Emergency Rapid Sequence Intubation: A - PowerPoint PPT Presentation

Loading...

PPT – Emergency Rapid Sequence Intubation: A PowerPoint presentation | free to download - id: 41e405-OThiZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Emergency Rapid Sequence Intubation: A

Description:

Rapid Sequence Intubation : Definition The near simultaneous administration of a sedative-hypnotic agent and a neuromuscular blocker in the presence of continuous ... – PowerPoint PPT presentation

Number of Views:1234
Avg rating:3.0/5.0
Slides: 59
Provided by: DrMar66
Learn more at: http://www.mcgill.ca
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Emergency Rapid Sequence Intubation: A


1
Emergency Rapid Sequence IntubationA How and
When To Guide
  • Pat Melanson, MD, FRCPC
  • Department of Emergency Medicine
  • Division of Critical Care Medicine
  • Royal Victoria Hospital

2
Rapid Sequence Intubation Definition
  • The near simultaneous administration of a
    sedative-hypnotic agent and a neuromuscular
    blocker in the presence of continuous cricoid
    pressure to facilitate endotracheal intubation
    and minimize risk of aspiration
  • modifications are made depending upon the
    clinical scenario

3
A Brief History of Emergency RSI
  • intubation of the newly/nearly dead (prehistoric)
  • techniques adapted from anesthetists in Case Room
    and crash full-stomach induction's
    (exploration)
  • rapid dissemination of RSI teaching to emergency
    physicians (proselytism)
  • evidence-based research supporting safety and
    advantages of emergency RSI (enlightenment)
  • increasingly sophisticated techniques and
    methodology critically evaluated (postmodern)

4
Intubation Dilemmas
  • Intubate Awake or Asleep
  • Oral or Nasal
  • Laryngoscopy or Blind Intubation
  • To Paralyze or Not

5
Oral Intubation Without Drugs
  • Reserved for the completely unconscious,
    unresponsive, pulseless and apneic
  • Arrest situations only
  • The CRASH AIRWAY

6
Oral Intubation with Sedation
  • proponents argue use of BZ or opioids
  • improves airway access
  • decreases patient resistance
  • avoids risks of NMB
  • Generally obtunds patient to point of loss of
    protective reflexes and respiratory drive
  • lower success rate, higher complications compared
    with RSI

7
Oral Intubation with Sedation
  • In general, the technique of administering a
    potent sedative agent to obtund the patients
    responses and permit intubation in the absence of
    NMB is hazardous and to be discouraged is not an
    appropriate alternative to properly conducted RSI
    and affords neither the success rate or the
    minimal complication rate of RSI.
  • RM Walls, page 4, Chapter 1, Rosen

8
Oral Intubation with Sedation
  • The avoidance of NMB actually creates a more
    hazardous situation for the patient and this
    practice should no longer be considered an
    appropriate method for emergency department ET
    intubation.
  • RM Walls, page 8, Chapter 1, Rosen

9
Oral Intubation with SedationUse for the
Anticipated Difficult Airway
  • if time permits
  • topical anesthesia
  • careful titrated sedation
  • avoid obtundation
  • Awake intubation technique

10
Blind Nasal Intubation
  • success rates 65 - 80 in most series
  • high complication rates
  • epistaxis
  • pharyngeal/ esophageal perforations
  • increased incidence of O2 desats
  • Considered second line approach only
  • reserved for when RSI contraindicated
  • The DIFFICULT AIRWAY

11
Approach to Airway Management Algorithms
  • Is intubation indicated ?
  • Is this a Crash Airway situation ?
  • Is this a potentially Difficult Airway?
  • Difficult laryngoscopy ?
  • Difficult Bag -Mask Ventilation?
  • Is RSI appropriate ?
  • Is this a Failed Airway?

12
Emergency Airway Concerns
  • full stomach
  • minimal respiratory reserve
  • hemodynamic instability
  • acute myocardial ischemia
  • increased intracranial pressure
  • C-spine injury
  • The Difficult Airway
  • Laryngoscopy
  • bag-mask difficulty

13
Advantages of RSI
  • facilitates and expedites endotracheal intubation
  • increased success rate
  • decreased time to intubation
  • minimizes trauma during laryngoscopy
  • minimizes hypoxia and hypercapnia
  • minimizes risk of aspiration
  • minimizes hemodynamic effects of intubation

14
Disadvantages of RSI
  • operator assumes complete responsibility for
    oxygenation, ventilation and airway patency
  • irreversible commitment
  • (burnt bridges)
  • adverse effects of medications
  • ?? increases surgical airway rate
  • no evidence

