Rapid Sequence Intubation Otto Sabando DO FACOEP Program Director Emergency Medicine Residency St. Joseph’s Regional Medical Center Paterson NJ

Objectives Overview of Rapid sequence induction (RSI) RSI Procedure Pretreatment agents Induction agents Paralytic medications Case studies: “Pitfalls” Questions

Overview of RSI 1979, Taryle and colleagues reported complications in 24 of 43 patients needing an emergent airway Improvement of house officer training More liberal use of procedures used in the OR

Overview of RSI Objectives: Immediate airway control necessitating induction of anesthesia and muscle relaxation Provision of anesthesia and sedation to the awake patient Minimization of intubation adverse effects, including systemic and intracranial hypertension

Overview of RSI Prehospital? In non-cardiac arrest patients, overall RSI success rate 92%-98%. Comparable to ED settings Without a full compliment of medications, success rate are ~60% as in ED settings i.e.: Patient combative, intact gag reflex, preexisting muscle tone

Overview of RSI Impact of prehospital intubations on outcome….Controversial! Gausche and Colleagues Comparison bag-mask ventilation and endotracheal intubation for critically ill and injured pediatric patients 820 subjects, no paralytics and sedation used 57% intubation success rate Similar outcomes for both study groups

Overview of RSI Winchell and Hoyt Retrospective review of 1092 blunt trauma patients with GCS score of less than 9 Prehospital intubation reduced mortality from 36% to 26% (impact on most severely injured) Endotracheal intubation without medications had success rate of 66%

Overview of RSI Bochicchio and colleagues Compared brain injured patient outcomes in patients with and without prehospital RSI Pre-hospital RSI Higher mortality rate and more ventilator days Equivalence of the patient groups upon paramedic arrival is unknown Study suggest that prehospital RSI and intubation may adversely affect outcomes

Overview of RSI Further prospective evaluations Prehospital physiology Notation of preexisting aspiration Better prospective studies!

RSI Procedure Preoxygenate with 100% NRB if the patient is spontaneously breathing No positive pressure ventilations Intravenous line: Preferably 2 lines 20 gauge or larger in adults Cardiac monitor, pulse oximetry, and Capnography Prepare equipment: suction, difficult airway cart,

RSI Procedure Explain the procedure: Document neurologic status Sedative agent Defasciculating agent, lidocaine, and or atropine Perform Sellick maneuver Neuromuscular agent Intubate trachea and release Sellick maneuver Confirm placement

RSI Procedure Sample Rapid Sequence Intubation Using Etomidate and Succinylcholine: Timed Step Zero minus 10 min Preparation Zero minus 5 min Preoxygenation 100% oxygen for 3 min or eight vital capacity breaths Zero minus 3 min Pretreatment   as indicated "LOAD“ Zero Paralysis with induction   Etomidate, 0.3 mg/kg   Succinylcholine, 1.5 mg/kg Zero plus 45 sec Placement   Sellick's maneuver   Laryngoscopy and intubation   End-tidal carbon dioxide confirmation Zero plus 2 min Post-intubation management   Midazolam 0.1 mg/kg, plus   Pancuronium, 0.1 mg/kg, or   Vecuronium, 0.1 mg/kg

RSI Procedure Principal contraindication: Any condition preventing mask ventilation or intubation

Pretreatment agents Goal: Attenuate pathophysiologic responses to Laryngoscopy and intubation Reflex sympathetic response Increase in heart rate and blood pressure Children: vagal response predominates Bradycardia Laryngeal stimulation Lanrygospasm, cough, and bronchospasm

Pretreatment agents To be effective, pretreatment agents should be given 3-5min prior to RSI Not practical at times

Pretreatment agents Pretreatment Agents for Rapid Sequence Intubation (LOAD) Lidocaine: in a dose of 1.5 mg/kg, used to mitigate bronchospasm in patients with reactive airways disease and to attenuate ICP response to Laryngoscopy and intubation in patients with elevated ICP Opioid: Fentanyl, in a dose of 3 μg/kg, attenuates the sympathetic response to Laryngoscopy and intubation and should be used in patients with ischemic coronary disease, intracranial hemorrhage, elevated ICP, or aortic dissection Atropine: 0.02 mg/kg is given to prevent bradycardia in children ≤ 10 years old who are receiving succinylcholine for intubation Defasciculation: a Defasciculating dose (1/10 of the paralyzing dose) of a competitive neuromuscular blocker is given to patients with elevated ICP who will be receiving succinylcholine to mitigate succinylcholine-induced elevation of ICP

Induction agents Ketamine: 1-2mg/kg, onset 1min, duration 5 min Phencyclidine derivative Potent bronchodilator Status asthmaticus Hypertension, increased ICP Increase secretions Atropine to offset Emergence phenomenon Contraindications Elderly “Cautious” Head injury (ICP increase), increase IOP

Induction agents Etomidate: 0.3mg/kg.Onset <1min, duration 10-20min. Non-barbiturate, non-receptor hypnotic Water and lipid soluble and reaches the brain quickly Sedation comparable to barbiturates Acts on CNS to stimulate ∂-aminobutyric acid receptors and depress the RAS No analgesic activity

Induction agents Decreases cerebral oxygen consumption, cerebral blood flow and ICP Best used in patients with head injury and hypovolemia Side effects Nausea, vomiting, myoclonus Inhibition of adrenal cortical function (not really seen with one dose induction)

