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Rapid Sequence Intubation

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Patient safety in emergency airway management and rapid sequence ... Jay Leno. Micronathia. Down's syndrome. FLK. 23. Difficult Surgical Airway (SHORT) Surgery ... – PowerPoint PPT presentation

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Title: Rapid Sequence Intubation


1
Rapid Sequence Intubation
  • John Bradley, MD
  • Metropolitan Hospital
  • November 14, 2009

2
Lessons from SkydivingLevitan RM. Patient safety
in emergency airway management and rapid sequence
intubation metaphorical lessons from skydiving.
Ann Emerg Med. 20034281-87.
  • Redundancy of safety (primary and backup chute)
  • Planned stepwise approach to deploy 1ary chute
    Simple, fast, easy backup chute deployment
  • Attention to monitoring exit plane at correct
    altitude, altimeter determines when to deploy
    backup chute
  • Equipment vigilance

3
Overview
  • Rapid Sequence Intubation
  • Airway Assessment
  • The Difficult Airway
  • The Failed Airway
  • Airway Options
  • Your Approach

4
Rapid Sequence Intubation (RSI)
  • Definition
  • Assumptions
  • Goals
  • Indications
  • Contraindications
  • Alternatives
  • Procedure
  • Steps
  • Pharmacology

5
RSI Definition
  • The administration of a potent induction agent
    followed immediately by a rapid acting
    neuromuscular blocker (NMB) to render
    unconsciousness and motor paralysis for tracheal
    intubation

6
RSI Assumptions

7
RSI Assumptions
  • Intubation is indicated
  • The stomach is full
  • Intubation is anticipated to be successful
  • If intubation fails, ventilation is expected to
    be successful

8
RSI Goals
  • Optimize intubation conditions
  • Minimize aspiration risk by avoiding positive
    pressure ventilation until after intubation is
    accomplished

9
Indications for Tracheal Intubation

10
Indications for Tracheal Intubation
  • Inability to maintain an airway
  • Inability to maintain adequate oxygenation and
    ventilation
  • Anticipated airway obstruction /
  • Special situations

11
RSI Contraindications

12
RSI Contraindications
  • Tracheal / laryngeal injury / disruption
  • S/P Laryngectomy
  • Massive facial trauma
  • Anticipated difficult airway

13
RSI Alternatives
  • Awake oral intubation with local anesthesia and
    sedation
  • Blind nasotracheal intubation (BNTI)

14
RSIThe 7 Ps

15
RSIThe 7 Ps
  • Preparation
  • Preoxygenation
  • Pretreatment
  • Paralysis with induction
  • Protection with positioning
  • Placement with proof
  • Post-intubation management

16
RSI Timeline
  • Time Action
  • Zero - 10 min Preparation
  • Zero - 5 min Preoxygenation
  • Zero - 3 min Pretreatment
  • Zero Paralysis with induction
  • Zero 20-30 sec Protection with positioning
  • Zero 45-60 sec Placement with proof
  • Zero 60-90 sec Post-intubation management

17
RSI Compressed Timeline
  • Concurrent preparation and preoxygenation
  • Accelerated (2 min)
  • Shorten preoxygenation to 30 sec with 8 vital
    capacity breaths (VC) method
  • Shorten pretreatment interval from 3 min to 2 min
  • Immediate
  • Eliminate pretreatment
  • Preoxygenate with 8 VC breaths

18
Preparation
  • Patient
  • Discussion, airway assessment, IV access
  • Positioning
  • Equipment
  • Airway, monitoring, failed airway
  • Blade type and size, ETT size
  • OP airway, placement confirmation device
  • Cuff integrity and stylet, laryngoscope fxn
  • Personnel

19
Airway Assessment (LEMON)
  • Look externally
  • Evaluate 3-3-2
  • Mallampati
  • Obstruction
  • Neck
  • (Pediatrics)

20
Look Externally
  • Difficult BVM Ventilation ?
  • Difficult Laryngoscopy / Intubation ?
  • Difficult Surgical Airway ?

21
Difficult BVM Ventilation(BONES)
  • Beard
  • Obesity
  • No teeth
  • (Elderly)
  • (Snores)
  • Severe facial burns / angioedema / trauma
  • Unstable midface and/or mandible

22
Difficult Laryngoscopy / Intubation
  • (Severe facial burns / angioedema / trauma)
  • Buck teeth
  • Jay Leno
  • Micronathia
  • Downs syndrome
  • FLK

23
Difficult Surgical Airway(SHORT)
  • Surgery
  • Hematoma or infection
  • Obesity
  • Radiation
  • Tumor (including goiter)
  • Anatomic variability
  • Females

24
Evaluate(3-3-2 Rule)
  • 3 finger breadths between upper lower teeth
  • Ability to visualize
  • 3 finger breadths between the mandible and hyoid
    bone
  • lt 3 suggests anterior larynx
  • Greater axes malalignment
  • 2 finger breadths between thyroid cartilage notch
    and the mandible or floor of the mouth
  • Cephalad larynx

