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Rapid Sequence Intubation

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Midazolam, Diazepam, Lorazepam. Provide excellent amnesia and sedation ... Diazepam and Lorazepam. Moderate/long acting agents. Longer onset time than midazolam ... – PowerPoint PPT presentation

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Title: Rapid Sequence Intubation


1
Rapid Sequence Intubation
  • Anthony G. Hillier, D.O.
  • EM Resident
  • St. John West Shore

2
Rapid Sequence Intubation
  • 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

3
Rapid Sequence IntubationIndications
  • Failure of airway maintenance/protection
  • - lost or diminished gag reflex
  • Failure of oxygenation/ventilation
  • - pulmonary edema, COPD
  • Anticipated clinical course
  • - multiple trauma, head injured
  • - intoxication, air transport

4
Rapid Sequence Intubation6 Ps
  • Preparation T-10
  • Positioning
  • Preoxygenation T-5
  • Premedication T-3
  • ParalysisT-0
  • Placement of tube T45
  • Post management T2

5
Preparation
6
Preparation
  • Evaluate
  • LEMON
  • Equipment Check
  • Positioning
  • Drug Selection
  • IVs, monitor, oximetry
  • Ancillary Staff
  • Anticipate alternative airway maneuver

7
Preparation
  • LEMON
  • L-look
  • E-evaluate the 3-3-2 rule
  • M-Mallampati
  • O-Obstruction
  • N-Neck mobility

8
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9
PREOXYGENATION
10
Preoxygenation
  • 100 O2 for 5 minutes of 5 vital capacity
    breaths can theoretically permit 3-5 minutes of
    apnea before desaturation to less than 90 occurs

11
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12
Preoxygenation
  • nitrogen wash-out
  • Avoid bagging the patient if adequately
    preoxygenated

13
PREMEDICATION
14
Premedication
  • Goal is to blunt the patients physiologic
    responses to intubation
  • Minimizes bradycardia, hypoxemia, cough/gag
    reflex, increases in intracranial, intraocular,
    and intragastric pressures

15
Premedication
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculating doses priming

16
Lidocaine
  • Thought to blunt the rise in intracranial
    pressure associated with airway manipulation and
    the use of depolarizing neuromuscular blocking
    agents
  • 1.5-3.0 mg/kg (average 100mg) three minutes prior
    to intubation

17
Atropine
  • 0.02 mg/kg, minimum 0.1 mg IV, max 1 mg, three
    minutes prior to intubation
  • Can minimize vagal effects, bradycardia and
    secretions
  • Infants and children lt 8 years may develop
    profound bradycardia during intubation

18
Defasciculating doses
  • Decreases muscle fasiculations caused by the
    depolarizing agents (succinylcholine)
  • Attenuates rise in intracranial pressure
  • Agents used are the non-depolarizing blocking
    agents (vecuronium, pancuronium etc.) usually
    1/10 of standard dose

19
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

20
Sedation
  • Barbiturates/hypnotics
  • Non-barbiturate
  • Neuroleptics
  • Opiates
  • Benzodiazepines

21
Barbiturates/Hypnotics
  • Thiopental (Pentothal), Methohexital (Brevital)
  • Short onset (10-20) seconds, duration 5-10
    minutes
  • May reduce intracranial pressure,
    cerebro-protective
  • Histamine release, hypotension, bronchospasm

22
Barbiturates/Hypnotics
  • Etomidate (Amidate) a nonbarbiturate hypnotic
  • Decreases ICP/IOP
  • Rapid onset, short duration
  • Minimal hemodynamic effects
  • No histamine release
  • Increases seizure threshold

23
Etomidate
  • No malignant hyperthermia reported
  • Watch for myoclonus, vomiting
  • May decrease cortisol synthesis (adrenal
    insufficiency)
  • Dose 0.3 mg/kg IV

24
Propofol
  • 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

25
Ketamine
  • Ketamine-dissociative anesthetic
  • Rapid onset, short duration
  • Potent bronchodilator, useful in asthmatics
  • Increases ICP, IOP, IGP
  • Contraindicated in head injuries
  • Increases bronchial secretions

26
Ketamine
  • Emergence phenomenon can occur though rarely in
    children less than 10 years
  • Emergence reactions occur in up to 50 of adults
  • Dose 1-2 mg/kg

27
Opiates
28
Fentanyl
  • Fentanyl
  • Broad dose-response relationship
  • Can be reversed with naloxone
  • Fentanyl is rapid acting (lt1 min), duration of 30
    min
  • Does not release histamine

