1. RSI: Rapid Sequence Intubation What, When, Where, Why & How
Michael T. Czarnecki, MD
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2. Objective What is RSI? Discuss the “7 P’s” of RSI
Review RSI pharmacologic agents
Highlight current controversies with RSI
20-Sep-18

3. RSI Defined
“Virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation”
20-Sep-18

4. Why Bother with RSI? Rapid airway control Less risk of aspiration
Highest success rates/lowest complications
More controlled
Optimal intubating conditions
20-Sep-18

5. What are The Problems Inherent to Intubation?
Laryngoscopy and Intubation
Increased bronchospasm
Increased ICP
Increased catecholamine release
20-Sep-18

6. Beneficial Effects of RSI
“Tight Heads”
Intracranial pathology
“Tight Hearts” or “Tight Vessels”
Cardiovascular disease
“Tight Lungs”
Reactive airway disease
20-Sep-18

7. Assumptions in Airway Management
Pt. has a full stomach
Pt. is preoxygenated
Pts. do not receive BVM ventilation unless necessary to keep O2 sat. over 90%
Sellick’s maneuver always used
20-Sep-18

8. RSI: “7 P’s” P = Preparation P = Preoxygenation P = Pretreatment
P = Paralysis with induction
P = Protection
P = Placement of the tube
P = Post-Intubation management
20-Sep-18

9. RSI: Timeline T – 10 minutes Prepare T – 5 minutes Preoxygenate
T – 3 minutes Pretreat
T = Paralysis with induction
T + 30 seconds Protection
T + 45 seconds Placement
T + 90 seconds Post-Intubation management
20-Sep-18

10. Preparation: T – 10 minutes
Prepare the patient
Monitoring/access
Positioning
Assess for difficult airway
“4 D’s”,“LEMON”, “BONES”, “SHORT”
Mallampati
Prepare your equipment
Prepare yourself (mental checklist)
Prepare your personnel
20-Sep-18

11. Difficult Airway Assessment
4 D’s
Distortion, Disproportion, Dysmobility, Dentition
BONES
Beard, Obese, No teeth, Elderly, Snores (sleep apnea)
SHORT
Surgery (head/neck/jaw), Hematoma, Obese, Radiation, Tumor
LEMON
MALLAMPATI
Always have a “Rescue Airway” technique ready
JUMP AHEAD
20-Sep-18

12. MALLAMPATI SCORE Class I Class II Class III Class IV JUMP BACK
20-Sep-18

13. 60-SECOND EXAM “LEMON” Look for external difficulty
Evaluate using 3=3=2 rule
Mallampati (Class I & II)
Obstruction
Neck Mobility
3 fingers fit in mouth
3 fingers fit from mentum
to hyoid cartilage
2 fingers fit from mandible
to top of thyroid cartilage
JUMP BACK
20-Sep-18

14. Rescue Airways Gum Elastic Bougie (GEB)
Laryngeal Mask Airway (LMA/ILMA)
Combitube
Surgical Cricothyrotomy
JUMP BACK
20-Sep-18

15. Preoxygenate: T – 5 minutes
Provides reservoir of oxygen during apnea
If pt. spont. breathing – then NRB for 5’
Provides maximum of 70% FiO2
Avoid bagging the spont. breathing patient
If needed, use sellick & airway adjunct
8 effective Vital Capacity breaths provides best preoxygenation
20-Sep-18

16. Pretreat: T – 3 minutes L - Lidocaine O - Opiates A - Atropine
D – Defasiculating Agent
20-Sep-18

17. Lidocaine (1.5 mg/kg) Consider in “Tight Head” or “Tight Lungs”
Blunts ICP rise (??)
Suppress cough response
may blunt bronchospasm
may blunt sympathetic response
Does Lido help in head trauma?
No clinical trials have answered question
Not proven to change outcome
Little downside in using
Robinson, Emeg Med J 2001; 18:453
20-Sep-18

18. Opioids Fentanyl (3 mcg/kg slow IV over 3’)
Consider in “Tight Heads”, “Tight Heart”, & “Tight Vessels”
Beware: cautious use in pt’s dependent on sympathetic drive (aka, trauma)
20-Sep-18

19. Atropine Only needed in: 0.01 mg/kg IV push Children under 10 y.o.
Adults receiving 2nd dose of succinylcholine
0.01 mg/kg IV push
Minumum dose: 0.1 mg
20-Sep-18

20. Defasiculating Agent Use any paralytic at 10% paralyzing dose
Consider in “Tight Heads”
Beware: may cause hypoventilation and frank paralysis – be prepared
Who needs defasiculation?
Helps mitigate ICP rise with succinylcholine
Not really useful in any other ICU situation
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21. Paralysis with Induction: T = 0
Tailor inducing agent to specific needs
Barbituates
Etomidate
Midazolam
Ketamine
Propofol
JUMP AHEAD
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22. Overall – Etomidate is better that Barbs
Barbituates
Decreases GABA dissociation at receptor
Rapid onset sedation
Decreases ICP
Hypotension (especially in hypovolemia)
Choices:
Thiopental, pentobarbital, methohexital
Overall – Etomidate is better that Barbs
JUMP BACK
20-Sep-18

