1. Rapid Sequence Intubation Khalid Al-Ansari, FRCP(C), FAAP(PEM)

2. Objectives Definition and goals of RSI Steps of RSI Controversies Protocol for RSI

3. Definition The virtually simultaneous administration, after preoxygenation, of potent sedative agent and rapidly acting neuromuscular blocking agent to facilitate rapid tracheal intubation without interposed mechanical ventilation.

4. Goals of RSI RSI produce excellent intubating condition 45 to 60 seconds after administration of neuromuscular blocking agent. Complete jaw relaxation. Open and immobile vocal cords. No coughing or diaphragmatic movements in response to intubation. Decrease Complication like aspiration. Control of agitation.

5. RSI Intubation using RSI was more successful on first attempt (78%) compare to NOM (47%) p=<0.01 or SED (44%) p=<0.05 Sagarin et al. pediatr Emerg care 2002

6. Steps of RSI 7 Ps Preparation Preoxygenation Premedication Paralysis/sedation Protection and positioning Placement with proof Postintubation management.

7. Preparation One of the most important step to success. Equipment (Monitors, suction, O2, bag-valve mask, oral airway, ETT, stylet, laryngoscope blade, CO2 detector). Medication Personnel.

8. RSI - Preparation S O A P ME S Suction (Yankauer) OOxygen AAirway (BVM set up, lryngoscope, ETT, stylet, Magill forceps, tape) PPharmacology (drugs including reversal agents) ME:Monitoring equipment

9. Preparation Short History + AMPLE Evaluate for difficult airway L E M O N: 1. Look 2. Mallampati classification 3. Obstruction ( stridor, drolling, muffled sound) 4. Neck mobility ( collar)

10. Mallampati classification

11. Look externally facial, cervical or neck trauma. Micrognathia Dysmorphic facial features Small mouth, large tongue Short neck

12. Normal Looking Kid – Right?

13. Pierre Robin Syndrome

14. Steps of RSI Preparation Preoxygenation Premedication Paralysis/sedation Protection and positioning Placement with proof Postintubation management.

15. Preoxygenation While preparing equipment It essential to the no bagging principle. Aim to establish an O2 reservoir within the lungs and body tissue. By 100% O2 via non-rebreather face mask. For 3-5 minutes.

16. Quiz In healthy 70 kg adult if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%. A- more than 9 minutes B- 7-8 minutes C- 4-6 minutes D- less than 4 minutes

17. Quiz In healthy 70 kg adult if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%. A- more than 9 minutes B- 7-8 minutes C- 4-6 minutes D- less than 4 minutes

18. Quiz In healthy 10 kg child if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%. A- > 8 minutes B- 6-8 minutes C- 3-4 minutes D- 1-2 minutes

19. Quiz In healthy 10 kg child if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%. A- > 8 minutes B- 6-8 minutes C- 3-4 minutes D- 1-2 minutes

20. Preoxygenation Anesthesiology: Volume 87(4) October 1997

21. Steps of RSI Preparation Preoxygenation Premedication Paralysis/sedation Protection and positioning Placement with proof Postintubation management.

22. Premedication Aim to block the physiologic reflex response to airway manipulation and insertion of ETT.

23. Atropine

24. Atropine To prevent Bradycardia. It should be given 1-2 min before intubation. PALS recommendation: - Children less than 1 year of age. - Children age 1-5 years receiving Sch. - Children > 5 years receiving second dose of Sch.

25. Atropine Bradycardia during intubation has 3 causes: Vagal stimulation during laryngoscopy. Succinylcholine administration Hypoxia

26. Fentanyl

27. Fentanyl Blunt the reflex sympathetic response. Used in pt with raised ICP Dose: 1-2 Mcg/kg Be careful about BP and respiratory depression. Add extra step

28. Lidocaine To blunt the rise in ICP associated with laryngoscopy and intubation. Dose : 1-2 mg/kg 2-5 min before intubation Evidence.

29. Defasciculating Non competitive N/M blocking agent ( rocuronium (0.06mg/kg). 10% of normal paralyzing dose. 3 min before intubation. In pt. with raised ICP receiving Sch for paralysis. No evidence to support it’s use in RSI. Add extra step.

