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Rapid Sequence Intubation


Rapid Sequence Intubation Otto Sabando DO FACOEP Program Director Emergency Medicine Residency St. Joseph s Regional Medical Center Paterson NJ Objectives Overview ... – PowerPoint PPT presentation

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Title: Rapid Sequence Intubation

Rapid Sequence Intubation
  • Otto Sabando DO FACOEP
  • Program Director
  • Emergency Medicine Residency
  • St. Josephs Regional Medical Center
  • Paterson NJ

  • Overview of Rapid sequence induction (RSI)
  • RSI Procedure
  • Pretreatment agents
  • Induction agents
  • Paralytic medications
  • Case studies Pitfalls
  • Questions

Overview of RSI
  • 1979, Taryle and colleagues reported
    complications in 24 of 43 patients needing an
    emergent airway
  • Improvement of house officer training
  • More liberal use of procedures used in the OR

Overview of RSI
  • Objectives
  • Immediate airway control necessitating induction
    of anesthesia and muscle relaxation
  • Provision of anesthesia and sedation to the awake
  • Minimization of intubation adverse effects,
    including systemic and intracranial hypertension

Overview of RSI
  • Prehospital?
  • In non-cardiac arrest patients, overall RSI
    success rate 92-98. Comparable to ED settings
  • Without a full compliment of medications, success
    rate are 60 as in ED settings
  • i.e. Patient combative, intact gag reflex,
    preexisting muscle tone

Overview of RSI
  • Impact of prehospital intubations on
  • Gausche and Colleagues
  • Comparison bag-mask ventilation and endotracheal
    intubation for critically ill and injured
    pediatric patients
  • 820 subjects, no paralytics and sedation used
  • 57 intubation success rate
  • Similar outcomes for both study groups

Overview of RSI
  • Winchell and Hoyt
  • Retrospective review of 1092 blunt trauma
    patients with GCS score of less than 9
  • Prehospital intubation reduced mortality from 36
    to 26 (impact on most severely injured)
  • Endotracheal intubation without medications had
    success rate of 66

Overview of RSI
  • Bochicchio and colleagues
  • Compared brain injured patient outcomes in
    patients with and without prehospital RSI
  • Pre-hospital RSI
  • Higher mortality rate and more ventilator days
  • Equivalence of the patient groups upon paramedic
    arrival is unknown
  • Study suggest that prehospital RSI and intubation
    may adversely affect outcomes

Overview of RSI
  • Further prospective evaluations
  • Prehospital physiology
  • Notation of preexisting aspiration
  • Better prospective studies!

RSI Procedure
  • Preoxygenate with 100 NRB if the patient is
    spontaneously breathing
  • No positive pressure ventilations
  • Intravenous line Preferably 2 lines 20 gauge or
    larger in adults
  • Cardiac monitor, pulse oximetry, and Capnography
  • Prepare equipment suction, difficult airway cart,

RSI Procedure
  • Explain the procedure Document neurologic status
  • Sedative agent
  • Defasciculating agent, lidocaine, and or atropine
  • Perform Sellick maneuver
  • Neuromuscular agent
  • Intubate trachea and release Sellick maneuver
  • Confirm placement

RSI Procedure
  • Sample Rapid Sequence Intubation Using Etomidate
    and Succinylcholine Timed Step
  • Zero minus 10 min Preparation
  • Zero minus 5 min Preoxygenation 100 oxygen
    for 3 min or eight vital capacity breaths
  • Zero minus 3 min Pretreatment  as indicated
  • Zero Paralysis with induction   Etomidate, 0.3
    mg/kg   Succinylcholine, 1.5 mg/kg
  • Zero plus 45 sec Placement   Sellick's
    maneuver   Laryngoscopy and intubation   End-tidal
    carbon dioxide confirmation
  • Zero plus 2 min Post-intubation
    management   Midazolam 0.1 mg/kg,
    plus   Pancuronium, 0.1 mg/kg, or   Vecuronium,
    0.1 mg/kg

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RSI Procedure
  • Principal contraindication
  • Any condition preventing mask ventilation or

Pretreatment agents
  • Goal Attenuate pathophysiologic responses to
    Laryngoscopy and intubation
  • Reflex sympathetic response
  • Increase in heart rate and blood pressure
  • Children vagal response predominates
  • Bradycardia
  • Laryngeal stimulation
  • Lanrygospasm, cough, and bronchospasm

