RSI REVIEW

for tracheal intubation WHAT IS RSI ? definition virtually simultaneous administration, after preoxygena- tion, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconscious- ness and motor paralysis for tracheal intubation simultaneous after preoxygenation for tracheal intubation

WHAT IS RSI ? definition assumes : patient has a full stomach : no interposed ventilation : preoxygenation : Sellick’s maneuver

supplemental oxygen nasal cannula ~44% 1L/min 24% 2L/min 28% 3L/min 32% 4L/min 36% 5L/min 40% 6L/min 44%

face mask with reservoir supplemental oxygen face mask with 6~10L/min ~60% face mask with reservoir ~100% 6L/min 60% 7L/min 70% 8L/min 80% 9L/min 90% 10L/min

preoxygenation (4) the time to desaturate from 90% to 0% is dramatically less than the time to desaturate from 100% to 90%

protection and positioning ZERO plus 20~30 sec Sellick’s maneuver : initiated immediately on the observation that the patient is losing consciousness : maintained throughout the entire intubation sequence until the ETT has been correctly placed, the position verified, and the cuff inflated 30 Newton

protection and positioning before placing the laryngoscope into the patient’s mouth, the sniffing position is created by placing a pillow, folded towel, or sheet under the patient’s head to facilitate extension of the head on the neck and slight forward flexion of the lower C-spine on the chest

moisture condensation placement and proof correct placement of tracheal tube (1) primary confirmation by P/Ex moisture condensation laryngoscopic view 5-point auscultation listen and observe direct visualization

placement and proof correct placement of tracheal tube (2) esophageal detector device capnography qualitative end-tidal CO2 detector correct placement of tracheal tube (2) secondary confirmation purple (poor) → yellow (yes) 4.5~6% EtCO2 = 35~45 mmHg Pco2 the aspiration bulb technique 2~5% EtCO2 = 15~38 mmHg Pco2 the aspiration syringe technique at least 6 ventilations cardiac arrest

the “standard care” is to perform both primary and secondary confirmation techniques sequencing differences are virtually the only contemporary areas of debate and disagreement whenever there is doubt about the results from primary or secondary confirmation, the best course of action is to remove the tracheal tube and provide BMV

visualize chest expansion bilaterally listen over epigastrium and the lung fields bilaterally use exhaled CO2 detectors direct visualization using laryngoscope or EDD if in doubt, remove the tube, provide BMV, replace

end-tidal CO2 detector TRUE (+) FALSE (+) thinks tube is in trachea inserted in trachea distended stomach, recent ingestion of carbonated beverage FALSE (-) TRUE (-) thinks tube is in esophagus cardiac arrest inserted in esophagus

esophageal detector device TRUE (+) FALSE (+) thinks tube is in esophagus inserted in esophagus secretions in trachea, right mainstem bronchus insertion FALSE (-) TRUE (-) thinks tube is in trachea obesity, late pregnancy, COPD, asthma, recent bagging inserted in trachea

RSI PHARMACOLOGY Pretreatment Agents Sedative And Induction Agents Neuromuscular Blocking Agents Depolarizing (Noncompetitive) NMBAs Nondepolarizing (Competetive) NMBAs

Pretreatment Agents the CNS response : ↑ ICP the cardiovascular system response (sympathetic nervous system) : bradycardia : tachycardia and hypertension the respiratory system response : laryngospasm and coughing : bronchospasm

the LOAD approach lidocaine (xylocaine) opioid - fentanyl (sublimaze) ↑ ICP coughing bronchospasm lidocaine (xylocaine) opioid - fentanyl (sublimaze) atropine defasciculating agents tachycardia hypertension bradycardia ↑ ICP

