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 pharmacologic agents Highlight current controversies with RSI 20-Sep-18

RSI Defined “Virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation” 20-Sep-18

Why Bother with RSI? Rapid airway control Less risk of aspiration Highest success rates/lowest complications More controlled Optimal intubating conditions 20-Sep-18

What are The Problems Inherent to Intubation? Laryngoscopy and Intubation Increased bronchospasm Increased ICP Increased catecholamine release 20-Sep-18

Beneficial Effects of RSI “Tight Heads” Intracranial pathology “Tight Hearts” or “Tight Vessels” Cardiovascular disease “Tight Lungs” Reactive airway disease 20-Sep-18

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% Sellick’s maneuver always used 20-Sep-18

RSI: “7 P’s” P = Preparation P = Preoxygenation P = Pretreatment P = Paralysis with induction P = Protection P = Placement of the tube P = Post-Intubation management 20-Sep-18

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 20-Sep-18

Preparation: T – 10 minutes Prepare the patient Monitoring/access Positioning Assess for difficult airway “4 D’s”,“LEMON”, “BONES”, “SHORT” Mallampati Prepare your equipment Prepare yourself (mental checklist) Prepare your personnel 20-Sep-18

Difficult Airway Assessment 4 D’s 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 20-Sep-18

MALLAMPATI SCORE Class I Class II Class III Class IV JUMP BACK 20-Sep-18

60-SECOND EXAM “LEMON” Look for external difficulty Evaluate using 3=3=2 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 20-Sep-18

Rescue Airways Gum Elastic Bougie (GEB) Laryngeal Mask Airway (LMA/ILMA) Combitube Surgical Cricothyrotomy JUMP BACK 20-Sep-18

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 20-Sep-18

Pretreat: T – 3 minutes L - Lidocaine O - Opiates A - Atropine D – Defasiculating Agent 20-Sep-18

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; 18:453 20-Sep-18

Opioids Fentanyl (3 mcg/kg slow IV over 3’) Consider in “Tight Heads”, “Tight Heart”, & “Tight Vessels” Beware: cautious use in pt’s dependent on sympathetic drive (aka, trauma) 20-Sep-18

Atropine Only needed in: 0.01 mg/kg IV push Children under 10 y.o. Adults receiving 2nd dose of succinylcholine 0.01 mg/kg IV push Minumum dose: 0.1 mg 20-Sep-18

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 20-Sep-18

Paralysis with Induction: T = 0 Tailor inducing agent to specific needs Barbituates Etomidate Midazolam Ketamine Propofol JUMP AHEAD 20-Sep-18

Overall – Etomidate is better that Barbs 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 20-Sep-18

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 20-Sep-18

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 20-Sep-18

Etomidate (con’t) 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 Mar Murray, Chest 2005 Mar; 127:707-709 JUMP BACK 20-Sep-18

Midazolam Nonanalgesic sedative, anxiolytic, amnestic Respiratory depressant and hypotension Give slow IV Give ½ the dose in elderly or COPD Rapid onset (< 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; 10:329-38 JUMP BACK 20-Sep-18

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 20-Sep-18

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 20-Sep-18

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 20-Sep-18

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 20-Sep-18

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 20-Sep-18

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 20-Sep-18

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 20-Sep-18

Align the 3 axes – critical for success Sellick’s maneuver 20-Sep-18

Confirm placement/review CXR Secure tube Vent Settings Administer sedation Maintain paralysis if indicated And….. 20-Sep-18

Don’t 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 20-Sep-18

WHEN IN DOUBT, PULL IT OUT! 20-Sep-18