Rapid Sequence Intubation

Control the situation; don’t let the situation control you!! Why are you here? ‘Don’t be afraid’ Control the situation; don’t let the situation control you!!

Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

Paralytic and NonParalytic RSI Paralytic: use of a NeuroMuscular Blocking (NMB) drug in addition to an Induction agent NonParalytic: induction agent only

Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

Rapid Sequence Intubation Definition Assumes: Patient has a full stomach No interposed ventilation Preoxygenation Sellick’s maneuver

Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

Universal EMS Airway Algorithm Agonal/ Unresponsive? Crash Airway Algorithm Yes Fails Needs Intubation No Difficult Airway? Difficult Airway Algorithm Failed Airway Algorithm Yes Fails No RSI Fails

Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

Rapid Sequence Intubation The Seven Ps of RSI Preparation Preoxygenation Pretreatment Paralysis with induction Protection Placement Post-Intubation Management

Rapid Sequence Intubation The Sequence Zero: the time of administration of succinylcholine.

Rapid Sequence Intubation The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Zero - 10 minutes Preparation Difficult Airway: last chance Plan approach Assemble drugs and equipment Establish access, monitoring

Rapid Sequence Intubation The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Zero - 5 minutes Preoxygenation 100% oxygen for three minutes 8 vital capacity breaths Provides essential apnea time Apnea time varies

Rapid Sequence Intubation The Sequence Zero - 3 minutes Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Pretreatment Lidocaine Opioid Atropine Defasciculation “LOAD the patient before intubation.”

Rapid Sequence Intubation The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Zero!! Paralysis with induction Induction agent IV push Succinylcholine 1.5 mg/kg IVP

Rapid Sequence Intubation The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Zero + 30 seconds Protection Sellick’s Maneuver Position patient Do not bag unless SpO2 < 90%

Rapid Sequence Intubation The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Zero + 45 seconds Placement Check mandible for flaccidity Intubate, remove stylet Confirm tube placement - ETCO2 Release Sellick’s maneuver

Rapid Sequence Intubation The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Zero + 90 seconds Post-intubation Management Secure tube Chest x-ray Long acting sedation/paralysis Establish ventilator parameters

Rapid Sequence Intubation Summary The Seven Ps of RSI Preparation Preoxygenation Pretreatment Paralysis with induction Protection Placement Post-Intubation Management

Rapid Sequence Intubation Failed Attempt What if the intubation attempt is not successful? What is a failed attempt versus a failed airway?

Rapid Sequence Intubation Failed Attempt bag/mask ventilation think about the six attributes: operator optimum sniff position BURP paralysis length of blade type of blade

Rapid Sequence Intubation Failed Attempt Rescue Maneuvers The first rescue from failed intubation is bagging The first rescue from failed bagging is better bagging

Rapid Sequence Intubation Speeding Up RSI

Rapid Sequence Intubation Speeding Up RSI Accelerated RSI: preoxygenation for 8 VC breaths shorten pre-treatment interval Immediate RSI: preoxygenation for 8 VC breaths omit pre-treatment

Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

RSI Pharmacology Two pharmacologic decision points Pretreatment Paralysis and Induction

Rapid Sequence Intubation The Sequence Zero - 3 minutes Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation Pretreatment Lidocaine Opioid Atropine Defasciculation “LOAD the patient before intubation.”

PATIENTS AT RISK Larynx, trachea, carina are richly innervated Intubation is intensely stimulating Sympathetic Discharge (RSRL) ICP response (not 2o catecholamines) ICP response to SCh Bronchospastic response Bradycardia (in children)

PATIENTS AT RISK Intracranial pathology “tight brain” Cardiovascular disease “tight heart” “shear pressure” Reactive airways disease “tight lungs” Children

LIDOCAINE 1.5 mg/kg Increased intracranial pressure Blunts ICP response to stimulation Bronchospasm/reactive airways

LIDOCAINE 1.5 mg/kg Tight Brain Tight Lungs

OPIOID Fentanyl 3 mg/kg Blunts catecholamine release Cardiovascular disease Intracranial hypertension May give slowly over 1-3 minutes !! Caution if dependent on sympathetic drive

OPIOID Fentanyl 3 mg/kg Tight Heart/Shear Pressure Tight Brain

ATROPINE 0.02 mg/kg (minimum dose 0.1 mg) Children < 10 years who will receive SCh Standby for second dose of SCh

DEFASCICULATION Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg Intracranial hypertension

DEFASCICULATION Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg Tight Brain

INDUCTION AGENTS

INDUCTION AGENTS HEALTHY, STABLE PATIENTS Etomidate 0.3 mg/kg Midazolam 0.3 mg/kg Ketamine 1.5 mg/kg Propofol 1.5 mg/kg Pentothal 3 mg/kg “IV Push”

INDUCTION AGENTS COMPROMISED PATIENTS Etomidate 0.15-0.2 mg/kg Midazolam 0.1 mg/kg Ketamine 1 mg/kg Propofol 0.5 mg/kg Pentothal 1.5 mg/kg

For specific conditions INDUCTION AGENTS For specific conditions Reactive airways ketamine ICP etomidate, pentothal Hypotensive ketamine Operator preference

NEUROMUSCULAR BLOCKING AGENTS

NEUROMUSCULAR BLOCKING AGENTS Depolarizing - succinylcholine Competitive (nondepolarizing) Aminosteroids (“…onium”) Benzylisoquinolines (“…curi”)

Succinylcholine has one very, very lethal side effect… Succinylcholine is a universally safe drug. No-one is too sick to get succinylcholine. Fatal Hyperkalemia

Succinylcholine Hyperkalemia Receptor Upregulation Burns, crush, prolonged ICU care UMN lesions, including stroke spinal cord injury MS, ALS, other denervations Myopathic Processes Muscular dystrophy Rare idiopathic Mortality 11% Mortality 30% Gronert: Anesthesiology 94:523-529, 2001.

USE OF NONDEPOLARIZERS Pretreatment (Defasciculation) Rapid sequence intubation rocuronium 1 mg/kg vecuronium 0.01 mg/kg+0.15 mg/kg

Rapid Sequence Intubation Fin

Positive Pressure (Ventilation)

Negative Pressure (Inspiration)

Valve Effect: Inspiration