23. Thiopental Onset 15 seconds, duration 3-5 minutes
Cardiac depressant, venodilator
Hypotension
Dose depedent on pt. profile
Euvolemic adult (3-5 mg/kg IV)
Hypovolemic adult (1-3 mg/kg IV)
JUMP BACK
20-Sep-18

24. Etomidate Nonnarcotic, nonbarbituate, nonanalgesic
Minimal cardio effects, lowers ICP
Is it the ideal agent for RSI?
May cause critical adrenal suppression
Inhibits adrenal mitochondrial hydroxylase activity
Occurs after both single bolus and infusions
Infusions incr. ICU death rate & incr. infections
Clinical significance is unclear
Randomized, controlled trials on outcomes needed
Malerba, et al: Intensive Care Med 2005
20-Sep-18

25. Etomidate (con’t) Induction dose: 0.2 – 0.3 mg/kg IV
Onset: 20 – 30 seconds
Duration: 7 – 15 minutes
May cause myoclonic jerking, hiccups, injection pain, N/V (also on emergence)
Risk for adrenal insufficiency incr. 12-fold
Jackson, Chest 2005 Mar Murray, Chest 2005 Mar; 127:
JUMP BACK
20-Sep-18

26. Midazolam Nonanalgesic sedative, anxiolytic, amnestic
Respiratory depressant and hypotension
Give slow IV
Give ½ the dose in elderly or COPD
Rapid onset (< 1 minute)
Induction dose ( mg/kg) DIFFERENT than sedation dose (0.01 – 0.03 mg/kg)
In RSI, 92% of adults are underdosed
Sagarin, et al: Acad Emerg Med 2003 Apr; 10:329-38
JUMP BACK
20-Sep-18

27. Ketamine (1 – 2 mg/kg) Dissociative, analgesic, amnestic
Causes catecholamine release
Incr. BP, HR, ICP, Laryngospasm risk
Bronchodilator → induction agent in asthma
Onset: 15 – 30 seconds
Duration: 10 – 15 minutes
JUMP BACK
20-Sep-18

28. Propofol (0.5 – 1.2 mg/kg) (white magic, milk of amnesia)
Sedative-hypnotic
Cardiac depressant, venodilator
Hypotension
Decr. ICP at expense of CPP
JUMP BACK
20-Sep-18

29. NMBs: Neuromuscular Blocking Agents
Depolarizing
Succinylcholine
Non-Depolarizing
Pan/Vec/Atra/Rocuronium
Potential Problems
Inadequate pre-intubation neuro exam
Failure to sedate
Inadequate pre-treatment or inadequate dosing
Aspiration and Dysrhythmias
Failed intubation → surgical airway needed
20-Sep-18

30. Succinylcholine (1.5 – 2.0 mg/kg)
Onset: 15 – 30 sec; Duration: 5 – 12 min
Contraindications:
FHx malignant hyperthermia, burns, crush injuries, progressing neuromuscular disease
Side Effects:
Brady, hyper-K+, fasciculations, MH
↓HR: pretreat all kids; adults 2nd dose with atropine
↑K+: peaks in 5’, resolves in 15’
Treat like any hyperkalemia case
Use actual-body weight for dose
Rose, et al: Anesth Analg 2000
20-Sep-18

31. Non-depolarizing NMBs
Longer duration than SUX, onset about equal
Aminosteroid compounds
Pan/Vec/Rocuronium
Benzylisoquinolinum compounds
Atracuronium
Vecuronium
Rocuronium
0.1 – 0.2 mg/kg
1 mg/kg
1.5 – 2.5 minutes
60 seconds
25 – 45 minutes (90)
30 minutes (45)
Less vagolytic
Least cardio effects
20-Sep-18

32. Rocuronium Is it equivalent to SUX?
Meta-analysis 1600 pts → equivalent in:
Acceptable conditions for intubation
Rates of intubation success
But SUX is BEST at creating EXCELLENT conditions
Perry, AEM 2002
20-Sep-18

33. RSI: Timeline T – 10 minutes Prepare T – 5 minutes Preoxygenate
T – 3 minutes Pretreat
T = Paralysis with induction
T + 30 seconds Protection
T + 45 seconds Placement
T + 90 seconds Post-Intubation management
20-Sep-18

34. Align the 3 axes – critical for success Sellick’s maneuver
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35. Confirm placement/review CXR Secure tube Vent Settings
Administer sedation
Maintain paralysis if indicated
And…..
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36. Don’t Ever Forget the “7 Ps”
P = Preparation
P = Preoxygenation
P = Pretreatment
P = Paralysis with induction
P = Protection
P = Placement of the tube
P = Post-Intubation management
20-Sep-18

37. WHEN IN DOUBT, PULL IT OUT!
20-Sep-18