Induction agents Propofol : 0.5-1.5mg/kg IV onset 20-40 seconds, duration 8-15 minutes Highly lipophylic Alkylphenol sedative-hypnotic Has amnestic effect but no analgesic effects Dose dependant depression of consciousness ranging from light sedation to coma Lowers intracranial pressure Anti seizure effects

Induction agents Side effects Direct myocardial depression leading to hypotension especially in the elderly

Induction agents Opioids Not first line selections Fentanyl: 3-10µg/kg IV. Onset 1-2min, duration 20-30min Highly lipophylic, rapid serum clearance, high potency, and minimal histamine release 50-100 times more patent than morphine Best used for hypotensive patients in pain

Induction agents Side effects: Chest wall rigidity (>15µg/kg IV) ICP variable Respiratory depression (seen with other sedatives)

Induction agents Barbiturates: Thiopental: 3-5mg/kg IV. Onset 30-60sec. Duration 10-30 minutes Methohexital (brevital): 1mg/kg IV. Onset <1min. Duration 5-7 min. CNS depressant that leads to deep sedation and coma Best indication is for status epilepticus, ICP related to trauma or HTN emergency

Induction agents Side effects Myocardial depression leading to hypotension (MAP decrease by 40mm/hg) Decreased respiratory drive Lanrygospasm

Paralytic Medications Depolarizing agents Succinylcholine: 1-1.5mg/kg. Onset 45-60sec, duration 5-9 min. Most commonly used agent for paralysis Chemical structure similar to acetylcholine Depolarize postjuctional neuromuscular membrane Rapidly hydrolyzed by pseudocholiesterase

Paralytic Medications Complications: Bradyarrythmias Masseter spasm ICP?, IOP, increase intragastric pressure Malignant hyperthermia Tx: Dantrolene Hyperkalemia Increase 0.5mEq/ml Histamine release Fasciculation induced musculoskeletal trauma Prevent by using defisciulating dose of nondepolorizing agent (10% of normal dose) Prolonged apnea with pseudocholinesterase deficiency

Paralytic Medications Contraindications: Major burns Muscle trauma Crush injuries Myopathies Rhabdomyolysis Narrow angle glaucoma Renal failure Neurologic disorder Spinal cord injury Guillian-Barre Syndrome Children with undiagnosed myopathies?

Paralytic Medications Nondepolorizing agents: Vecuronium 0.08 mg/kg-0.15mg/kg, 0.15-0.28mg/kg. Onset 2-4min, duration 25-120min Rocuronium 0.6mg/kg. Onset 1-3min. Duration 30-45 min Atracurium 0.4-0.5mg/kg. Onset 2-3min. Duration 25-45 min. Pancuronium 0.1mg/kg. Onset 2-5min. Duration 40-60 min.

Paralytic Medications Competitive agents that block the effects of acetylcholine at the neuromuscular junction Rocuronium is the alternative medication when succinylcholine is contraindicated

Paralytic Medications Reversal agents: Mostly in OR anesthetized patients, rarely used in the ED setting Neostigmine 0.02mg-0.04mg slow IVP Additional doses of 0.01 to 0.02 mg/kg slow IVP can be given if reversal is incomplete Total dose not to exceed 5mg in an adult Give atropine 0.01mg/kg to block cholinergic effects of Neostigmine Max adult dose 1mg Minimum pediatric dose 0.1mg

Paralytic Medications Complications Vecuronium Prolonged recovery time in elderly and obese patients or hepatorenal dysfunction Rocuronium Tachycardia Atracurium Hypotension, histamine release, bronchospasm Pancuronium Hypertension, tachycardia, histamine release

Cases

Case 1 A 24 y.o. male with a medical history of asthma is short of breath secondary to his asthma. You note that the patient is hypoxic and getting tired. Which RSI Medications for sedation would be best for this case? Answer

Case 2 A patient is hit in the head by a bat. His GCS is 8. You decide to RSI this patient as he is combative and altered. Which medications would be best in this situation? Sedative Paralytic adjunct

Case 3 A 45 y.o. male in respiratory distress with crush injuries to his legs needs to be intubated. Which of the following paralytics are indicated in this case? Succinylcholine Rocuronium Vecuronium Pancuronium

Questions

References Yano M, et al: Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 64:651, 1986 Kirkegaard-Nielsen H, et al: Rapid tracheal intubation with rocuronium. Anesthesiology 91:131, 1999 Schneider RE, Caro D: Pretreatment agents. In Walls RM, et al (eds): Manual of Emergency Airway Management. Philadelphia, Lippincott Williams & Wilkins, 2004 Gausche M. Lewis RJ, Stratton SJ et al. Effect of out of Hospital Pediatric Endotracheal Intubation on Survival and Neurologic Outcome: A controlled Clinical Trial. JAMA 283:783,2000 Bochicchio GV, Ilahi O,Joshi M et al. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutly lethal traumatic brain injury. J Trauma 54:307, 2003 Winchell RJ, Hoyt DB: Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 132:592, 1997

References Roberts and Hedges. Clinical Procedures in Emergency Medicine. Edition 4. Saunders, 2004 Tintnalli J et al. Emergency Medicien: A comprehensive study guide. Edition 6. McGraw Hill, 2004 Rosen’s Emergency Medicine: Concept in Clinical Practice. Edition 6. Elsevier, 2006

Etomidate Propofol barbiturate

Lidocaine 1.5 mg/kg Suppresses cough Suppress ICP? Decrease pressor response secondary to intubation? Use with paralytics?