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RSI: Rapid Sequence Intubation What, When, Where, Why

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RSI: Rapid Sequence Intubation What, When, Where, Why & How Michael T. Czarnecki, MD 265 Objective What is RSI? Discuss the 7 P s of RSI Review RSI ... – PowerPoint PPT presentation

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Title: RSI: Rapid Sequence Intubation What, When, Where, Why


1
RSI Rapid Sequence IntubationWhat, When, Where,
Why How
  • Michael T. Czarnecki, MD

265
2
Objective
  • What is RSI?
  • Discuss the 7 Ps of RSI
  • Review RSI pharmacologic agents
  • Highlight current controversies with RSI

3
RSI Defined
  • Virtually simultaneous administration of a
    potent sedative agent and a neuromuscular
    blocking agent to induce unconsciousness and
    motor paralysis for tracheal intubation

4
Why Bother with RSI?
  • Rapid airway control
  • Less risk of aspiration
  • Highest success rates/lowest complications
  • More controlled
  • Optimal intubating conditions

5
What are The Problems Inherent to Intubation?
  • Laryngoscopy and Intubation
  • Increased bronchospasm
  • Increased ICP
  • Increased catecholamine release

6
Beneficial Effects of RSI
  • Tight Heads
  • Intracranial pathology
  • Tight Hearts or Tight Vessels
  • Cardiovascular disease
  • Tight Lungs
  • Reactive airway disease

7
Assumptions in Airway Management
  • Pt. has a full stomach
  • Pt. is preoxygenated
  • Pts. do not receive BVM ventilation unless
    necessary to keep O2 sat. over 90
  • Sellicks maneuver always used

8
RSI 7 Ps
  1. P Preparation
  2. P Preoxygenation
  3. P Pretreatment
  4. P Paralysis with induction
  5. P Protection
  6. P Placement of the tube
  7. P Post-Intubation management

9
RSI Timeline
  • T 10 minutes Prepare
  • T 5 minutes Preoxygenate
  • T 3 minutes Pretreat
  • T 0 Paralysis with induction
  • T 30 seconds Protection
  • T 45 seconds Placement
  • T 90 seconds Post-Intubation management

10
Preparation T 10 minutes
  • Prepare the patient
  • Monitoring/access
  • Positioning
  • Assess for difficult airway
  • 4 Ds,LEMON, BONES, SHORT
  • Mallampati
  • Prepare your equipment
  • Prepare yourself (mental checklist)
  • Prepare your personnel

11
Difficult Airway Assessment
  • 4 Ds
  • Distortion, Disproportion, Dysmobility, Dentition
  • BONES
  • Beard, Obese, No teeth, Elderly, Snores (sleep
    apnea)
  • SHORT
  • Surgery (head/neck/jaw), Hematoma, Obese,
    Radiation, Tumor
  • LEMON
  • MALLAMPATI
  • Always have a Rescue Airway technique ready

JUMP AHEAD
12
MALLAMPATI SCORE
Class I Class II Class III Class
IV
JUMP BACK
13
60-SECOND EXAM LEMON
  • Look for external difficulty
  • Evaluate using 332 rule
  • Mallampati (Class I II)
  • Obstruction
  • Neck Mobility
  • 3 fingers fit in mouth
  • 3 fingers fit from mentum
  • to hyoid cartilage
  • 2 fingers fit from mandible
  • to top of thyroid cartilage

JUMP BACK
14
Rescue Airways
  • Gum Elastic Bougie (GEB)
  • Laryngeal Mask Airway (LMA/ILMA)
  • Combitube
  • Surgical Cricothyrotomy

JUMP BACK
15
Preoxygenate T 5 minutes
  • Provides reservoir of oxygen during apnea
  • If pt. spont. breathing then NRB for 5
  • Provides maximum of 70 FiO2
  • Avoid bagging the spont. breathing patient
  • If needed, use sellick airway adjunct
  • 8 effective Vital Capacity breaths provides best
    preoxygenation

16
Pretreat T 3 minutes
  • L - Lidocaine
  • O - Opiates
  • A - Atropine
  • D Defasiculating Agent

17
Lidocaine (1.5 mg/kg)
  • Consider in Tight Head or Tight Lungs
  • Blunts ICP rise (??)
  • Suppress cough response
  • may blunt bronchospasm
  • may blunt sympathetic response
  • Does Lido help in head trauma?
  • No clinical trials have answered question
  • Not proven to change outcome
  • Little downside in using

Robinson, Emeg Med J 2001 18453
18
Opioids
  • Fentanyl (3 mcg/kg slow IV over 3)
  • Consider in Tight Heads, Tight Heart,
    Tight Vessels
  • Beware cautious use in pts dependent on
    sympathetic drive (aka, trauma)

19
Atropine
  • Only needed in
  • Children under 10 y.o.
  • Adults receiving 2nd dose of succinylcholine
  • 0.01 mg/kg IV push
  • Minumum dose 0.1 mg

20
Defasiculating Agent
  • Use any paralytic at 10 paralyzing dose
  • Consider in Tight Heads
  • Beware may cause hypoventilation and frank
    paralysis be prepared
  • Who needs defasiculation?
  • Helps mitigate ICP rise with succinylcholine
  • Not really useful in any other ICU situation

