AIRWAY 1: - PowerPoint PPT Presentation

Loading...

PPT – AIRWAY 1: PowerPoint presentation | free to download - id: 461cf4-MzEwO



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

AIRWAY 1:

Description:

AIRWAY 1: RAPID SEQUENCE INTUBATION Stuart Swadron, MD, FRCPC, FACEP Program Director Residency in Emergency Medicine Keck-USC School of Medicine LAC+USC Dept. of ... – PowerPoint PPT presentation

Number of Views:204
Avg rating:3.0/5.0
Slides: 84
Provided by: tdhOrgNz
Learn more at: http://www.tdh.org.nz
Category:

less

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

Title: AIRWAY 1:


1
AIRWAY 1 RAPID SEQUENCE INTUBATION Stuart
Swadron, MD, FRCPC, FACEP Program
Director Residency in Emergency Medicine Keck-USC
School of Medicine
LACUSC Dept. of Emergency Medicine
July 19, 2007
2
DEFINITIONS
Rapid Sequence Intubation
INDUCTION AGENT PARALYTIC
UNCONSCIOUSNESS MOTOR PARALYSIS
3
DEFINITIONS
Pharmacologically Assisted Intubation
INDUCTION AGENT
UNCONSCIOUSNESS
4
DEFINITIONS
Geneva Convention Violation
PARALYTIC
MOTOR PARALYSIS
5
RATIONALE Principle
Decreased aspiration
Increased success
6
RATIONALE - Secondary
Better C-spine control
7
RATIONALE - Secondary
Blunting ? ICP / IOP
8
RATIONALE - Secondary
Avoid airway trauma
9
RATIONALE - Secondary
Avoid airway trauma
10
? Pain ? Discomfort ? Recall
11
HAZARDS
Prolonged intubation
12
HAZARDS
Adverse Drug Events
13
HAZARDS
May force crash airway scenario
14
INDICATIONS
  • Failure OR Imminent failure of
  • 1. oxygenation
  • 2. ventilation
  • 3. airway protection or maintenance

15
CONTRAINDICATIONS
RISK
INDICATION
16
(No Transcript)
17
RSI CAN ALSO BE
  • UNNECESSARY
  • - OR
  • INAPPROPRIATE

18
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
19
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
20
PREPARATIONt 10 minutes
  • 1. EQUIPMENT PRESENT AND WORKING
  • MUST INCLUDE EQUIPMENT
  • FOR PLAN B

21
PREPARATIONt 10 minutes
  • 2. ASK CAN I
  • BAG THE PATIENT
  • TUBE THE PATIENT
  • CRIC THE PATIENT

22
L ook at general anatomyE valuate the 3-3-2
ruleM allampati scoreO bstructionN eck
mobility
CAN I TUBE THIS PATIENT?
23
CAN I BAG THIS PATIENT?
Maybe.
Maybe Not.
24
CAN I CRIC THIS PATIENT?
may include alternative airway techniques
25
(No Transcript)
26
(No Transcript)
27
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
28
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
29
PREOXYGENATIONt 5 minutes
  • 1. PRIMUM NO BAGER!
  • (First, do not bag!)
  • 2. If you do need to bag,
  • Remember TOM

30
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
31
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
32
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
33
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
34
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
35
PREOXYGENATIONt 5 minutes
  • 1. Well-fitting mask
  • 8 vital capacity breaths

Nimmagadda et al. Anesthesiology 93 (3) 693-698,
2000 Baraka et al. Anesthesiology 91 (3) 612,
1999
36
PREOXYGENATIONt 5 minutes
Ill adult
Normal child
Normal adult
Obese adult
37
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
38
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
39
PRETREATMENTt 3 minutes
  • L Lidocaine
  • O Opioids
  • A Atropine
  • D Defasciculating Medication

40
PRETREATMENTt 3 minutes
  • LOAD
  • may just be a
  • LOAD

41
LIDOCAINE
  • Traditional Indications
  • Tight Brains
  • There is currently no evidence to support the
    use of intravenous lidocaine as a pretreatment
    for RSI in patients with head injury and its use
    should only occur in clinical trials
  • Robinson N, Clancy, M. Emergency Medicine
    Journal 18(6)453-7, 2001
  • Tight Lungs
  • no study has demonstrated a protective effect
    of both intravenous and topical anesthetic
    agents in preventing bronchospasm after
    intubation..
  • Maslow et al. Anesthesiology, 93(5) 1198-1204,
    2000

42
OPIOIDS (Fentanyl)
  • Traditional Indications
  • 1. Blunt hemodynamic response
  • 2. Decrease pain

Adachi et al. Anesthesia Analgesia.
95(1)233-7, 2002
43
FENTANYL DOSE
  • Dose 3µg/kg IV slow push

Beware of hypotension and apnea
44
ATROPINE
  • Standard practice
  • Give atropine to
  • 1. all children less than 8 years old
  • 2. prior to second dose of succinylcholine
  • Dose 0.01-0.02 mg/kg IVP

Evidence is mounting that questions routine use
of atropine
Fastle et al. Pediatr Emerg Care20(10)651-5,
2004 McAuliffe et al. Can J Anaesth 43(7)
754-5,1996 Fleming et al. CJEM. 20057(2)114-7
45
DEFASCICULATING DOSEOne tenth the RSI dose
  • Traditional Indications
  • Blunt rise in ICP
  • 2. Decrease risk of aspiration
  • Prevent muscular pain

