1. RSI REVIEW

4. for tracheal intubation
WHAT IS RSI ?
definition
virtually simultaneous administration, after preoxygena-
tion, of a potent sedative agent and a rapidly acting
neuromuscular blocking agent to induce unconscious-
ness and motor paralysis for tracheal intubation
simultaneous
after preoxygenation
for tracheal intubation

5. WHAT IS RSI ? definition assumes : patient has a full stomach
: no interposed ventilation
: preoxygenation
: Sellick’s maneuver

6. supplemental oxygen nasal cannula ~44% 1L/min 24% 2L/min 28% 3L/min
32%
4L/min
36%
5L/min
40%
6L/min
44%

7. face mask with reservoir
supplemental oxygen
face mask with 6~10L/min
~60%
face mask with reservoir
~100%
6L/min
60%
7L/min
70%
8L/min
80%
9L/min
90%
10L/min

8. preoxygenation (4)
the time to desaturate from 90% to 0% is dramatically
less than the time to desaturate from 100% to 90%

9. protection and positioning
ZERO plus 20~30 sec
Sellick’s maneuver
: initiated immediately on the observation that
the patient is losing consciousness
: maintained throughout the entire intubation
sequence until the ETT has been correctly
placed, the position verified, and the cuff
inflated
30 Newton

10. protection and positioning
before placing the laryngoscope into the patient’s mouth,
the sniffing position is created by placing a pillow,
folded towel, or sheet under the patient’s head to
facilitate extension of the head on the neck and slight
forward flexion of the lower C-spine on the chest

11. moisture condensation
placement and proof
correct placement of tracheal tube (1)
primary confirmation by P/Ex
moisture condensation
laryngoscopic view
5-point auscultation
listen and observe
direct visualization

12. placement and proof correct placement of tracheal tube (2)
esophageal detector device
capnography
qualitative end-tidal CO2 detector
correct placement of tracheal tube (2)
secondary confirmation
purple (poor) → yellow (yes)
4.5~6% EtCO2 = 35~45 mmHg Pco2
the aspiration bulb technique
2~5% EtCO2 = 15~38 mmHg Pco2
the aspiration syringe technique
at least 6 ventilations
cardiac arrest

13. the “standard care” is to perform both primary
and secondary confirmation techniques
sequencing differences are virtually the only
contemporary areas of debate and disagreement
whenever there is doubt about the results from
primary or secondary confirmation, the best course of
action is to remove the tracheal tube and provide BMV

14. visualize chest expansion bilaterally
listen over epigastrium and the lung fields bilaterally
use exhaled CO2 detectors
direct visualization using laryngoscope or EDD
if in doubt, remove the tube, provide BMV, replace

15. end-tidal CO2 detector TRUE (+) FALSE (+) thinks tube is in trachea
inserted in trachea
distended stomach,
recent ingestion of carbonated beverage
FALSE (-)
TRUE (-)
thinks tube is in esophagus
cardiac arrest
inserted in esophagus

16. esophageal detector device
TRUE (+)
FALSE (+)
thinks tube is in esophagus
inserted in esophagus
secretions in trachea,
right mainstem bronchus insertion
FALSE (-)
TRUE (-)
thinks tube is in trachea
obesity, late pregnancy,
COPD, asthma,
recent bagging
inserted in trachea

17. RSI PHARMACOLOGY Pretreatment Agents Sedative And Induction Agents
Neuromuscular Blocking Agents
Depolarizing (Noncompetitive) NMBAs
Nondepolarizing (Competetive) NMBAs

18. Pretreatment Agents the CNS response : ↑ ICP
the cardiovascular system response
(sympathetic nervous system)
: bradycardia
: tachycardia and hypertension
the respiratory system response
: laryngospasm and coughing
: bronchospasm

19. the LOAD approach lidocaine (xylocaine) opioid - fentanyl (sublimaze)
↑ ICP
coughing
bronchospasm
lidocaine (xylocaine)
opioid - fentanyl (sublimaze)
atropine
defasciculating agents
tachycardia
hypertension
bradycardia
↑ ICP