29
Fentanyl
  • May decrease tachycardia and hypertension
    associated with intubation
  • Seizures and chest wall rigidity have been
    reported
  • Dose 2-10 mcg/kg IV

30
Morphine Sulfate
  • Longer onset (3-5) minutes and duration (4-6)
    hours
  • May not blunt the rise in ICP, hypertension and
    tachycardia as well as fentanyl
  • Dose 0.1-0.2 mg/kg IV
  • Histamine release

31
Benzodiazepines
32
Benzodiazepines
  • Midazolam, Diazepam, Lorazepam
  • Provide excellent amnesia and sedation
  • Broad dose-response relationship
  • Reversed with Flumazenil (Romazicon)
  • Doses required are higher for RSI than for
    general sedation

33
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

34
Diazepam and Lorazepam
  • Moderate/long acting agents
  • Longer onset time than midazolam
  • May be more beneficial post-intubation for
    sedation

35
Paralysis
36
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
  • Thyromental Distance

37
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38
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39
Depolarizing Agents
  • Exert their affect by binding with acetylcholine
    receptors at the neuromuscular junction, causing
    sustained depolarization of the muscle cell

40
Nondepolarizing
  • Bind to acetylcholine receptors in a competitive,
    non-stimulatory manner, no receptor
    depolarization
  • Histamine release
  • Agents can be reversed with edrophonium or
    neostigmine
  • Caution with myasthenia gravis

41
  • Depolarizing agents
  • Succinylcholine (Anectine)
  • Nondepolarizing Agents
  • Pancuronium (Pavulon)
  • Vecuronium (Norcuron)
  • Atracurium (Tracrium)
  • Rocuronium (Zemuron)
  • Mivacurium (Mivacron)

42
Succinylcholine
  • Stimulates nicotinic/muscarinic cholinergic
    receptors
  • Gold standard for 50 years
  • Onset 45 seconds, duration 8-10 minutes
  • Dose (adults 1.5 mg/kg IV)
  • Children 2.0 mg/kg IV
  • Inactivated by pseudocholinesterase

43
Succinylcholine cont
  • Prolonged paralysis seen with
  • Pregnancy
  • Liver disease
  • Malignancies
  • Cytotoxic drugs
  • Certain antibiotics
  • Cholinesterase inhibitors
  • Organophosphate poisoning

44
Succinylcholine
  • Adverse reactions
  • Muscle fasiculations
  • Hyperkalemia
  • Bradycardia
  • Prolonged neuromuscular blockade
  • Trismus
  • Malignant hyperthermia

45
Depolarizing Agents
  • Muscle fasiculations
  • Thought to increase ICP/IOP/IGP
  • Causes muscle pain
  • Minimized by priming dose of NMB
  • Hyperkalemia
  • Average increase in potassium of 0.5-1 mEq/L
  • Burns, crush injuries, spinal cord injuries,
    neuromuscular disorders, chronic renal failure

46
Depolarizing agents
  • Bradycardia
  • Most common in children lt10 years due to higher
    vagal tone
  • Also with repeated doses of succinylcholine
  • Premedicate with atropine

47
Depolarizing Agents
  • Malignant hyperthermia
  • From excessive calcium influx through open
    channels
  • Genetic predisposition
  • Rapid temperature, rhabdomyolysis, muscle
    rigidity, DIC
  • 60 mortality
  • Treatment IV Dantrolene

48
Depolarizing Agents
  • Trismus (Masseter spasm)
  • Usually in children
  • Unknown cause
  • Treat with a nondepolarizing NMB

49
Pancuronium
  • Long-acting agent (45-90 min)
  • Slow onset (1-5 min)
  • Renal excretion
  • Vagolytic tachyarrythmias common
  • Dose 0.10-0.15 mg/kg IV

50
Vecuronium
  • Duration of 30-60 min
  • Onset of 1-4 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

51
Rocuronium
  • Has the shortest onset of the nondepolarizing
    agents (1-3 min)
  • Duration 30-45 min
  • Tachycardia can occur
  • Dose 0.6-1.2 mg/kg

52
Placement of Endotracheal Tube
53
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

54
Post Intubation
55
Post Intubation Management
  • Secure tube
  • Continuous pulse oximetry
  • Reassess vital signs frequently
  • Obtain chest x-ray, ABG
  • Restrain patient
  • Consider long term sedation

56
Questions??
  • Thank You!
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