15
Rapid Sequence Intubation Principles
  • Emergency intubation is indicated
  • The patient has a full stomach
  • Intubation is predicted to be successful
  • If intubation fails, ventilation is predicted to
    be successful
  • Consists of a series of planned discrete steps

16
Principles of RSI
  • Competing demands
  • Minimizing risk of aspiration vs. risk of hypoxia
  • Preoxygenation
  • ideally avoid BMV-PPV to minimize aspiration
  • adequate N2 washout (5 min 100 O2 ) gives oxygen
    reservoir providing several minutes of O2 supply
    despite apnea
  • 4 assisted PPV breaths prior to paralysis
  • pulse oximetry essential
  • ANTICIPATE the O2 trend!

17
Principles of RSI (cont)
  • Minimizing gastric distention
  • avoidance of BMV-PPV
  • cricoid pressure
  • caudal to thyroid cartilage
  • complete ring esophageal occlusion
  • release if vomiting occurs
  • maintain until ETT position confirmed
  • minimize peak pressures if BMV-PPV
  • immediate ID of esophageal intubation

18
Typical Emergency RSI Time Course
  • 100 O2, iv access, monitor, oximetry
  • assemble equipment, meds and team
  • thiopental 3mg/kg iv
  • succinylcholine 1.5mg/kg iv
  • cricoid pressure with LOC no bagging
  • laryngoscopy after fasciculations
  • tube position confirmed and secured
  • positive pressure ventilation begins
  • To CT/lavage/OR/etc.
  • O2 sat 100 throughout
  • time 000
  • 200
  • 215
  • 300
  • 320
  • 500

19
Drugs used for RSI Overview
  • Essential
  • Paralytic
  • Sedative/ Induction agent
  • Optional
  • Defasciculant
  • Modulators of hemodynamics/ICP/etc.

20
Emergency RSI Selecting the Patient
  • Is RSI contraindicated?
  • Absolute
  • Cardiopulmonary arrest present/imminent
  • Operator inexperience
  • Relative
  • Anticipated technical difficulties with
    laryngoscopy and/or intubation
  • Anticipated difficulty with BVM

21
Emergency RSI Selecting the Paralytic
  • Neuromuscular blocking agents
  • Depolarizing
  • Succinylcholine
  • Non-depolarizing
  • Vecuronium
  • Rocuronium

22
Emergency RSI Selecting the Paralytic
  • Is succinylcholine contraindicated?
  • NO choose succinylcholine
  • YES choose rocuronium (or vecuronium)
  • If using SUX, is atropine needed?
  • atropine 0.02mg/kg (.15mg-.5mg) 2min before
  • If using SUX, is a defasciculant desired?
  • 10 dose of non-depolarizing agent 2 min prior

23
Succinylcholine ( Anectine)
  • dose 1.5 mg/kg
  • onset 45 - 60 seconds
  • duration 6 to 10 min (3 to 15)
  • disadvantages
  • ACh analog - bradycardia
  • fasciculations
  • hyperkalemia ( K release)
  • malignant hyperthermia

24
Succinylcholine Contraindications
  • Hyperkalemia - renal failure
  • Active neuromuscular disease with functional
    denervation
  • ( 6 days to 6 months)
  • Extensive burns, crush injuries
  • Malignant hyperthermia
  • Pseudocholinesterase deficiency
  • Organophosphate poisoning

25
Succinylcholine Complications
  • Inability to secure airway
  • Increased vagal tone ( second dose )
  • Histamine release ( rare )
  • Increased ICP/ IOP/ gastric pressure
  • Myalgias
  • Hyperkalemia with burns, NM disease
  • Malignant hyperthermia

26
Vecuronium ( Norcuron )
  • dose 0.1 - 0.2 mg/kg
  • action 120 secs to 60 minutes
  • prime with 1/10 dose 2 min prior
  • onset in 90 secs
  • advantages
  • non-depolarizing
  • neutral hemodynamics
  • hepatic clearance

27
Rocuronium ( Zemuron )
  • dose 0.6 - 1.2 mg/kg
  • onset 60 -90 secs
  • advantages
  • almost as rapid as SUX
  • disadvantages
  • less rapid in elderly
  • long duration

28
Emergency RSI Selecting the Sedative
?
  • Thiopental
  • Ketamine
  • Midazolam
  • Propofol
  • Etomidate
  • (nothing)