20. Summary pretreatment agents are used to attenuate the adverse
LIDOCAINE (xylocaine)
: 1.5 mg/kg IV 3 minutes before airway manipulation
: IICP, bronchospastic disease (asthma, COPD, cardiac asthma)
Summary
pretreatment agents are used to attenuate the adverse
physiologic responses to laryngoscopy and intubation
should be administered 3 minutes before induction to
match peak drug effect with airway manipulation
LOAD
(lidocaine, opioids, atropine, defasciculating agents)
OPIOID fentanyl (sublimaze)
: 3 mcg/kg IV 3 minutes before induction
: IICP, ischemic heart disease, aneurysm or dissection,
hemodynamically stable penetrating vascular trauma
ATROPINE
: 0.02 mg/kg IV 3 minutes before induction
: any child less than 10 years of age undergoing RSI with Sch
DEFASCICULATION
: vecuronium, pancuronium, or rocuronium at 10% of the normal
paralyzing dose 3 minutes before induction
: IICP who will be receiving Sch

21. Sedative And Induction Agents
ultra-short-acting barbiturates
thiopental sodium (pentothal)
benzodiazepines
miscellaneous agents
etomidate (amidate)
ketamine (ketalar)
propofol (diprivan)

22. thiopental sodium (pentothal)
induction dose (mg/kg)
3-6
onset (sec)
<30
t1/2α (min)
2-4
duration (min)
5-10
t1/2β (hr)
10-12

23. thiopental sodium (pentothal) : indications and contraindications
Ix : IICP or status epilepticus
absolute CIx : acute intermittent porphyria
relative CIx : reactive airways disease

24. thiopental sodium (pentothal) : dosage and clinical use
potent venodilator and myocardial depressant
: dose must be decreased in patients with
decreased intravascular volume, compromised
myocardial function, and the elderly
(1 to 2 mg/kg IV)
avoided entirely in frankly hypotensive patients

25. benzodiazepines midazolam lorazepam diazepam induction dose (mg/kg) a a
onset (sec)
30-60
60-120
45-60
t1/2α (min)
7-15
3-10
10-15
duration (min)
15-30
t1/2β (hr)
2-4
10-20
20-40
a not recommended for use as an induction agent for emergency RSI

26. miscellaneous agents etomidate (amidate) ketamine (ketalar)
propofol (diprivan)

27. induction dose (mg/kg)
etomidate (amidate)
induction dose (mg/kg)
0.3
onset (sec)
15-45
t1/2α (min)
2-4
duration (min)
3-12
t1/2β (hr)
2-5

28. etomidate (amidate) : indications and contraindications
induction agent of choice for most emergent RSIs
because of its rapid onset, its profound hemodynamic
stability, its positive CNS profile, and its rapid recovery
no contraindications to its use
not FDA approved for use in children

29. etomidate (amidate) : adverse effects
myoclonic movement during induction is common and
has been confused for seizures
: no clinical consequence and generally terminates
promptly as the N-M blocking agent takes effect
decrease both serum cortisol and aldosterone levels
(reversible blockade of 11-beta-hydroxylase)
: more common with continuous infusions

30. induction dose (mg/kg)
ketamine (ketalar)
induction dose (mg/kg)
1-2
onset (sec)
45-60
t1/2α (min)
11-17
duration (min)
10-20
t1/2β (hr)
2-3

31. ketamine (ketalar) : clinical pharmacology
releases catecholamines, stimulates the sympathetic
nervous system, and therefore augments HR and BP
directly stimulates the CNS, increasing cerebral
metabolism, cerebral metabolic oxygen demand (CMRO2),
and CBF, thus potentially increasing ICP
: corresponding increases in MAP may offset the rise
in ICP
directly relaxes bronchial smooth muscle, producing
bonchodilatation

32. ketamine (ketalar) : indications and contraindications
induction agent of choice
: reactive airways disease
: hypovolemic or hypotensive without serious brain injury
in normotensive or hypertensive patients with
ischemic heart disease, catecholamine release may
adversely increase myocardial oxygen demand

33. induction dose (mg/kg)
propofol (diprivan)
induction dose (mg/kg)
1.5-3
onset (sec)
15-45
t1/2α (min)
2-4
duration (min)
5-10
t1/2β (hr)
1-3

34. propofol (diprivan) : clinical pharmacology
direct reduction in BP through vasodilatation and direct
myocardial depression, resulting in a decrease in
cerebral perfusion pressure
: rarely, if ever, the induction agent of choice in
emergenct RSI, where patient instability is the
norm