Questionable value no definitive evidence that
SCh caused a rise in ICP no studies that
investigated the issue of pretreatment with
defasciculating doses and their effect on ICP
Clancy et al. Emergency Medicine Journal.
18(5)373-5, 2001
46
And whats moreDEFASCICULATING DOSEcan be
downright dangerous
  • it may cause premature apnea

47
PRETREATMENTt 3 minutes
  • If youre going to give these drugs
  • at least give them some time to circulate (3
    minutes)

48
Summary of LOADPRETREATMENT
  • L idocaine ? optional
  • O piates ? optional
  • A tropine ? still mandatory for kids lt 8
  • D efasciculating ? optional
  • dose

49
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
50
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
51
PARALYSIS WITH INDUCTIONTime 0
  • PARALYTIC AGENTS
  • DEPOLARIZING
  • Succinylcholine
  • NON-DEPOLARIZING
  • Vecuronium
  • Rocuronium
  • INDUCTION AGENTS
  • Etomidate
  • Thiopental
  • Ketamine
  • Propafol
  • Midazolam


52
SUX IS STILL KING
  • but nondepolarizing agents are gaining ground
  • Perry et al. Academic Emergency Medicine 9(8)
    813-23, 2002

53
SUX versus ROC
  • 45 seconds ONSET 1 minute
  • 9 minutes DURATION 45 minutes

1-2.5 mg/kg
1 mg/kg
54
When Sux Really SucksCONTRAINDICATIONS
  • 1. HYPERKALEMIA
  • RENAL FAILURE
  • RHABDOMYOLYSIS
  • 2. RECEPTOR UPREGULATION
  • SUBACUTE BURNS (gt1 day)
  • SUBACUTE DENERVATING DISORDER
  • HISTORY OF MALIGNANT HYPERTHERMIA

55
Advent of the Non-Depolarizing Agents
  • Pancuronium
  • Vecuronium
  • Rocuronium
  • Rapacuronium oops!

56
Making non-depolarizing agents FASTER
  • 1. Large Doses
  • 2. Priming Doses
  • 3. Better Induction Agents

Increase duration
57
The Choice of Induction Agent
  • ETOMIDATE the agent of choice
  • THIOPENTAL hypotension
  • not the greatest intubating conditions
  • PROPAFOL hypotension
  • storage, allergy concerns
  • KETAMINE not the greatest intubating
    conditions
  • some like it for asthma
  • good for penetrating neck trauma
  • MIDAZOLAM effective induction doses cause
    hypotension
  • usually underdosed (requires 0.3mg/kg)
  • better for conscious sedation

58
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
59
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
60
PROTECTION AND POSITIONING t 20 seconds
61
C Spine Precautions
62
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
63
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
64
PLACEMENT AND PROOF t 45 seconds
Over here, Socrates !!!
65
(No Transcript)
66
(No Transcript)
67
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
68
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
69
POST-INTUBATION MANAGEMENT t 90 seconds THE
APRÈS INTUBATION
  • CONFIRM INTUBATION
  • SECURE TUBE
  • CHECK CHEST X-RAY, ABGS

70
CONFIRMING INTUBATION
71
(No Transcript)
72
(No Transcript)
73
SECURING TUBE
74
(No Transcript)
75
(No Transcript)
76
(No Transcript)
77
THE 7 Ps OF RSI
  • PREPARATION
  • PREOXYGENATION
  • PRETREATMENT
  • PARALYSIS WITH INDUCTION
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF
  • POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
78
PUTTING IT ALL TOGETHER
79
TRAUMA WITH HEAD INJURY
  • PREPARATION
  • PREOXYGENATION WITH 100 O2 (t -5min)
  • PRETREATMENT (t -3min)
  • Lidocaine 1.5 mg/kg IVP (Optional - if
    time allows)
  • Vecuronium 0.01 mg/kg IVP (Optional - if
    time / resp status allows)
  • Fentanyl 3 µg/kg IVP (Optional - if
    time / BP allows)
  • PARALYSIS WITH INDUCTION (t 0)
  • Etomidate 0.3 mg/kg
  • Succinylcholine 1.5 mg/kg
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF (t 45 sec)
  • with in-line C-spine stabilization
  • POST-INTUBATION MANAGEMENT

80
STATUS ASTHMATICUS
  • PREPARATION
  • PREOXYGENATION WITH 100 O2 (t -5min)
  • PRETREATMENT (t -3min)
  • Lidocaine 1.5 mg/kg IVP (Optional - if
    time allows)
  • PARALYSIS WITH INDUCTION (t 0)
  • Ketamine 1.5 mg/kg IVP
  • Succinylcholine 1.5 mg/kg
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF (t 45 sec)
  • POST-INTUBATION MANAGEMENT

81
ONE SIZE FITS ALL!
  • PREPARATION
  • PREOXYGENATION WITH 100 O2 (t -5min)
  • PARALYSIS WITH INDUCTION (t 0)
  • Etomidate 0.3 mg/kg
  • Succinylcholine 1.5 mg/kg OR Rocuronium
    1mg/kg
  • PROTECTION AND POSITIONING
  • PLACEMENT AND PROOF (t 45 sec)
  • POST-INTUBATION MANAGEMENT

82
INTUBATION HURTS!!!
  • And it keeps on hurting once the tube is in.

83
Thank you!
About PowerShow.com