?
?
?
29
Thiopental ( Pentothal )
  • dose 1- 5 mg/kg
  • action 20 sec to 5 minutes
  • advantages
  • ultrafast, short duration
  • neuroprotective, anticonvulsant
  • familiar
  • disadvantages
  • hypotension ( myocardial depression, vd)
  • ultrashort duration ( 3 - 5 minutes )
  • demyelination in porphyria
  • chemical endarteritis, thrombosis

30
Midazolam ( Versed )
  • dose 0.1 - 0.4 mg/kg
  • action 2 min to 120 minutes
  • advantages
  • wide therapeutic index
  • amnesia
  • disadvantages
  • variable dose response
  • slower onset
  • suboptimal effect at lower doses
  • negative inotrope, vasodilation

31
Ketamine ( Ketalar )
  • dose 1 - 2 mg/kg
  • action 30 secs to 15 minutes
  • advantages
  • bronchodilation
  • supports BP
  • disadvantages
  • increases ICP and IOP
  • salivation
  • emergence reactions

32
Propofol ( Diprivan )
  • dose 0.5 - 2.5 mg/kg (20-40mg q10 s)
  • action 20 sec to 5 minutes
  • advantages
  • ultrarapid
  • neuroprotective
  • disadvantages
  • hypotension, bradycardia
  • ultrashort duration

33
Etomidate ( Amidate )
  • dose 0.3 mg/kg
  • action 1 minute to 10 minutes
  • advantages
  • hemodynamically neutral
  • neuroprotective
  • disadvantages
  • unfamiliar
  • vomiting
  • cortisol suppression

34
Emergency RSI Selecting the Sedative
  • Identify Primary Concern
  • Hemodynamics fentanyl, ketamine, etomidate
  • Neuroprotection thiopental, propofol
    (midazolam)
  • Bronchodilation ketamine
  • Speed thiopental, propofol (ketamine)

35
Emergency RSI Selecting the Sedative
  • Identify any Secondary Concerns
  • Hemodynamics beware thiopental, propofol
    (midazolam)
  • Neuroprotection avoid ketamine (??)
  • Speed beware midazolam
  • Patient given naloxone avoid fentanyl
  • Specific contraindications (e.g. porphyria)
    avoid drug

36
The Intubation Reflex
  • Catecholamine release in response to laryngeal
    manipulation
  • Tachycardia, hypertension, raised ICP
  • Attenuated by beta-blockers, fentanyl
  • ICP rise possibly attenuated by lidocaine
  • Midazolam and thiopental have no effect

37
Emergency RSI Selecting optional medications
  • Increased ICP Lidocaine
  • Bronchospasm Lidocaine
  • Tachycardia harmful fentanyl (esmolol) 3 min
    before
  • atropine if child receiving Sux
  • defasciculant
  • priming dose of neuromuscular blocking agent
  • topical/regional anesthetics

38
Emergency RSI Checklist Flight planning
  • Move patient to resuscitation suite
  • Assemble personnel
  • 100 O2
  • Patient too unstable for RSI gt intubate ASAP
  • Inadequate ventilation/sat lt90 gt BMV
  • Select drugs and doses, delegate Drug Nurse
  • Cardiac monitor, BP cuff, O2 sat continuously
  • IV running in limb contralateral to BP cuff
  • Cleared to taxi

39
Emergency RSI Checklist Taxiing
  • C-Spine? OK pillow/folded sheet under head
  • ? designate assistant in-line stabilization
  • Check ETT and lubricate (/- stylet)
  • Check laryngoscope (and other airway device prn)
  • Yankauer suction on and under mattress (to right)
  • Final neuro assessment (AVPU, posturing, pupils)
  • Baseline HR, BP, O2 sat
  • Review drugs, doses and sequence with Drug Nurse
  • Cleared for take-off

40
Emergency RSI Checklist Take-off
  • administer optional drugs
  • administer sedative
  • administer paralytic
  • cricoid pressure with loss of ciliary reflex
  • BMV if hypercapnia deleterious/sat lt90
  • laryngoscopy once fully relaxed
  • BURP to visualize larynx
  • Confirm ETT placement and secure
  • Ventilator settings
  • Treat fluctuations in VS as indicated
  • CXR
  • 000
  • 300
  • 315
  • 400
  • 430
  • 500-1500

time (mmss)
41
Rapid Sequence Intubation Procedure
  • Pre-intubation assessment
  • Pre-oxygenate
  • Prepare
  • Premedicate
  • Paralyze with Induction
  • Pressure on cricoid
  • Place the tube
  • Post intubation assessment

