1. Chapter 5 Emergency Airway Management — Rapid Sequence Intubation Loren G Yamamoto MD, MPH, MBA, FAAP, FACEP Textbook reading Ped ED group of CGMH MA 陳冠甫

2.  Rapid Sequence Intubation Sedatives Rapid Sequence Intubation Sedatives  Sedative Selection Sedative Selection  Muscle Relaxants Muscle Relaxants  Muscle Relaxant Selection Muscle Relaxant Selection  Defasciculation and Priming Defasciculation and Priming  Adjunctive Agents Adjunctive Agents  Rapid Sequence Intubation Protocol Rapid Sequence Intubation Protocol  Nasal Intubation Compared with Oral Intubation in the Trauma Patient Nasal Intubation Compared with Oral Intubation in the Trauma Patient  Cervical Spine Immobilization During Endotracheal Intubation Cervical Spine Immobilization During Endotracheal Intubation  Alternative Intubation and Airway Techniques Alternative Intubation and Airway Techniques  Avoiding Problems Avoiding Problems  Multiple Trauma Multiple Trauma  Head Trauma Head Trauma  Burns Burns  Status Epilepticus Status Epilepticus  Agitated Patients Who Require Procedures or Transport Agitated Patients Who Require Procedures or Transport

3. Table 5.1. Equipment Needed for Rapid Sequence Intubation Pulse oximeter End-tidal CO 2, monitor or detector Electrocardiogram monitor Uncuffed endotracheal tubes, sizes 2.5 – 6.0 Cuffed endotracheal tubes, sizes 6.0 – 8.5 Endotracheal tube stylets Laryngoscopes (straight blade sizes 0 – 3, curved blade sizes 2 – 4) Oral airways Oxygen masks, preferably a nonrebreather Ventilation masks in all sizes for bag-valve-mask ventilation Large and small self-inflating ventilation bag with oxygen reservoir tail and positive end-expiratory pressure valve attachment Laryngeal mask airways in all sizes Oxygen source Suctioning source Large-bore stiff suction tips Flexible suction catheters Nasogastric tubes Tracheostomy tubes Tracheostomy surgical instrument set 12- and 14-Gauge needle catheters for needle cricothyrotomy Preassembled transtracheal ventilation setup

4. Indication 1.severe hypoxenia 2.inadequate alveolar ventilation 3.inadequate lung expansion 4.inadequate resp muscle strength 5.excessive work of breathing 6.unstable ventilatory drive 7.prophylactic mechanic ventilation,TB 8.IICP 9.flail chest,TB 10.COPD,asthma

5. Rapid Sequence Intubation Sedatives Table 5.2. Significant Properties of Rapid Sequence Intubation Sedatives DrugOnsetDuration Cerebro Protective Effect Cardiovascular EffectBronchial EffectOther Disadvantages Etomidate RapidBriefGood Neutral Myoclonus, cortisol suppression Thiopental RapidBriefGood Significant depression Broncho spasm MidazolamLess Rapid BriefModest Neutral Titration recommended, is not feasible in rapid sequence intubation (RSI) Ketamine RapidBrief Adverse StimulatoryBronchodilator Psychic reactions and excessive airway secretions FentanylLess rapid BriefModest Neutral Seizurelike activity and chest wall rigidity Propofol RapidBriefGood Significant depression Neutral Less experience with agent in emergency department RSI

6. Other side effect or precaution  Thiopental  Contra: porphyria and status asthmaticus  Midazolam  Contra: glaucoma  Insufficient unconsciousness  Ketamine  Contra: ICP, IOP, HTN  Lorazepam for psychi  Etomidate (standard in US)  Adrenal insufficiency: long term user  Fentanyl  Pre: MAOI  All sedatives cause some degree of CV depression!!

7. Sedative Selection

10. Muscle Relaxants  Depolarizing muscle relaxant, Succinylcholine  Onset: 30 to 60 seconds  Duration: 3 to 12 minutes  Disadvantages:  ↑ICP, IOP, IGP  Fasciculations: rhabdomyolysis, myoglobinuria  Defasciculating dose of vecuronium, 10% (>5y/o)  Atropine premedication: bradycardia and bronchodilate  Contraindicated: glaucoma, penetrating eye injuries, significant neuromuscular disease, history or family history of malignant hyperthermia, and pseudocholinesterase deficiency, at 3 to 60 days after trauma or burns, severe burns or large crush injuries

11. Muscle Relaxants  nondepolarizing muscle relaxants  Rocuronium vs Vecuronium  Onset: 30-90 vs 90-120 seconds  Duration: both 25 to 60 minutes  Ro: premixed  Pancuronium vs Atracurium  Pan: slower onset and more CV side effects  Atra: same as Ve but more histamine and CV SE

12. Muscle Relaxant Selection  Rocuronium and succinylcholine  Safer: Rocuronium  Reversible /c edrophonium: Rocuronium  Onset: same  Quicker: succinylcholine, good in difficult one  Defasciculation and Priming Defasciculation and Priming  Defasciculation: in Succ,1/10 dose of Roc,1-3 mins prior  Muscular p’t  Priming: in non-dep, 1/10 dose of it, 5 mins prior  Shorten onset  Min effect in Roc

13. Adjunctive Agents  Atropine  Routine in kid, add /c ketamine in adult  Lidocaine  ↓ICP and airway reactivity  Cerebroproctect not clear if /c other agent  Topical: add complexity  Asthma: ↓bronchospasm to PREVENT ETT!  Opiate analgesics  Unconsciousness: reliable in etomidate & thiopental  BZD: need titrated & less reliable

14. Rapid Sequence Intubation Protocol  Protocol  6 Ps: important to stress  Sequence: relaxant to sedatives?  Regularly review  Nasal vs Oral Intubation in Trauma Patient Nasal vs Oral Intubation in Trauma Patient  N>O: Older literature  O>N:  more reliable,  lesser neck movement, ICP, vomiting, no difference in C-spine movement  Laryngoscope: no evidence, and RSI can improve  C-Spine Immobilization During Endotracheal Intubation C-Spine Immobilization During Endotracheal Intubation  Philadelphia collars, Axial (inline) traction: no evidence  Anterior portion of neck collar  2005 CPR: still moved by jaw thrust

15. Alternative Intubation & Airway Techniques  Flexible fiberoptic scopes, lighted stylets to guide nasal tracheal intubation, retrograde intubations, and surgical airways  Reserved for conventional airway techniques prove unsuccessful  not  not recommended in ED: aided by bronchoscopy, lighted stylets, and retrograde wire technique  Recommended  Recommended: Combitube and LMACombitube  Surgical airway: favor needle cricothyrotomy

16. Avoiding Problems  Possible CV adverse effect: wide open IVF  Paralysis: not a substitute for sedation except…  Multiple Trauma Multiple Trauma  Still ABCDEs  Oximetry for perfusion  Sedatives in hypovolemic or hypotensive: reduced or avoided  Head Trauma Head Trauma  ICH can cause significant hypovolemia in infant  Burns Burns  avoid succinylcholine  Status Epilepticus Status Epilepticus  initiate RSI earlier rather than later.  Agitated Patients Who Require Procedures or Transport Agitated Patients Who Require Procedures or Transport  Consider RSI earlier