Summary pretreatment agents are used to attenuate the adverse LIDOCAINE (xylocaine) : 1.5 mg/kg IV 3 minutes before airway manipulation : IICP, bronchospastic disease (asthma, COPD, cardiac asthma) Summary pretreatment agents are used to attenuate the adverse physiologic responses to laryngoscopy and intubation should be administered 3 minutes before induction to match peak drug effect with airway manipulation LOAD (lidocaine, opioids, atropine, defasciculating agents) OPIOID fentanyl (sublimaze) : 3 mcg/kg IV 3 minutes before induction : IICP, ischemic heart disease, aneurysm or dissection, hemodynamically stable penetrating vascular trauma ATROPINE : 0.02 mg/kg IV 3 minutes before induction : any child less than 10 years of age undergoing RSI with Sch DEFASCICULATION : vecuronium, pancuronium, or rocuronium at 10% of the normal paralyzing dose 3 minutes before induction : IICP who will be receiving Sch

Sedative And Induction Agents ultra-short-acting barbiturates thiopental sodium (pentothal) benzodiazepines miscellaneous agents etomidate (amidate) ketamine (ketalar) propofol (diprivan)

thiopental sodium (pentothal) induction dose (mg/kg) 3-6 onset (sec) <30 t1/2α (min) 2-4 duration (min) 5-10 t1/2β (hr) 10-12

thiopental sodium (pentothal) : indications and contraindications Ix : IICP or status epilepticus absolute CIx : acute intermittent porphyria relative CIx : reactive airways disease

thiopental sodium (pentothal) : dosage and clinical use potent venodilator and myocardial depressant : dose must be decreased in patients with decreased intravascular volume, compromised myocardial function, and the elderly (1 to 2 mg/kg IV) avoided entirely in frankly hypotensive patients

benzodiazepines midazolam lorazepam diazepam induction dose (mg/kg) 0.2-0.3 0.03-0.06 a 0.3-0.6 a onset (sec) 30-60 60-120 45-60 t1/2α (min) 7-15 3-10 10-15 duration (min) 15-30 t1/2β (hr) 2-4 10-20 20-40 a not recommended for use as an induction agent for emergency RSI

miscellaneous agents etomidate (amidate) ketamine (ketalar) propofol (diprivan)

induction dose (mg/kg) etomidate (amidate) induction dose (mg/kg) 0.3 onset (sec) 15-45 t1/2α (min) 2-4 duration (min) 3-12 t1/2β (hr) 2-5

etomidate (amidate) : indications and contraindications induction agent of choice for most emergent RSIs because of its rapid onset, its profound hemodynamic stability, its positive CNS profile, and its rapid recovery no contraindications to its use not FDA approved for use in children

etomidate (amidate) : adverse effects myoclonic movement during induction is common and has been confused for seizures : no clinical consequence and generally terminates promptly as the N-M blocking agent takes effect decrease both serum cortisol and aldosterone levels (reversible blockade of 11-beta-hydroxylase) : more common with continuous infusions

induction dose (mg/kg) ketamine (ketalar) induction dose (mg/kg) 1-2 onset (sec) 45-60 t1/2α (min) 11-17 duration (min) 10-20 t1/2β (hr) 2-3

ketamine (ketalar) : clinical pharmacology releases catecholamines, stimulates the sympathetic nervous system, and therefore augments HR and BP directly stimulates the CNS, increasing cerebral metabolism, cerebral metabolic oxygen demand (CMRO2), and CBF, thus potentially increasing ICP : corresponding increases in MAP may offset the rise in ICP directly relaxes bronchial smooth muscle, producing bonchodilatation

ketamine (ketalar) : indications and contraindications induction agent of choice : reactive airways disease : hypovolemic or hypotensive without serious brain injury in normotensive or hypertensive patients with ischemic heart disease, catecholamine release may adversely increase myocardial oxygen demand

induction dose (mg/kg) propofol (diprivan) induction dose (mg/kg) 1.5-3 onset (sec) 15-45 t1/2α (min) 2-4 duration (min) 5-10 t1/2β (hr) 1-3

propofol (diprivan) : clinical pharmacology direct reduction in BP through vasodilatation and direct myocardial depression, resulting in a decrease in cerebral perfusion pressure : rarely, if ever, the induction agent of choice in emergenct RSI, where patient instability is the norm

propofol (diprivan) : indications and contraindications excellent induction agent in a very stable patient no absolute contraindications