42
Pre-oxygenate ( Time
- 5 Minutes)
  • 100 oxygen for 5 minutes
  • 4 conscious deep breaths of 100 O2
  • Fill FRC with reservoir of 100 O2
  • Allows 3 to 5 minutes of apnea
  • Essential to allow avoidance of bagging
  • If necessary bag with cricoid pressure

43
Preparation (
Time - 5 Minutes )
  • ETT, stylet, blades, suction, BVM
  • Cardiac monitor, pulse oximeter, ETCO2
  • One ( preferably two ) iv lines
  • Drugs
  • Difficult airway kit including cric kit
  • Patient positioning

44
Pre-treatment/ Prime ( Time
- 2 Minutes )
  • Lidocaine 1.5 mg/kg iv
  • Defasciculating dose of non-depolarizing NMB
  • Fentanyl 3- 5 mcg/kg
  • Atropine 0.02 mg/kg
  • ( The above agents are optional and given if
    there is a specific indication and time permits)

45
Induction agent
  • Thiopental 3 - 5 mg/kg
  • Midazolam 0.1 - 0.4mg/kg
  • Ketamine 1.5 - 2.0 mg/kg
  • Propafol 0.5 - 2.0 mg/kg
  • Etomidate 0.2 - 0.3 mg/kg

46
Paralyze ( Time Zero )
  • Succinylcholine 1.5 mg/kg iv
  • Allow 45 - 60 seconds for complete muscle
    relaxation
  • Alternatives
  • Vecuromium 0.1 - 0.2 mg/kg
  • Rocuronium 0.6 - 1.2 mg/kg

47
Pressure
  • Sellick maneuver
  • initiate upon loss of consciousness
  • continue until ETT balloon inflation
  • release if active vomiting

48
Place the Tube (
Time Zero 45 Secs )
  • Wait for optimal paralysis
  • Confirm tube placement with ETCO2

49
Post-intubation Hypotension
  • Loss of sympathetic drive
  • Myocardial infarction
  • Tension pneumothorax
  • Auto-peep

50
Difficult Airway Kit
  • Multiple blades and ETTs
  • ETT guides ( stylets, bougé, light wand)
  • Emergency nonsurgical ventilation
    ( LMA, Combitube, TTJV )
  • Emergency surgical airway access (
    cricothyroidotomy kit, cricotomes )
  • ETT placement verification
  • Fiberoptic and retrograde intubation

51
Amitriptyline tripper
  • 27 year old overdose benzos TCAs 1 hour PTA.
  • Decreasing LOC (?ciliary reflex). HR 140
    wide-complex regular, BP 90/50, RR 24,
  • O2 sat 99 on O2.

52
Walking at the scene
  • 22 yr old multiple abdominal stab wounds 6
    knife.
  • Evisceration, agitation and uncooperative.
  • HR 140, BP 90/50, RR 22,
  • O2 sat 99 on O2.

53
Status asthmaticus severus
  • 50 yr old asthmatic x years, never admitted O/N.
    SOB x 2d despite prednisone, antibiotics, and
    salbutamol q1h. Despite continuous salbutamol,
    epi s/c x 2, and SoluMedrol iv, begins to
    fatigue.
  • pH 7.22, pCO2 70, pO2 140.

54
Collapse at bank
  • 38 year old male, standing in line at bank,
    complained of sudden severe HA and collapsed.
  • On arrival, HR 55 BP 170/100 RR 12 decorticate
    posturing.

55
NOT renal colic
  • 68 year old male, hypertensive, no past history
    of urolithiasis, presents with R flank pain and
    hematuria. While you are booking the spiral CT,
    he complains of increasing back pain, then
    vomits. HR 140 BP 85/palp diaphoretic .
  • And then he gets worse.

56
Overdue for dialysis
  • 68 yr old hemodialysis-dependent pt in florid
    pulmonary edema and decreasing LOC.
  • HR 120 reg, BP 220/120,
  • O2 sat 85 on non-rebreather 15L/min.

57
Too much Nintendo
  • 14 year old known epileptic on multiple meds,
    still seizing after diazepam, phenobarb and over
    30 minutes in the ED.
  • 160 100/50 37.2 99 sat.
  • Small jaw.

58
I would especially commend the physician who,
in acute diseases, by which the bulk of mankind
are cutoff, conducts the treatment better than
others. Hippocrates
About PowerShow.com