Pretreatment agents
  • To be effective, pretreatment agents should be
    given 3-5min prior to RSI
  • Not practical at times

Pretreatment agents
  • Pretreatment Agents for Rapid Sequence Intubation
  • Lidocaine in a dose of 1.5 mg/kg, used to
    mitigate bronchospasm in patients with reactive
    airways disease and to attenuate ICP response to
    Laryngoscopy and intubation in patients with
    elevated ICP
  • Opioid Fentanyl, in a dose of 3 µg/kg,
    attenuates the sympathetic response to
    Laryngoscopy and intubation and should be used in
    patients with ischemic coronary disease,
    intracranial hemorrhage, elevated ICP, or aortic
  • Atropine 0.02 mg/kg is given to prevent
    bradycardia in children 10 years old who are
    receiving succinylcholine for intubation
  • Defasciculation a Defasciculating dose (1/10 of
    the paralyzing dose) of a competitive
    neuromuscular blocker is given to patients with
    elevated ICP who will be receiving
    succinylcholine to mitigate succinylcholine-induce
    d elevation of ICP

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Induction agents
  • Ketamine 1-2mg/kg, onset 1min, duration 5 min
  • Phencyclidine derivative
  • Potent bronchodilator
  • Status asthmaticus
  • Hypertension, increased ICP
  • Increase secretions
  • Atropine to offset
  • Emergence phenomenon
  • Contraindications
  • Elderly Cautious
  • Head injury (ICP increase), increase IOP

Induction agents
  • Etomidate 0.3mg/kg.Onset lt1min, duration
  • Non-barbiturate, non-receptor hypnotic
  • Water and lipid soluble and reaches the brain
  • Sedation comparable to barbiturates
  • Acts on CNS to stimulate ?-aminobutyric acid
    receptors and depress the RAS
  • No analgesic activity

Induction agents
  • Decreases cerebral oxygen consumption, cerebral
    blood flow and ICP
  • Best used in patients with head injury and
  • Side effects
  • Nausea, vomiting, myoclonus
  • Inhibition of adrenal cortical function (not
    really seen with one dose induction)

Induction agents
  • Propofol 0.5-1.5mg/kg IV onset 20-40 seconds,
    duration 8-15 minutes
  • Highly lipophylic
  • Alkylphenol sedative-hypnotic
  • Has amnestic effect but no analgesic effects
  • Dose dependant depression of consciousness
    ranging from light sedation to coma
  • Lowers intracranial pressure
  • Anti seizure effects

Induction agents
  • Side effects
  • Direct myocardial depression leading to
    hypotension especially in the elderly

Induction agents
  • Opioids
  • Not first line selections
  • Fentanyl 3-10µg/kg IV. Onset 1-2min, duration
  • Highly lipophylic, rapid serum clearance, high
    potency, and minimal histamine release
  • 50-100 times more patent than morphine
  • Best used for hypotensive patients in pain

Induction agents
  • Side effects
  • Chest wall rigidity (gt15µg/kg IV)
  • ICP variable
  • Respiratory depression (seen with other sedatives)

Induction agents
  • Barbiturates
  • Thiopental 3-5mg/kg IV. Onset 30-60sec. Duration
    10-30 minutes
  • Methohexital (brevital) 1mg/kg IV. Onset lt1min.
    Duration 5-7 min.
  • CNS depressant that leads to deep sedation and
  • Best indication is for status epilepticus, ICP
    related to trauma or HTN emergency

Induction agents
  • Side effects
  • Myocardial depression leading to hypotension (MAP
    decrease by 40mm/hg)
  • Decreased respiratory drive
  • Lanrygospasm

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Paralytic Medications
  • Depolarizing agents
  • Succinylcholine 1-1.5mg/kg. Onset 45-60sec,
    duration 5-9 min.
  • Most commonly used agent for paralysis
  • Chemical structure similar to acetylcholine
  • Depolarize postjuctional neuromuscular membrane
  • Rapidly hydrolyzed by pseudocholiesterase

Paralytic Medications
  • Complications
  • Bradyarrythmias
  • Masseter spasm
  • ICP?, IOP, increase intragastric pressure
  • Malignant hyperthermia
  • Tx Dantrolene
  • Hyperkalemia
  • Increase 0.5mEq/ml
  • Histamine release
  • Fasciculation induced musculoskeletal trauma
  • Prevent by using defisciulating dose of
    nondepolorizing agent (10 of normal dose)
  • Prolonged apnea with pseudocholinesterase

Paralytic Medications
  • Contraindications
  • Major burns
  • Muscle trauma
  • Crush injuries
  • Myopathies
  • Rhabdomyolysis
  • Narrow angle glaucoma
  • Renal failure
  • Neurologic disorder
  • Spinal cord injury
  • Guillian-Barre Syndrome
  • Children with undiagnosed myopathies?