21
Paralysis with Induction T 0
  • Tailor inducing agent to specific needs
  • Barbituates
  • Etomidate
  • Midazolam
  • Ketamine
  • Propofol

JUMP AHEAD
22
Barbituates
  • Decreases GABA dissociation at receptor
  • Rapid onset sedation
  • Decreases ICP
  • Hypotension (especially in hypovolemia)
  • Choices
  • Thiopental, pentobarbital, methohexital
  • Overall Etomidate is better that Barbs

JUMP BACK
23
Thiopental
  • Onset 15 seconds, duration 3-5 minutes
  • Cardiac depressant, venodilator
  • Hypotension
  • Dose depedent on pt. profile
  • Euvolemic adult (3-5 mg/kg IV)
  • Hypovolemic adult (1-3 mg/kg IV)

JUMP BACK
24
Etomidate
  • Nonnarcotic, nonbarbituate, nonanalgesic
  • Minimal cardio effects, lowers ICP
  • Is it the ideal agent for RSI?
  • May cause critical adrenal suppression
  • Inhibits adrenal mitochondrial hydroxylase
    activity
  • Occurs after both single bolus and infusions
  • Infusions incr. ICU death rate incr. infections
  • Clinical significance is unclear
  • Randomized, controlled trials on outcomes needed

Malerba, et al Intensive Care Med 2005
25
Etomidate (cont)
  • Induction dose 0.2 0.3 mg/kg IV
  • Onset 20 30 seconds
  • Duration 7 15 minutes
  • May cause myoclonic jerking, hiccups, injection
    pain, N/V (also on emergence)
  • Risk for adrenal insufficiency incr. 12-fold

Jackson, Chest 2005 MarMurray, Chest 2005 Mar
127707-709
JUMP BACK
26
Midazolam
  • Nonanalgesic sedative, anxiolytic, amnestic
  • Respiratory depressant and hypotension
  • Give slow IV
  • Give ½ the dose in elderly or COPD
  • Rapid onset (lt 1 minute)
  • Induction dose (0.1 - 0.3 mg/kg) DIFFERENT than
    sedation dose (0.01 0.03 mg/kg)
  • In RSI, 92 of adults are underdosed

Sagarin, et al Acad Emerg Med 2003 Apr 10329-38
JUMP BACK
27
Ketamine (1 2 mg/kg)
  • Dissociative, analgesic, amnestic
  • Causes catecholamine release
  • Incr. BP, HR, ICP, Laryngospasm risk
  • Bronchodilator ? induction agent in asthma
  • Onset 15 30 seconds
  • Duration 10 15 minutes

JUMP BACK
28
Propofol (0.5 1.2 mg/kg) (white magic, milk of
amnesia)
  • Sedative-hypnotic
  • Cardiac depressant, venodilator
  • Hypotension
  • Decr. ICP at expense of CPP

JUMP BACK
29
NMBs Neuromuscular Blocking Agents
  • Depolarizing
  • Succinylcholine
  • Non-Depolarizing
  • Pan/Vec/Atra/Rocuronium
  • Potential Problems
  • Inadequate pre-intubation neuro exam
  • Failure to sedate
  • Inadequate pre-treatment or inadequate dosing
  • Aspiration and Dysrhythmias
  • Failed intubation ? surgical airway needed

30
Succinylcholine (1.5 2.0 mg/kg)
  • Onset 15 30 sec Duration 5 12 min
  • Contraindications
  • FHx malignant hyperthermia, burns, crush
    injuries, progressing neuromuscular disease
  • Side Effects
  • Brady, hyper-K, fasciculations, MH
  • ?HR pretreat all kids adults 2nd dose with
    atropine
  • ?K peaks in 5, resolves in 15
  • Treat like any hyperkalemia case
  • Use actual-body weight for dose

Rose, et al Anesth Analg 2000
31
Non-depolarizing NMBs
  • Longer duration than SUX, onset about equal
  • Aminosteroid compounds
  • Pan/Vec/Rocuronium
  • Benzylisoquinolinum compounds
  • Atracuronium

Vecuronium Rocuronium
0.1 0.2 mg/kg 1 mg/kg
1.5 2.5 minutes 60 seconds
25 45 minutes (90) 30 minutes (45)
Less vagolytic Least cardio effects
32
Rocuronium
  • Is it equivalent to SUX?
  • Meta-analysis 1600 pts ? equivalent in
  • Acceptable conditions for intubation
  • Rates of intubation success
  • But SUX is BEST at creating EXCELLENT conditions

Perry, AEM 2002
33
RSI Timeline
  • T 10 minutes Prepare
  • T 5 minutes Preoxygenate
  • T 3 minutes Pretreat
  • T 0 Paralysis with induction
  • T 30 seconds Protection
  • T 45 seconds Placement
  • T 90 seconds Post-Intubation management

34
  • Align the 3 axes critical for success
  • Sellicks maneuver

35
  • Confirm placement/review CXR
  • Secure tube
  • Vent Settings
  • Administer sedation
  • Maintain paralysis if indicated
  • And..

36
Dont Ever Forget the 7 Ps
  • P Preparation
  • P Preoxygenation
  • P Pretreatment
  • P Paralysis with induction
  • P Protection
  • P Placement of the tube
  • P Post-Intubation management

37
WHEN IN DOUBT, PULL IT OUT!
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