1. Rapid Sequence Intubation Anthony G. Hillier, D.O. EM Resident St. John West Shore

2. Rapid Sequence Intubation The induction of a state of unconsciousness with complete neuromuscular paralysis to achieve intubation without interposed mechanical ventilation in efforts to facilitate the procedure and minimize risks of gastric aspiration

3. Rapid Sequence Intubation Indications Failure of airway maintenance/protection - lost or diminished gag reflex Failure of oxygenation/ventilation - pulmonary edema, COPD Anticipated clinical course - multiple trauma, head injured - intoxication, air transport

4. Rapid Sequence Intubation “6 P’s” Preparation: T-10” – Positioning Preoxygenation: T-5” Premedication : T-3” Paralysis:T-0 Placement of tube: T+45 Post management: T+2”

5. Preparation

6. Evaluate – LEMON Equipment Check Positioning Drug Selection IV’s, monitor, oximetry Ancillary Staff Anticipate alternative airway maneuver

7. Preparation LEMON – L-look – E-evaluate the 3-3-2 rule – M-Mallampati – O-Obstruction – N-Neck mobility

9. PREOXYGENATION

10. Preoxygenation 100% O2 for 5 minutes of 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs

12. Preoxygenation “nitrogen wash-out” Avoid bagging the patient if adequately preoxygenated

13. PREMEDICATION

14. Premedication Goal is to blunt the patient’s physiologic responses to intubation Minimizes bradycardia, hypoxemia, cough/gag reflex, increases in intracranial, intraocular, and intragastric pressures

15. Premedication Lidocaine Opioid Atropine Defasciculating doses “priming”

16. Lidocaine Thought to blunt the rise in intracranial pressure associated with airway manipulation and the use of depolarizing neuromuscular blocking agents 1.5-3.0 mg/kg (average 100mg) three minutes prior to intubation

17. Atropine 0.02 mg/kg, minimum 0.1 mg IV, max 1 mg, three minutes prior to intubation Can minimize vagal effects, bradycardia and secretions Infants and children < 8 years may develop profound bradycardia during intubation

18. Defasciculating doses Decreases muscle fasiculations caused by the depolarizing agents (succinylcholine) Attenuates rise in intracranial pressure Agents used are the non-depolarizing blocking agents (vecuronium, pancuronium etc.) usually 1/10 of standard dose

19. Sedation Sedative agents administered at doses capable of producing unconsciousness with little or no cardiovascular effects No ideal agent exists Sedation should nearly always be used when paralyzing the patient

20. Sedation Barbiturates/hypnotics Non-barbiturate Neuroleptics Opiates Benzodiazepines

21. Barbiturates/Hypnotics Thiopental (Pentothal), Methohexital (Brevital) Short onset (10-20) seconds, duration 5-10 minutes May reduce intracranial pressure, cerebro- protective Histamine release, hypotension, bronchospasm

22. Barbiturates/Hypnotics Etomidate (Amidate) a nonbarbiturate hypnotic Decreases ICP/IOP Rapid onset, short duration Minimal hemodynamic effects No histamine release Increases seizure threshold

23. Etomidate No malignant hyperthermia reported Watch for myoclonus, vomiting May decrease cortisol synthesis (adrenal insufficiency) Dose 0.3 mg/kg IV

24. Propofol Propofol (Diprivan), sedative hypnotic Extremely rapid onset (10 sec), duration of 10-15 minutes Decreases ICP Can cause profound hypotension Dose 1-3 mg/kg IV for induction Dose: 100-200 mcg/kg/min for maintenance

25. Ketamine Ketamine-dissociative anesthetic Rapid onset, short duration Potent bronchodilator, useful in asthmatics Increases ICP, IOP, IGP Contraindicated in head injuries Increases bronchial secretions

26. Ketamine “Emergence” phenomenon can occur though rarely in children less than 10 years Emergence reactions occur in up to 50% of adults Dose: 1-2 mg/kg

27. Opiates

28. Fentanyl Broad dose-response relationship Can be reversed with naloxone Fentanyl is rapid acting (<1 min), duration of 30 min – Does not release histamine

29. Fentanyl May decrease tachycardia and hypertension associated with intubation Seizures and chest wall rigidity have been reported Dose: 2-10 mcg/kg IV