25
Mallampati Classification
  • I Tonsillar pillars and fauces visible
  • II Upper portion of pillars and uvula visible
  • III Base of uvula / soft palate visible
  • IV Only tongue and hard palate visible
  • Patients mouth open, tongue sticking out
  • Correlates with laryngoscopy classification, but
    not as sensitive in grades 3 and 4

26
Laryngoscopic Classification
  • Grade I Entire glottis visible
  • Grade II Arytenoid cartilage and
  • posterior glottis visible
  • Grade III Epiglottis only visible
  • Grade IV Tongue or soft palate visible
  • Grade III and IV are considered difficult
    intubations (about 5 of OR cases)
  • Visualization predicts intubation success

27
Obstruction
  • Angioedema
  • Epiglottis
  • Abscess
  • Burn
  • Trauma
  • Tumor

28
Neck
  • Possible cervical spine injury
  • Rheumatoid arthritis
  • Ankylosing spondylitis

29
High Risk Patients
  • ASA Class III and higher
  • Chronic pulmonary or cardiac disease
  • Fever, volume depletion, current URI
  • Airway assessment suggestive
  • Consider OR, anesthesia consult and/or awake
    intubation

30
ETT Size and Depth
  • Size
  • Females 7.5-8 Males 8-8.5
  • Broslow tape, little finger diameter
  • 4 age/4
  • Depth
  • Females - 21 cm Males - 23 cm
  • Broslow tape, markings on ETT
  • ETT size x 3 (cm) age 10

31
Preoxygenation
  • Establish an O2 reservoir in the lungs body
  • Essential to no bagging principle of RSI
  • Function residual capacity is primary reservoir
  • Permits several minutes of apnea without
    desaturation
  • 100 O2 via nonrebreather for 5 minutes
  • OR
  • 8 VC breaths with 100 O2 via bag/mask

32
Pretreatment (LOAD)

33
Pretreatment (LOAD)
  • Mitigate adverse effects of laryngoscopy
  • Lidocaine 1.5 mg/kg
  • Airway bronchospasm / cough reflex
  • Increased ICP
  • Opiates (Fentanyl 3-6 mcg/kg)
  • Increased ICP, aortic dissection, ruptured aortic
    or IC aneurysm, ischemic heart disease
  • Blunts reflex sympathetic response to
    laryngoscopy
  • Not recommended under age 1

34
Pretreatment (LOAD)
  • Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg)
  • Children lt 10 yo
  • Blunts vagal response to laryngoscopy
  • Defasiculation (with succinylcholine)
  • Increased ICP
  • 1/10th dose of a non-depolarizing NMB
  • Not indicated under age 5

35
Paralysis with Induction
  • Rapid IV administration of sedation followed
    immediately by rapid administration of a
    neuromuscular blocking agent

36
Protection and Positioning
  • Sellicks maneuver
  • Firm pressure (10 )
  • Maintain until placement confirmation and cuff
    inflation
  • Positioning
  • Keep the pillow to maximize POGO
  • Height of bed, height in bed

37
Placement with Proof
  • Test for jaw flaccidity
  • Extend head on neck
  • Gentle controlled technique
  • Blade entry on right, sweep tongue to left
  • Lift handle up and away
  • Suction prn
  • Insert into esophagus, then slowly withdraw
  • Visualize vocal cords
  • Watch ETT pass through vocal cords
  • Check ETT depth
  • Never let go of the tube!
  • Inflate cuff
  • Auscultation

38
Placement with Proof
  • Confirm tracheal placement
  • Direct visualization plus either
  • EtCO2 detector or
  • Esophageal detector
  • Preferred in cardiopulmonary arrest
  • Confirm depth (cords gt bronchus)
  • Auscultation
  • CXR

39
Post-Intubation Management
  • Secure ETT
  • Reassess VS
  • PCXR for depth of placement
  • Bradycardia / Hypoxia -gt Nontracheal tube
  • placement until proven otherwise (DOPE)
  • Hypertension-gtinadequate sedation/analgesia
  • Hypotension

40
Post-intubation Management(Hypotension)
  • Tension PTX
  • High PIP, hard to bag, decreased BS, hypoxia
  • Immediate thoracostomy
  • Decreased venous return
  • High PIPs 2ndary to high intrathoracic pressure
  • Fluids, bronchodilators,
  • Increase expiratory time, decrease TV

41
Post-intubation Management(Hypotension)
  • Induction agent
  • Other causes excluded
  • Fluid bolus, consider reversal agent, expectant
  • Cardiogenic
  • Usually a compromised pt
  • Check EKG, exclude other causes
  • Fluid bolus (caution), pressors

42
Medications
  • Pretreatment drugs (LOAD)
  • Lidocaine
  • Opiates
  • Atropine
  • Defasiculation
  • Sedation
  • Paralysis

