1. Rapid Sequence Intubation Erik D. Barton, MD, MS, MBA University of Utah Affiliated Emergency Medicine Residency Program

2. The Decision to Intubate Four Reasons for Intubation Establish, maintain or protect airway Failure to ventilate Failure to oxygenate Anticipated clinical course

3. Sagarin, Barton, et al, Ann Emer Med, 2005 First Provider Intubations

4. Sagarin, Barton, et al, Ann Emer Med, 2005 Rescue Intubations

5. Rapid Sequence Intubation Definition The virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

6. Just like Skydiving…. Skydiving is lethal unless one deploys a parachute… RSI is lethal unless you rescue the airway! Rapid Sequence Intubation

7. Just like Skydiving…. –Redundancy of safety (primary & backup) –Planned, stepwise approach to primary system –Simple, fast backup system –Attention to monitoring –Equipment vigilance Levitan, RM. Ann Emerg Med. 2003;42:81-87. Rapid Sequence Intubation

8. Definition Incorporates: Every patient has a full stomach Preoxygenation No interposed ventilations Sellick’s maneuver

9. Rapid Sequence Intubation Advantages of RSI Rapid control of the airway Minimizes risk of aspiration Highest success rates Lowest complication rates Optimal intubating conditions Adaptable to patient condition Can mitigate adverse effects

10. Rapid Sequence Intubation The Six Ps of RSI Preparation Preoxygenation Pretreatment Paralysis with Sedation Protection Placement

11. Rapid Sequence Intubation The Sequence Zero: the time of administration of succinylcholine.

12. Rapid Sequence Intubation The Sequence Zero - 10 minutes Preparation Assess airway difficulty (LEMON) Plan approach Assemble drugs and equipment Establish access Establish monitoring

13. Rapid Sequence Intubation The Difficult Airway Rule L ook externally E valuate 3-3-2 M allampati O bstruction? N eck mobility

14. Rapid Sequence Intubation Zero - 5 minutes Preoxygenation 100% oxygen for five minutes 8 vital capacity breaths Provides essential apnea time Apnea time varies The Sequence

15. Rapid Sequence Intubation Time to Desaturation

16. Rapid Sequence Intubation Zero - 3 minutes Pretreatment Lidocaine Opioid Atropine Defasciculation “LOAD the patient before intubation.” The Sequence

17. THE AIRWAY COURSE National Emergency Airway Management Course PRETREATMENT AGENTS

18. THE AIRWAY COURSE National Emergency Airway Management Course L idocaine O pioid A tropine D efasciculation Give 3 minutes before SCh PRETREATMENT AGENTS

19. THE AIRWAY COURSE National Emergency Airway Management Course PRETREATMENT AGENTS 1.5 mg/kg Increased intracranial pressure Bronchospasm L IDOCAINE

20. THE AIRWAY COURSE National Emergency Airway Management Course PRETREATMENT AGENTS O PIOID Fentanyl 3  g/kg Cardiovascular disease Intracranial hypertension Caution: sympathetic drive

21. THE AIRWAY COURSE National Emergency Airway Management Course PRETREATMENT AGENTS A TROPINE 0.01 mg/kg Children < 10 years who receive Sch

22. THE AIRWAY COURSE National Emergency Airway Management Course PRETREATMENT AGENTS 10% of the paralyzing dose: Vecuronium (0.01 mg/kg) Pancuronium (0.01 mg/kg) Rocuronium (0.06 mg/kg) Intracranial hypertension D EFASCICULATION

23. THE AIRWAY COURSE National Emergency Airway Management Course INDUCTION AGENTS

24. THE AIRWAY COURSE National Emergency Airway Management Course INDUCTION AGENTS HEALTHY, STABLE PATIENTS Etomidate 0.3 mg/kg Midazolam 0.2 mg/kg Ketamine 1.5 mg/kg Propofol 1 mg/kg Pentothal 3 mg/kg

25. THE AIRWAY COURSE National Emergency Airway Management Course COMPROMISED/UNSTABLE PATIENTS Etomidate 0.1 mg/kg Midazolam 0.1 mg/kg Ketamine 1 mg/kg Propofol 0.5 mg/kg Pentothal 1.5 mg/kg INDUCTION AGENTS

26. THE AIRWAY COURSE National Emergency Airway Management Course INDUCTION AGENTS FOR SPECIFIC CONDITIONS  Reactive airways ketamine  ICP etomidate, pentothal  Hypotensive ketamine  Operator preference

27. Rapid Sequence Intubation Zero!! Paralysis with sedation Induction agent IV push Succinylcholine 1.5 mg/kg IVP Entering the red zone... The Sequence

28. THE AIRWAY COURSE National Emergency Airway Management Course NEUROMUSCULAR BLOCKADE Depolarizing succinylcholine Competitive (nondepolarizing) Aminosteroids Benzylisoquinolines

29. Rapid Sequence Intubation Succinylcholine Still the ED NMB of choice Rapid effect Short duration Generally well tolerated A few important side effects

30. THE AIRWAY COURSE National Emergency Airway Management Course NEUROMUSCULAR BLOCKADE SUCCINYLCHOLINE Rapid onset / brief duration May ICP Fatal hyperkalemia burns beyond day one active neuromuscular disease crush injuries intra-abdominal sepsis (7D)

31. THE AIRWAY COURSE National Emergency Airway Management Course NEUROMUSCULAR BLOCKADE AminosteroidsBenzylisoquinolines atracurium cisatracurium mivacurium metocurine DTC rocuronium pancuronium vecuronium rapacuronium