Paralytic Medications
  • Nondepolorizing agents
  • Vecuronium 0.08 mg/kg-0.15mg/kg, 0.15-0.28mg/kg.
    Onset 2-4min, duration 25-120min
  • Rocuronium 0.6mg/kg. Onset 1-3min. Duration 30-45
  • Atracurium 0.4-0.5mg/kg. Onset 2-3min. Duration
    25-45 min.
  • Pancuronium 0.1mg/kg. Onset 2-5min. Duration
    40-60 min.

Paralytic Medications
  • Competitive agents that block the effects of
    acetylcholine at the neuromuscular junction
  • Rocuronium is the alternative medication when
    succinylcholine is contraindicated

Paralytic Medications
  • Reversal agents
  • Mostly in OR anesthetized patients, rarely used
    in the ED setting
  • Neostigmine 0.02mg-0.04mg slow IVP
  • Additional doses of 0.01 to 0.02 mg/kg slow IVP
    can be given if reversal is incomplete
  • Total dose not to exceed 5mg in an adult
  • Give atropine 0.01mg/kg to block cholinergic
    effects of Neostigmine
  • Max adult dose 1mg
  • Minimum pediatric dose 0.1mg

Paralytic Medications
  • Complications
  • Vecuronium
  • Prolonged recovery time in elderly and obese
    patients or hepatorenal dysfunction
  • Rocuronium
  • Tachycardia
  • Atracurium
  • Hypotension, histamine release, bronchospasm
  • Pancuronium
  • Hypertension, tachycardia, histamine release

Case 1
  • A 24 y.o. male with a medical history of asthma
    is short of breath secondary to his asthma. You
    note that the patient is hypoxic and getting
  • Which RSI Medications for sedation would be best
    for this case?
  • Answer

Case 2
  • A patient is hit in the head by a bat. His GCS is
    8. You decide to RSI this patient as he is
    combative and altered. Which medications would be
    best in this situation?
  • Sedative
  • Paralytic
  • adjunct

Case 3
  • A 45 y.o. male in respiratory distress with crush
    injuries to his legs needs to be intubated. Which
    of the following paralytics are indicated in this
  • Succinylcholine
  • Rocuronium
  • Vecuronium
  • Pancuronium

  • Yano M, et al Effect of lidocaine on ICP
    response to endotracheal suctioning.
    Anesthesiology 64651, 1986
  • Kirkegaard-Nielsen H, et al Rapid tracheal
    intubation with rocuronium. Anesthesiology
    91131, 1999
  • Schneider RE, Caro D Pretreatment agents. In
    Walls RM, et al (eds) Manual of Emergency Airway
    Management. Philadelphia, Lippincott Williams
    Wilkins, 2004
  • Gausche M. Lewis RJ, Stratton SJ et al. Effect of
    out of Hospital Pediatric Endotracheal Intubation
    on Survival and Neurologic Outcome A controlled
    Clinical Trial. JAMA 283783,2000
  • Bochicchio GV, Ilahi O,Joshi M et al.
    Endotracheal intubation in the field does not
    improve outcome in trauma patients who present
    without an acutly lethal traumatic brain injury.
    J Trauma 54307, 2003
  • Winchell RJ, Hoyt DB Endotracheal intubation in
    the field improves survival in patients with
    severe head injury. Arch Surg 132592, 1997

  • Roberts and Hedges. Clinical Procedures in
    Emergency Medicine. Edition 4. Saunders, 2004
  • Tintnalli J et al. Emergency Medicien A
    comprehensive study guide. Edition 6. McGraw
    Hill, 2004
  • Rosens Emergency Medicine Concept in Clinical
    Practice. Edition 6. Elsevier, 2006

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  • Etomidate
  • Propofol
  • barbiturate

  • 1.5 mg/kg
  • Suppresses cough
  • Suppress ICP?
  • Decrease pressor response secondary to
  • Use with paralytics?
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