1. #5 Intro to EM Airway Management- RSI Pharmacology Andrew Brainard 1

2. #5 RSI Medications on a Dialysis Pt Learning Objectives: Prep team/plan/room/equipment Mask Seal, BVM, adjuncts, suction, Pre & apnoeic oxygenation Positioning – Airway assessment and plan MOANS/LEMON Briefing for Plans A, B, C, & D Completes airway checklist – Call and response – <1 min – Dose, timing, advantages/disadvantages of RSI sedatives Etomidate Propofol Ketamine Thiopental – Dose, timing, and of RSI paralytics Rocuronium Suxamethonium R40: 50y/o M unresponsive – Unresponsive for >24 hours – Has missed last several dialysis appointments – GCS 7, RR 6, SaO2 95%, pulse 50, BP 80/60. – ECG shows wide complex bradycardia On arrival: – Same vitals – Pt being bagged well by Ambos 2-hands, 2 people w/ OPA + NPA – Obvious dialysis shunt – LEMON shows: Beard, 2-1-1 (small mouth, no neck, small jaw), no obstruction, no neck Very difficult airway: – harder than you feel comfortable with – MOANS Easy to ventilate/oxygenate with BVM Consultant suggests RSI – Pt will gradually desaturate unless: Bagged, positioned, and preoxygenated – Prepare for sedation w/ minimal thio or etomidate or ketamine – Prepare for paralytic w/ rocuronium – Run through checklist – Be prepared for intubation but… – Wait for help

3. Sedatives for RSI 3

4. Sedatives Etomidate (0.3mg/kg TBW) – Minimal hemodynamic effects – Minimal respiratory depression – Controversial in sepsis – Myoclonus Fentanyl (5-10mcg/kg) – Familiar agent for paeds – Minimal Sedation Ketamine (0.5-2mg/kg IBW) – Minimal hemodynamic effects – Minimal respiratory depression – Bronchodilator – Increased secretions – Laryngeal spasm (very rare) Propofol (0.5-3mg/kg TBW) – Familiar agent – Respiratory depression – Hypotension Thiopental (0.25-3mg/kg TBW) – Antiepileptic – Respiratory depression – Hypotension – Histamine release 4

5. Paralytics for RSI 5

6. Paralytics Rocuronium (1.2mg/kg IBW) – Identical intubationing conditions – Few contraindications – Longer duration Avoid in status Difficulty canceling cases Suxamethonium (1.5-2mg/kg TBW) – Familiar and fast – 10 minute duration – Bradycardia – Short duration Poor relaxation Can lead to redosing – Contraindications Hyperkalemia – Renal failure, rhabdo, crush injuries Upregulated aCh receptors – Old burns, old strokes, old paralysis Malignant Hyperthermia 6

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8. Drug Controversies Access – IV/IO Equal – IM Double dose ketamine/sux When are drugs needed? – Type – Dose Pushing RSI Drugs – Sedative Flush (for thio) – Paralytic – Fluid/presser RSI – Rapid push of Sedative and Paralytic Non-RSI regimens – Awake Intubation Cooperative patient Topical airway anesthesia DL/VL or FiberOptic intubation – Delayed Sequence Intubation (DSI) Sedation for agitation and pre-oxygenation then RSI for ETT – Rapid Sequence Airway (RSA) Sedation/Paralysis to SGA ETT after pt optimized via SGA – Premeditations? Oxygen, sedation, analgesia, neuroprotection? – Sedation only intubation Give sedative (+/- topical anesthesia) DL/VL/FOI – Non-rapid RSI Small doses of analgesia and sedation then paralysis – No Drug Intubation Almost all pts require sedation and paralysis for optimal conditions 8

9. ACEP Practice Management- Focus on Rapid Sequent Intubation: http://www.acep.org/Clinical---Practice- Management/Focus-On--Rapid-Sequence-Intubation- Pharmacology/ (Accessed 21/03/2013)http://www.acep.org/Clinical---Practice- Management/Focus-On--Rapid-Sequence-Intubation- Pharmacology/ Walls RM. Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF. (Eds), Lippincott Williams and Wilkins, Philadelphia 2012 Morris et al Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009 May;64(5):532-9.