32. THE AIRWAY COURSE National Emergency Airway Management Course NEUROMUSCULAR BLOCKADE Summary SCh for RSI Competitive for pre-treatment Rocuronium for competitive RSI

33. Rapid Sequence Intubation Zero + 30 seconds Protection Sellick’s Maneuver Position patient Do not bag unless S O < 90% p 2 The Sequence

34. Rapid Sequence Intubation Zero + 45 seconds Placement The Sequence Check mandible for flaccidity Intubate, remove stylet Confirm tube placement - E CO Release Sellick’s maneuver Long acting agents/ventilator t2

35. Rapid Sequence Intubation Failed Attempt Plan in advance Systematic approach essential Equipment Training …remember “Skydiving!!” Rescue Maneuvers

36. Rapid Sequence Intubation The first rescue from failed intubation is bagging. The first rescue from failed bagging is better bagging. Rescue devices Failed Attempt Rescue Maneuvers

37. How do we know that RSI really works? Rapid Sequence Intubation

38. The “Science” of Airway Management The problems… Self-reporting Emergency conditions Multiple factors influence each course: highly variable operator dependent “Jargon” not standardized Wang, HE. Acad Emerg Med. 2003;10:644-5.

39. 6294 ED Intubations from the second report of the ongoing National Emergency Airway Registry Study (NEAR II) NEAR

40. Methods: Prospective, observational study from 8/97 to 4/00 of 26 teaching hospitals in the U.S. during the second phase of the ongoing National Emergency Airway Registry (NEAR II) study. 6294 Intubations from the National Emergency Airway Registry

41. Personnel Performing ED Intubations 6294 Intubations from the National Emergency Airway Registry

42. Demographics of Cases: IndicationCasesFemaleMaleUnknown Trauma1605 (22%)349 (22%)1059 (65%)97 (3%) Medical4286 (72%)1740 (40%)2194 (51%)352 (9%) Not Provided277 (6%)84 (2%)166 (3%)27 (1%) TOTAL6294 (100%)1642 (36%)2545 (55%)415 (9%) 6294 Intubations from the National Emergency Airway Registry

43. 6294 Intubations from the National Emergency Airway Registry Oral RSI 4377 (69%) Oral no meds 1088 (17%) Oral induction without paralysis 427 (7 %) Nasal awake with topical 206 (3%) Nasal no meds 69 (1%) Nasal induction without paralysis 45 Surgical cric/tracheotomy 39 (0.6%) Other 16 Oral awake with topical 21 Unknown 5 TOTAL 6294

44. 1st Course Success Rates: Medical Trauma Oral RSI99.8%97.7% Oral no meds94.7% 96.3% Oral induction without paralysis95.0%93.7% Nasal awake with topical97.2%98.1% Nasal no meds91.3%45.4% Nasal induction without paralysis97.0%100% Oral awake with topical93.7%N/A Other50.0%100% Surgical cricothyrotomy60.0%68.7% Unknown50.0%N/A TOTAL 94.7%96.2% 6294 Intubations from the National Emergency Airway Registry

45. 6294 Intubations from the National Emergency Airway Registry Success Rates by Intubator: First pass Overall EM 84.7%98.5% Anesthesia93.5%93.5% Other64.9%97.4% Attending EM90.2%97.9% PGY 3 or 487.2% 98.4% PGY 1 or 277.5%98.7% Other81.1%98.5%

46. NEAR Other Studies: Analysis of failed intubations and rescue techniques - Bair, AE, et al. J Emerg Med. 2002;23:131-40. Sedative agents facilitate intubations with NMB - Sivilotti, MLA, et al. Acad Emerg Med. 2003;10:612-20. Underdosing of midazolam in 92% of adults, 56% of kids - Sagarin, MJ, et al. Acad Emerg Med. 2003;10:329-38. Benchmarking intubation data for North American EM residents - Sagarin, MJ, et al. Ann Emerg Med. 2004.

47. Golden Hour Data Systems project Prospectively collect data on all intubations in the field by air medical personnel 13 Helicopter and air ambulance companies in the U.S. “RSI” defined as the use of Suxx + an induction agent Air Medical Research Collaborative (AMTC)

48. Results: –Over 30,000 patient transports from 1998-2004 –2853 patients had intubations (9%) –RSI = 68% (1944 patients) –Non-RSI = 32% (909 patients) Air Medical Research Collaborative (AMTC)

49. Success Failure Total Success Rate Trauma/Burn RSI (58%) 1542 115 1657 93.1% Trauma/Burn non-RSI (22%) 532 92 624 85.3%* Medical RSI (10%) 265 22 287 92.3% Medical non-RSI (9%) 238 30 268 88.8% Total RSI (68%) 1807 137 1944 93.0% Total non-RSI (32%) 777 132 909 85.5%* (*p<0.05) Surgical Cric/tracheotomy 45 (1.6%) Air Medical Research Collaborative (AMTC)

50. The Future: Standardize the jargon What is an intubation attempt? Immediate vs. long-term complications Difficult airway assessments Rapid and predictive Universally applied The “Science” of Airway Management

51. The Future: Unbiased reporting systems Large-scale data collection (web) Standardized reporting tools NEAR III and IV Data analysis Trends and outcomes New devices/technologies

52. Emergency medicine…

53. …the specialty that…

54. …ALWAYS…

55. …has customers!! The End…