30. Morphine Sulfate Longer onset (3-5) minutes and duration (4- 6) hours May not blunt the rise in ICP, hypertension and tachycardia as well as fentanyl Dose 0.1-0.2 mg/kg IV Histamine release

31. Benzodiazepines

32. Midazolam, Diazepam, Lorazepam Provide excellent amnesia and sedation Broad dose-response relationship Reversed with Flumazenil (Romazicon) Doses required are higher for RSI than for general sedation

33. Midazolam Slower onset (3-5) min than the barbiturate/hypnotic agents Considered short-acting (30-60 min) Does not increase ICP Causes respiratory and cardiovascular depression Dose: 0.1-0.4mg/kg IV

34. Diazepam and Lorazepam Moderate/long acting agents Longer onset time than midazolam May be more beneficial post-intubation for sedation

35. Paralysis

36. Neuromuscular Blocking Agents Chemical paralysis facilitates intubation by allowing visualization of the vocal cords and optimizing intubating condition Only CONTRAINDICATION is anticipated difficult airway – Mallampati Class – Thyromental Distance

39. Depolarizing Agents Exert their affect by binding with acetylcholine receptors at the neuromuscular junction, causing sustained depolarization of the muscle cell

40. Nondepolarizing Bind to acetylcholine receptors in a competitive, non-stimulatory manner, no receptor depolarization Histamine release Agents can be reversed with edrophonium or neostigmine Caution with myasthenia gravis

41. Depolarizing agents – Succinylcholine (Anectine) Nondepolarizing Agents – Pancuronium (Pavulon) – Vecuronium (Norcuron) – Atracurium (Tracrium) – Rocuronium (Zemuron) – Mivacurium (Mivacron)

42. Succinylcholine Stimulates nicotinic/muscarinic cholinergic receptors Gold standard for 50 years Onset 45 seconds, duration 8-10 minutes Dose: (adults 1.5 mg/kg IV) Children 2.0 mg/kg IV Inactivated by pseudocholinesterase

43. Succinylcholine cont Prolonged paralysis seen with: – Pregnancy – Liver disease – Malignancies – Cytotoxic drugs – Certain antibiotics – Cholinesterase inhibitors – Organophosphate poisoning

44. Succinylcholine Adverse reactions – Muscle fasiculations – Hyperkalemia – Bradycardia – Prolonged neuromuscular blockade – Trismus – Malignant hyperthermia

45. Depolarizing Agents Muscle fasiculations – Thought to increase ICP/IOP/IGP – Causes muscle pain – Minimized by “priming” dose of NMB Hyperkalemia – Average increase in potassium of 0.5-1 mEq/L – Burns, crush injuries, spinal cord injuries, neuromuscular disorders, chronic renal failure

46. Depolarizing agents Bradycardia – Most common in children <10 years due to higher vagal tone – Also with repeated doses of succinylcholine – Premedicate with atropine

47. Depolarizing Agents Malignant hyperthermia – From excessive calcium influx through open channels – Genetic predisposition – Rapid temperature, rhabdomyolysis, muscle rigidity, DIC – 60% mortality – Treatment: IV Dantrolene

48. Depolarizing Agents Trismus (Masseter spasm) – Usually in children – Unknown cause – Treat with a nondepolarizing NMB

49. Pancuronium Long-acting agent (45-90 min) Slow onset (1-5 min) Renal excretion Vagolytic tachyarrythmias common Dose: 0.10-0.15 mg/kg IV

50. Vecuronium Duration of 30-60 min Onset of 1-4 min Hypotension may occur from loss of venous return and sympathetic blockade Mostly biliary excretion Dose 0.1 mg/kg “priming dose” 0.01 mg/kg

51. Rocuronium Has the shortest onset of the nondepolarizing agents (1-3 min) Duration 30-45 min Tachycardia can occur Dose: 0.6-1.2 mg/kg

52. Placement of Endotracheal Tube

53. Placement of Tube Allow medications to work and assure complete neuromuscular blockade of the patient Maintain Sellick maneuver until cuff inflated Ventilate with bag-valve mask if unsuccessful Additional doses of sedatives/NMB may be necessary Confirm tube placement

54. Post Intubation

55. Post Intubation Management Secure tube Continuous pulse oximetry Reassess vital signs frequently Obtain chest x-ray, ABG Restrain patient Consider long term sedation

56. Questions?? Thank You!