1. Rapid Sequence Intubation In the Emergency Department

2. Rapid Sequence Intubation  RSI The use of medication to facilitate passing the endotracheal tube  Analgesics  Sedatives  Paralytics CONTROLLED procedure  Will take several minutes to accomplish  Requires a team effort The ultimate goal is to secure an airway without having the patient vomit and aspirate.

3. Indications for RSI  Impending airway obstruction Facial fractures…no excessive oral bleeding Facial burns…inhalation injury Expanding retropharyngeal hematoma  Excessive work of breathing Example…the exhausted asthmatic  Shock  GCS <8  Persistent hypoxia (<90%)

4. 6 P's of RSI  Preparation  Preoxygenation  Pretreatment  Paralysis (with induction)  Placement of the tube  Post intubation management

5. Preparation  Oxygen Source  Suction Equipment  Endotracheal tubes  Bag-valve-mask device  Glidescope  Cardiac Monitor  Pulse oximeter  End-tidal CO² monitor  Temperature probe (LONG TERM)  Alternative airway equipment-laryngeal mask airway or jet ventilator or crich tray

6. Preparation  Assign roles and responsibilities Leader Intubationist Cricoid pressure Monitoring Medications Documentation

7. 2. Preoxygenate  3-5 minutes with 100% O2 bag mask to ensure adequate oxygen reservoir in lungs during apnea  Assure age appropriate fitting mask

8. 3. Pre-treatment  Laryngoscopy causes stimulation of afferent receptors in the posterior pharynx, hypopharynx and larynx.  Reflexes can cause: – Increased intracranial pressure (ICP) – Stimulation of upper & lower respiratory tract increasing airway resistance. – Stimulation of autonomic nervous system, with increase heart rate and BP (vagal stimulation cause decrease in pediatric!)

9. Pre-treatment  Attenuate (weaken) normal physiologic & pathophysiological reflex responses caused by airway manipulation during laryngoscope and insertion of an endotracheal tube. - Lidocaine - Atropine - Defasiculating agent

10. Pre-treatment meds  Atropine – Treats brady response to SUX, and in young children.  Lidocaine – Helps decrease ICP associated with intubation.  Vecuronium (defasiculationg dose)- keeps muscles from fasiculating (twitching) when using “Succs”

11. 4. Paralysis (with induction)  Check patency of line first!  Make sure everyone is ready  Give IV pushes rapidly and flush  Anesthesia before paralysis!  *Induction agent is followed immediately by the paralytic without waiting to see if ventilation can be maintained  Hallmark of RSI

12. Anesthesia  Etomidate  Short acting sedative hypnotic  Dose=0.3 mg/kg  Induction time= 5-10 min.  *Myoclonus

13. Ketamine  IM or IV  Dissociative anesthesia  Dose = 1-2 mg/kg (IV)/ 4-10mg/kg IM  Lasts approx. 30”  Glazed eyes & nystagmus  Watch for agitated recovery  *Increased BP, HR,tonic/clonic,N/V, hypersalivation

14. Anesthesia  Versed  Benzodiazepine,  Sedative  1-2 mg IV  Onset 1.5 min. to 2H  *Hypotension

15. Anesthesia  Fentanyl  Narcotic analgesic  50-100 mcg/kg  Lasts 30 min.  *Resp. depression

16. Propofol (Diprivan)  Induction agent  Standard dose: 2 mg/kg  Rapid onset, short duration  Considerations: *Hypotension,apnea

17. Paralytic (Neuromuscular block)  VECURONIUM Skeletal Muscle Relaxer 0.1 MG/KG IV(PARALYZING DOSE) Lasts 25 to 45 min.

18. Paralytic  SUCCINYLCHOLINE  Neuromuscular blocking agent  Dose: 1 mg/kg  Duration: 5 min.  Side effects:  Fasciculations, muscle pain,rhabdo, hyper K, brady, vent. Dysthythmias  Malignant Hyperthermia

19. Paralytic Contraindications  – Personal or family history of malignant  hyperthermia  – Significant, verified, hyperkalemia is an  absolute contraindication  – End-stage renal disease / dialysis dependent  patients with unknown potassium level

20. 5. Placement of Tube  Position patient Do not bag unless SpO2 < 90% Sellick’s Maneuver (Cricoid pressure)

21. Placement of tube

22. Placement and Proof  Confirm tube placement  – ETCO2  – Bilateral breath sounds  – Absent epigastric sounds

23. Failed attempt What if the intubation attempt is not successful?  1st step = bag/mask ventilation for support Rescue Maneuvers  – The first rescue from failed intubation is bagging  – The first rescue from failed bagging is better bagging

24. 6. Post-intubation Management  Secure tube  ETCO2  Chest x-ray  Long acting sedation (+/- paralysis)  – Midazolam 0.2mg/kg  – Propofol 25-50μg/kg/min  Establish ventilator parameters

25. 6P’s RSI Summary Preparation (zero – 10 minutes) Preoxygenation (zero – 5 minutes) Pretreatment (zero – 3 minutes) Paralysis with induction (time zero) Positioning (zero + 30 seconds) Placement (zero + 45 seconds) Post-tube management (zero + 90 seconds)

26. Questions?