Summary THIOPENTAL SODIUM 3~6mg/kg Ix : IICP or status epilepticus Caution : respiratory depression, venodilation, myocardial depression Summary MIDAZOLAM 0.2~0.3mg/kg Ix : procedural sedation Caution : ↓systemic vascular resistance, myocardial depression ETOMIDATE 0.3mg/kg Ix : induction agent of choice Caution : children KETAMINE 1~2mg/kg Ix : reactive airways disease, hypovolemic or redistributive shock Caution : IICP, ↑myocardial oxygen demand PROPOFOL 1.5~3mg/kg Ix : very stable patients Caution : vasodilatation, myocardial depression

Neuromuscular Blocking Agents depolarizing (noncompetitive) NMBA nondepolarizing (competetive) NMBAs

adverse effects fasciculations hyperkalemia bradycardia prolonged N-M blockade malignant hyperthermia trismus/masseter muscle spasm

fasciculations occur simultaneously with increases in ICP, IOP, and intragastric pressure : only the increase in ICP is clinically important fasciculations inhibited by defasciculating dose (10% of the normal paralyzing dose) of a nondepolarizing NMBA : 0.01 mg/kg of vecuronium or pancuronium, or 0.06 mg/kg of rocuronium

hyperkalemia (1) serum K+ increases minimally (0 to 0.5 mEq/L) when Sch is administerd : rhabdomyolysis and receptor upregulation rhabdomyolysis : often associated with myopathies : resuscitation less successful than in receptor up- regulation because of less physiologic reserve

receptor upregulation hyperkalemia (2) immature receptors immature receptors 4- to 5-day period immature receptors immature receptors immature receptors receptor upregulation (1) immature receptors immature receptors immature receptors mature receptors immature receptors receptor upregulation burns denervation crush injuries intraabdominal infections myopathies renal failure

prolonged channel opening (4 times longer than mature receptors) immature receptors prolonged channel opening (4 times longer than mature receptors) increasing levels of K+

bradycardia most commonly in children because of their heightened vagotonic state : bradycardia is attenuated or abolished by administering atropine 0.02 mg/kg IV as a pretreatment drug in adults, repeated doses of Sch may produce the same vagotonic effects and administration of atropine may become necessary

prolonged N-M blockade reduced concentrations of pseudocholinesterase : liver disease, pregnancy, burns, oral contraceptives, metoclopramide, bambuterol, or esmolol a 20% reduction in normal levels will increase apnea time about 3 to 9 minutes

malignant hyperthermia (1) a personal or family Hx of malignant hyperthermia is an absolute CIx to the use of Sch triggered by halogenated anesthetics, Sch, vigorous exercise, and even emotional stress acute loss of intracellular Ca2+ control : muscular rigidity, autonomic instability, hypoxia, hypotension, severe lactic acidosis, hyperkalemia, myoglobinemia, and DIC

malignant hyperthermia (2) elevations in temperature are a late manifestation masseter spasm has been claimed to be the hallmark : Sch can promote isolated masseter spasm : alone is not pathognomonic treatment consists of discontinuing the known or suspected precipitant and the immediate administration of dantrolene sodium (dantrium) : initial dose 2.5 mg/kg IV repeated every 5 minutes (maximum dose 10 mg/kg)

trismus/masseter muscle spasm if masseter spasm interferes with intubation, a full paralyzing dose of a competitive nondepolarizing agent should be administered serious consideration should be given to the Dx of malignant hyperthermia

nondepolarizing (competitive) N-M blocking agents pancuronium vecuronium rocuronium intubating dose (mg/kg) 0.15 1 pretreatment (mg/kg) 0.01 0.06 onset (sec) 100-150 90-120 55-70 duration (min) 120-150 60-75 30-60 full recovery (hr) 3-5 1.5-2 1-2

Summary 1.5~2.0mg/kg 0.15mg/kg 1.0mg/kg