35. propofol (diprivan) : indications and contraindications
excellent induction agent in a very stable patient
no absolute contraindications

36. Summary THIOPENTAL SODIUM 3~6mg/kg Ix : IICP or status epilepticus
Caution : respiratory depression, venodilation, myocardial depression
Summary
MIDAZOLAM 0.2~0.3mg/kg
Ix : procedural sedation
Caution : ↓systemic vascular resistance, myocardial depression
ETOMIDATE 0.3mg/kg
Ix : induction agent of choice
Caution : children
KETAMINE 1~2mg/kg
Ix : reactive airways disease, hypovolemic or redistributive shock
Caution : IICP, ↑myocardial oxygen demand
PROPOFOL 1.5~3mg/kg
Ix : very stable patients
Caution : vasodilatation, myocardial depression

37. Neuromuscular Blocking Agents
depolarizing (noncompetitive) NMBA
nondepolarizing (competetive) NMBAs

38. adverse effects fasciculations hyperkalemia bradycardia
prolonged N-M blockade
malignant hyperthermia
trismus/masseter muscle spasm

39. fasciculations occur simultaneously with increases in ICP, IOP, and
intragastric pressure
: only the increase in ICP is clinically important
fasciculations inhibited by defasciculating dose (10% of
the normal paralyzing dose) of a nondepolarizing NMBA
: 0.01 mg/kg of vecuronium or pancuronium, or
0.06 mg/kg of rocuronium

40. hyperkalemia (1)
serum K+ increases minimally (0 to 0.5 mEq/L) when Sch
is administerd
: rhabdomyolysis and receptor upregulation
rhabdomyolysis
: often associated with myopathies
: resuscitation less successful than in receptor up-
regulation because of less physiologic reserve

41. receptor upregulation
hyperkalemia (2)
immature
receptors
immature
receptors
4- to 5-day period
immature
receptors
immature
receptors
immature
receptors
receptor upregulation (1)
immature
receptors
immature
receptors
immature
receptors
mature
receptors
immature
receptors
receptor upregulation
burns
denervation
crush
injuries
intraabdominal
infections
myopathies
renal failure

42. prolonged channel opening (4 times longer than mature receptors)
immature
receptors
prolonged channel opening
(4 times longer than mature receptors)
increasing levels of K+

43. bradycardia most commonly in children because of their heightened
vagotonic state
: bradycardia is attenuated or abolished by
administering atropine 0.02 mg/kg IV as a
pretreatment drug
in adults, repeated doses of Sch may produce the same
vagotonic effects and administration of atropine may
become necessary

44. prolonged N-M blockade
reduced concentrations of pseudocholinesterase
: liver disease, pregnancy, burns, oral contraceptives,
metoclopramide, bambuterol, or esmolol
a 20% reduction in normal levels will increase apnea time
about 3 to 9 minutes

45. malignant hyperthermia (1)
a personal or family Hx of malignant hyperthermia is an
absolute CIx to the use of Sch
triggered by halogenated anesthetics, Sch, vigorous
exercise, and even emotional stress
acute loss of intracellular Ca2+ control
: muscular rigidity, autonomic instability, hypoxia,
hypotension, severe lactic acidosis, hyperkalemia,
myoglobinemia, and DIC

46. malignant hyperthermia (2)
elevations in temperature are a late manifestation
masseter spasm has been claimed to be the hallmark
: Sch can promote isolated masseter spasm
: alone is not pathognomonic
treatment consists of discontinuing the known or
suspected precipitant and the immediate administration
of dantrolene sodium (dantrium)
: initial dose 2.5 mg/kg IV repeated every 5 minutes
(maximum dose 10 mg/kg)

47. trismus/masseter muscle spasm
if masseter spasm interferes with intubation, a full
paralyzing dose of a competitive nondepolarizing agent
should be administered
serious consideration should be given to the Dx of
malignant hyperthermia

48. nondepolarizing (competitive) N-M blocking agents
pancuronium
vecuronium
rocuronium
intubating dose (mg/kg)
0.15 1
pretreatment (mg/kg)
0.01
0.06
onset (sec)
90-120
55-70
duration (min)
60-75
30-60
full recovery (hr)
3-5
1.5-2
1-2

49. Summary
1.5~2.0mg/kg
0.15mg/kg
1.0mg/kg