43
Sedation
  • Midazolam
  • Etomidate
  • Methohexital / Thiopental
  • Ketamine
  • Propofol

44
Neuromuscular Blocking Agents
  • Noncompetitive depolarizer
  • Succinylcholine (Anectine)
  • Competitive nondepolarizer
  • Benzylisoquinolinium group
  • Atracurium (Tracrium), cisatracurium (Nimbex),
    mivacurium (Mivacron)
  • Aminosteroid group
  • Pancuronium (Pavulon), vecuronium (Norcuron),
    rocuronium (Zemuron)

45
Succinylcholine (SCh) (Anectine)
  • Rapid onset (45 seconds) and short duration of
    action (lt 10 minutes)
  • Mechanism of action
  • Metabolism
  • Sequence of action
  • Dosing

46
SCh Adverse Effects

47
SCh Adverse Effects
  • Malignant hyperthermia
  • Masseter spasm
  • Hyperkalemia
  • Increased ICP / Increased IOP
  • Fasciculations
  • Bradycardia (peds)
  • Prolonged NMB
  • Hypotension (histamine release, (-) inotrope)

48
SCh Contraindications

49
SCh Contraindications
  • Personal or FH of malignant hyperthermia
  • Known or suspected hyperkalemia
  • gt 24 hours post-burn (gt10 BSA, 1-2 yrs)
  • gt 1 week post crush injury (60-90 days)
  • gt 1 week post SCI or CVA (6 months)
  • Neuromuscular disease (indefinite)
  • MS, ALS, muscular dystrophy
  • Anticipated difficult airway

50
Competitive, Nondepolarizing NMB
  • Most commonly utilized post-intubation
  • No CIs other than the difficult airway
  • Disadvantage is longer onset and duration
  • Metabolism variable
  • Higher dose reduces time to paralysis but
    prolongs time to recovery

51
Competitive, Nondepolarizing NMB
  • Aminosteroid group dose not cause histamine
    release
  • Reversible with AChesterase inhibitor
  • Requires 40 spontaneous recovery
  • Consider administering sedation shortly after
    administering vecuronium or pancuronium for RSI

52
Competitive, Nondepolarizing NMB
  • Rapacurium off the market
  • Rocuronium (0.6-1.2 mg/kg)
  • Mivacurium (0.15 mg/kg)
  • Vecuronium (0.3 mg/kg)
  • Pancuronium (0.1 mg/kg)

53
Awake Oral Intubation
  • Upper airway distortion is anticipated
  • Prepare the patient
  • Anesthetize the airway
  • Lidocaine 4 4 cc / neosynephrine 0.5 1cc OR
  • Lidocaine 2 w/EPI 5cc / Lidocaine 2 Plain 5 cc
  • Via nebulizer for 10 minutes OR
  • Lidocaine spray
  • Sedation (Midazolam or Etomidate /- Fentanyl)
  • Onset 3-5 minutes
  • Perform laryngoscopy
  • Immediate intubation / consider RSI / surgical
    airway
  • Can the epiglottis be visualized?
  • Is an abnormal glottis anticipated?

54
Pediatrics
  • Relatively large tongue / more oral secretions
  • High tracheal opening (C1 gt C4,5 adult)
  • Large occiput
  • Cricoid ring is narrowest portion
  • Large tonsils and adenoids and greater angle
    between epiglottis and larygeal opening
  • Minimal cricothyroid membrane until age ¾
  • Small relative FRC
  • Basal oxygen consumption twice the adult rate

55
Pediatrics
  • Appropriately sized equipment (Broslow)
  • Positioning
  • Avoid hyperextension
  • May need to elevate shoulders
  • Effective BVM
  • C-grip / good seal
  • Squeeze, release, release
  • Tidal volume
  • Cricoid pressure

56
Pediatrics
  • Atropine lt age 10
  • Avoid fentanyl lt age, use cautiously
  • Lower barbituate dose per kg
  • No defasciculation lt age 5 / 20 kg
  • Succinylcholine dose
  • Straight blade
  • Uncuffed ETT lt age 8

57
Pediatrics
  • No BNTI lt age 10
  • Adult EtCO2 detector gt 15 kg
  • Securing the tube
  • Place NGT or OGT early
  • Orotracheal intubation for better security
  • No surgical cricothyroidotomy lt age 10

58
The Second Attempt
  • Learn from your first attempt (experience)
  • Blade type or size (Use Mac as a Miller)
  • ETT size
  • Sellicks technique / stylet
  • BURP
  • Reposition the head and neck
  • Chest pressure looking for air bubble
  • Monitor VS, interposed BVM ventilation
  • Find the epiglottis
  • Call for help

59
The Bottom Line
  • The Broslow Tape / Cart
  • Get the trachea intubated efficiently
  • Have a plan
  • Have a back-up plan
  • Call for help early
  • Airway assessment is an integral part of RSI and
    procedural sedation
  • Practice, practice, practice

60
Resources
  • Manual of Emergency Airway Management by Ron
    Walls et al
  • Airway Courses
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