moderate/long acting agents
  • Longer onset time than midazolam
  • May be more beneficial post-intubation for
    sedation

31
Paralysis
32
Neuromuscular Blocking Agents
  • Chemical paralysis facilitates intubation by
    allowing visualization of the vocal cords and
    optimizing intubating condition
  • Only CONTRAINDICATION is anticipated difficult
    airway
  • Mallampati Class (I-IV)
  • Thyromental Distance

33
Depolarizing Agents
  • Exert their affect by binding with acetylcholine
    receptors at the neuromuscular junction, causing
    sustained depolarization of the muscle cell

34
Nondepolarizing
  • Bind to acetylcholine receptors in a competitive,
    non-stimulatory manner, no receptor
    depolarization
  • Histamine release
  • Reversed with edrophonium or neostigmine
  • Caution with myasthenia gravis

35
Agents
  • Depolarizing agents
  • Succinylcholine (Anectine)
  • Nondepolarizing Agents
  • Pancuronium (Pavulon)
  • Vecuronium (Norcuron)
  • Atracurium (Tracrium)
  • Rocuronium (Zemuron)
  • Mivacurium (Mivacron)

36
Succinylcholine
  • Gold standard for gt50 years
  • Stimulates nicotinic/muscarinic cholinergic
    receptors
  • Onset 45 secs, duration 8-10 mins
  • Dose Children 2.0 mg/kg IV
  • (adults 1.5 mg/kg IV)
  • Inactivated by pseudocholinesterase

37
Succinylcholine cont
  • Prolonged paralysis seen with
  • Pregnancy
  • Liver disease
  • Malignancies
  • Cytotoxic drugs
  • Certain antibiotics
  • Cholinesterase inhibitors
  • Organophosphate poisoning

38
Succinylcholine
  • Adverse reactions
  • Muscle fasiculations
  • Hyperkalemia
  • Bradycardia
  • Prolonged neuromuscular blockade
  • Trismus
  • Malignant hyperthermia

39
Depolarizing Agents
  • Muscle fasiculations
  • Thought to increase ICP/IOP/IGP
  • Causes muscle pain
  • Minimized by priming dose of non-depolarizing
    NMB
  • Hyperkalemia
  • Average increase in potassium of 0.5-1 mEq/L
  • Burns, crush injuries, spinal cord injuries,
    neuromuscular disorders, chronic renal failure

40
Depolarizing agents
  • Bradycardia
  • Most common in kids lt10 yrs 2o higher vagal tone
  • Especially w/ repeated doses of succinylcholine
  • Premedicate with atropine

41
Depolarizing Agents
  • Malignant hyperthermia
  • From excessive calcium influx through open
    channels
  • Genetic predisposition
  • Rapid rise in temperature, rhabdomyolysis, muscle
    rigidity, DIC
  • 60 mortality
  • Treatment IV Dantrolene

42
Depolarizing Agents
  • Trismus (Masseter spasm)
  • Usually in children
  • Unknown cause
  • Treat with a nondepolarizing NMB

43
Pancuronium
  • Slow onset (1-5 min)
  • Long-acting agent (45-90 min)
  • Renal excretion
  • Vagolytic tachyarrythmias common
  • Dose 0.10-0.15 mg/kg IV

44
Vecuronium
  • Onset of 1-4 min
  • Duration of 30-60 min
  • Hypotension may occur from loss of venous return
    and sympathetic blockade
  • Mostly biliary excretion
  • Dose 0.1 mg/kg
  • priming dose 0.01 mg/kg

45
Rocuronium
  • Shortest onset of the nondepolarizing agents (1-3
    min)
  • Duration 30-45 min
  • Tachycardia can occur
  • Dose 0.6-1.2 mg/kg (1mg/kg)

46
Placement of Tube
  • Allow medications to work and assure complete
    neuromuscular blockade of the patient
  • Maintain Sellick maneuver until cuff inflated
  • Ventilate with bag-valve mask if unsuccessful
  • Additional doses of sedatives/NMB may be
    necessary
  • Confirm tube placement

47
Post Intubation Management
  • Secure tube
  • Continuous pulse oximetry
  • Reassess vital signs frequently
  • Obtain chest x-ray, ABG
  • Restrain (physical/chemical)patient
  • Consider long term sedation

48
Questions??
  • Thank You!
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