1. Components of Rapid Sequence Intubation Ryan J Fink, MD Raquel Bartz, MD Duke University Medical Center Dept. of Anesthesiology

2. Learning Objectives Components of Rapid Sequence Intubation (RSI) Basic Equipment Preparation Reasons for RSI

3. Good Clinical Judgment Required Clinical judgment is required who, when, and how to support ventilation in a patient Choices, Choices, and more Choices – Mechanical ventilation via endotracheal tube or Bilevel positive airway pressure (BIPAP) – Which tools to use – How to intubate: awake versus unconscious and/or paralyzed – Which induction agent or paralytic

4. Intubation Goal Provide means for improved oxygenation, improved ventilation, securing the airway Minimize risk of complication and/or death associated with the procedure of intubation

5. Reported Complications Mort Study; N = 102Jaber Study; N = 251Schwartz Study; N = 238 Hypoxemia : 17%Hypoxemia: 26% Aspiration: 1.7%Aspiration: 4% Regurgitation: 4.4%Dental Injury: 1% Surgical Airway: 0.4%Pneumothorax: 1% Esophageal Intubation: 10% Esophageal Intubation: 4% Esophageal Intubation: 8% Bradycardia: 3.5%Severe Hemodynamic Collapse: 25% Cardiac Arrest: 2%Cardiac Arrest: 1%Cardiac Arrest/ Death 3% > 3 Attempts: 10%> 3 Attempts: 11% Mort TC J Clin Anesth 2004; 16: 508-516 Schwartz DE Anesthesiology 1995; 82:367-376 Jaber S Crit Care Med 2006; 34:2355 - 2361

6. Rapid Sequence Induction/Intubation Purpose: – To decrease the risk of pulmonary aspiration – Improve likelihood of quick intubation with minimal physiologic compromise Indications: – Patients considered to have a “full stomach” NPO < 8 hours Pregnancy Significant GERD, delayed gastric emptying, hiatial hernia Ileus, SBO, acute abdomen, or trauma Many times this is unknown in the Emergency Room or Intensive Care Unit Contraindication to RSI: – Predicted difficult mask ventilation or intubation Consider awake fiberoptic intubation Even the most experienced practitioners ask for help

7. What is Rapid Sequence Induction/Intubation Preparation (equipment and patient) Induction agent – To cause hypnosis/unconsciousness – To prevent memory of intubation – Maintain hemodynamics Paralytic – To increase success of endotracheal tube placement – To prevent aspiration Cricoid Pressure – To reduce risk of aspiration No mask ventilation Intubation

8. Basic Equipment (MS-MAIDS) M – machine (ambubag, ventilator) S – suction is available and turned on M – monitors, O 2 saturation tone is audible A – airway to include endotracheal tube with stylet, LMA, blades or other intubating device I– IV free, functioning, and flowing D – drugs available – Induction agent, Paralytic agent, drugs to increase blood pressure, drug to increase heart rate S– suction again/Special stuff

9. Preparation For RSI: Pt Positioning Position your patient for success – Patient at the head of the bed – Bed is locked and fully inflated – Bed is at proper height – “Sniffing position” Contraindicated: – Cervical spine injury Goal is to align airway axes

10. Preparation For RSI: Pt Positioning

11. Preparation For RSI: Pt Positioning Sniffing Position

12. Preparation For RSI Pre-oxygenation: – 5 minutes while preparing for intubation – BiPAP works well, with F I O 2 at 100% – Assist with bag-mask ventilation if decreased level of consciousness Supply 100% oxygen into bag-valve mask Have more than one practitioner available to help with intubation

13. Why Preoxygenate?

14. Time of Apnea 90% 100% 8 min Why Preoxygenate?

15. Preparation For RSI Suction should be audible Monitors in place: – Non-invasive BP at least every 1-3 minutes – ECG – O 2 saturation monitor with audible tone Airway devices should be readily available: – Endotracheal tube – multiple sizes (7.0 for women, 8.0 for men) – Stylet if needed, endotracheal tube cuff checked – Laryngeal Mask Airway (LMA) – Blades (Multiple types – Miller, MacIntosh, Phillips, etc. – Oral/nasal airways IV should be checked and free-flowing

16. Preparation For RSI: Drugs Induction agent (next module) -Etomidate/Propofol/Midazolam/Ketamine Paralytic (next module) -Succinylcholine/Rocuronium Vasopressor – to treat hypotension if it develops Anticholinergic – to treat bradycardia -Atropine 0.2 – 1 mg -Glycopyrrolate 0.2 – 0.6 mg Post-intubation sedation/anesthesia

17. Preparation For RSI: Cricoid Pressure Pressure on cricoid cartilage – Backwards against cervical vertebra – Purpose: to occlude esophagus – (Possibly) prevents aspiration

18. Preparation For RSI: Cricoid Pressure – Warn your patient

19. Preparation For RSI: Cricoid Pressure Controversy still exists – Amount of pressure: 10 - 40 Newtons – May cause retching/vomiting in awake patients – Decreases lower esophageal sphincter tone – Aspiration can still occur – May limit laryngeal visualization – Pushes esophagus to the side, not always compressed Still a standard of care

20. RSI: Completion No mask ventilation Confirm endotracheal tube placement – End-tidal carbon dioxide monitoring May be inaccurate in cases of cardiac arrest (no CO = no EtCO2) – Condensation in the tube – Chest rise – Bilateral breath sounds – Bronchoscopy – Esophageal detection device Do not release cricoid pressure until confirmed Begin post-intubation sedation

21. Prepare equipment and patient Preoxygenate for 5 min with 100% O2 Assistant holds cricoid pressure – Lightly when patients is still awake Assistant pushes induction agent and then paralytic Intubate after approximately 45 seconds Confirm endotracheal tube placement Begin sedation/anesthesia Rapid Sequence Intubation (RSI)

22. Rapid Sequence Intubation (RSI): Conclusions Preparation is key! MSMAIDS mnemonic Free flowing IV Assistance available for drugs and cricoid pressure Multiple airway devices Have a back-up plan if intubation is difficult