30. Steps of RSI Preparation Preoxygenation Premedication Paralysis/sedation Protection and positioning Placement with proof Postintubation management.

31. Sedation Aim to rapidly make the pts unconscious to eliminate pt awareness of being paralyzed and intubated and facilitate the intuabtion. The choice depend on: - Shock - Head trauma - bronchoconstriction

32. Thiopentale Barbiturate Dose 2-4mg/kg Onset: 30-60 seconds Duration : 10-30min Side effects: decrease cardiac output, hypotension, broncho & laryngo spasm. Contraindication: Porphyria, Barbiturate sensitivity, Asthma (caution in decreased BP)

33. Ketamine Non barbiturate dissociative agent Dose: 1-2mg/kg Onset:<2minutes Duration: 10-30minutes Maintain BP & bronchodilator Side effects: Inrease BP, hallucination, increase secreations, laryngospasm & emergence reaction. Contraindication: raised IOP, psyhosis &hypertension.

34. Midazolam Benzodiazepine Dose 0.1-0.3mg/kg Onset: 30-60 seconds Duration : 30-60min Side effects: Respiratory depression & hypotension.

35. Etomidate Imidazole Non barbiturate hypnotic Dose: 0.3mg/kg Onset:<1minute Duration: 10-30minutes Hemodynamic stability. Side effects: Adrenal suppression, myoclonus & trismus. Contraindication: Adrenal insufficiency & focal seizure.

36. Sedation Etomidate used in 42% of pediatric RSI in US. Thiopental used in 22%. Benzodiazepine used in ~ 18% (90% Midazolam) Sagarin et al, pediatr Emer Care 2002;18

37. N/M blocking agents pediatr Emerg Care 2000;16(6):441

38. N/M blocking agents Sch contraindication Hyperkalemia ( renal failure) Myopathy Malignant hyperthermia > 3-5 days of burns, crush injury, Denervation due to stroke or spinal cord injury.

39. Steps of RSI Preparation Preoxygenation Premedication Paralysis/sedation Protection and positioning Placement with proof Postintubation management.

40. Protection Sellick’s maneuver ( cricoid pressure ) Thumb and long fingers applying posterior pressure to occlude the esophagus against the anterior surface of the vertebral body to prevent passive regurgitation of gastric content Initiated after sedation given and maintained throughout the entire intubation sequence until ETT placed and verified.

41. Steps of RSI Preparation Preoxygenation Premedication Paralysis/sedation Protection and positioning Placement with proof Postintubation management.

42. Placement with proof 45 seconds – 60 seconds after administration of N/M blocking agent Intubation should be performed. Tube placement should be checked ( auscultation, end tidal CO2 detector and CXR)

43. Post intubation management ETT must be taped in place. Low BP should be Rx CXR Long term sedation and paralysis - Midazolam infusion - pancuronium or vecuronium 0.1mg/kg. Opioid analgesia if needed.

44. TimeAction 0Assess if appropriate for RSI 0-3 minutesPre-oxygenate Obtain IV access (2 preferable) Assemble necessary equipment and personnel Draw up medications 3-5 minutesContinue to pre-oxygenate Premedicate Atropine (< 1 year, 1 through 5 years if receiving succinylcholine, and adolescents receiving a second dose of succinylcholine) Fentanyl (for substantial head trauma) 5-6 minutesAdminister sedation

45. No shock, head injury or asthma Shock, no head trauma no asthma Head trauma, no shock, no asthma Asthma, no shock no head trauma Thiopental Etomidate Etomidate, ketamine Consider no sedation Thiopental Etomidate Ketamine Etomidate Apply cricoid pressure Administer neuromuscular blockade agent Succinylcholine (preferred, except when contraindicated) Or Rocuronimum 6-7 minutes (one minute after NMB agent administered) Perform orotracheal intubation Remove cricoid pressure when tracheal intubation confirmed (including CO2 detection) Consider need for more sedation/paralysis

46. Take home message Preparation is one of the most important step for success. Try to identify difficult airway. Preoxygenate with no bagging principle. Back up plan.

47. Thank You