1. RSI Presented By: Dr. Mohamad Husain Ahmad
Supervised By: Dr. Manal Al-Maskati

2. Introduction
Airway management is the most important skill for an emergency practitioner to master because failure to secure an adequate airway can quickly lead to death or disability.

3. Introduction
Despite the existence of the guidelines, little data exist about RSI and most of the data comes from anaesthesia literature.

4. RSI in comparison to regular intubation
RSI is superior in terms of higher success rate, better intubation conditions and lower incidence of complications. Proved by:
Clinical experience.
randomized, controlled trials describing intubating conditions for patients intubated in the operating room have consistently reported a significantly higher frequency of excellent intubation conditions with deep sedation plus paralysis (80 to 98 percent) versus that observed with deep sedation alone (0 to 30 percent).

5. RSI
Stands for:
Rapid Sequence Intubation.
Rapid Sequence Induction.

6. Definition
The process of administering a sedative and muscle relaxant to induce a state of unconsciousness and complete neuromuscular paralysis to facilitate the process of endotracheal intubation.

7. Aim To take: An awake patient. With assumed full stomach.
Very quickly induce a state of unconsciousness and paralysis and securing the airway.
Without using positive pressure ventilation as much as possible.

8. Major Advantages
Decreases the stimulation of potentially harmful autonomic reflexes ass e intubation:
E.g elevated intracranial pressure, HTN & brady.
Controls the clinical environment:
In case of anxious, frightened or uncooperative.
Minimizes the risk of pulmonary aspiration:
If done along with cricoid pressure.

9. Major Advantages Provides better intubation conditions:
Complete jaw relaxation, open and immobile vocal cords, and no coughing, bucking or diaphragmatic movement in response to intubation.
Minimizes the psychic trauma:
Cuz the p.t will be unconscious.

10. Indications
Indicated for almost all the patients undergoing emergent endotracheal intubation.

11. Contraindications
Total upper airway obstruction (requires surgical airway)
Total loss of facial/oropharyngeal landmarks (requires surgical airway)

12. Used e Caution
In patients e H/O or F/H/O allergy to anesthetic agents.
In patients known to have a difficult airway:
Cuz the patient will be irreversibly paralyzed for few minutes after administering the NMB agent.

13. Unnecessary
Although not contraindicated, it is unnecessary and time wasting in unconscious patients.

14. Time needed
In the majority of situations, RSI, from the decision to intubate to successful intubation, is accomplished in 10 minutes

15. Steps 6 Ps Preparation (T: -10m). Pre-oxygenation (T: -5m).
Pre-medication (T: -3m).
Paralysis (T: 0).
Placement of tube (T: +45s).
Post management (T: +2m).

16. Preparation Preparation of equipment:
Best remembered by the mnemonic (SOAP-ME):
S: Suction.
O: Oxygen.
A: Airway equipments.
P: Pharmacology agents.
ME: Monitoring Equipment.

17. Preparation Equipments:
Available.
Proper size.
Functioning.
Assess for the possibility of difficult intubation or bag-mask ventilation.
Decide which sedative and paralytic agents you will use:
Dose.
Keep them ready and drawn in syringes.
IV access (preferable 2).

18. Rapid Review Rapid review includes: Rapid and specific history taking.
Rapid and specific physical examination.

19. Rapid Review
Purpose:
Identify or current conditions that may adversly affected by medications or airway manipulation (NM diseases, cardiovascular compromise, increased ICP or bronchospasm).
Clinical features that may make laryngoscopy and/or tracheal inubation difficult.
Coditions that may interfere with bag mask ventilation.

20. Rapid Review History: Allergies to medications.
History or F.history of malignant hyperthermia.
History of asthma.
Previous intubations.
Siezure disorders.
Noisy breathing suggestive of upper airway obstruction.

21. Rapid Review Physical examination:
Clinical features suggestive of NM disorders.
Increased ICP.
Bronchospasm.
Cardiovascular compromise:
Unexplained tachcardia, poor peripheral perfusion, and hypotension.

22. Pre-Oxygenation Benefit:
To establish a reservoir of oxygen within the lungs, as well as an oxygen surplus throughout the body. So the patient can then tolerate several minutes of apnea without oxygen desaturation, allowing intubation to be safely performed without bag-mask ventilation.

23. Pre-Oxygenation Ways:
Hypoxic, in respiratory failure, or have insufficient respiratory reserve to achieve adequate preoxygenation with spontaneous respirations:
careful bag-mask ventilation with small tidal volumes (while maintaining cricoid pressure) should be performed for several minutes to achieve adequate preoxygenation.
Breathing spontaneously:
nonrebreather mask for a minimum of three minutes.

24. Pre-Oxygenation Oxygen concentration used:
The highest concentration available.

25. Pre-Treatment
Agents:
Atropine.
Lidocaine.

26. Pre-Treatment Atropine:
Indicated in p.ts receiving ketamine to reduce the risk of excessive secretions.
Indicated in p.ts at risk of developing bradycardia:
Children < 1yr.
Children < 5 yrs receiving succinylcholine.
Children receiving a second dose of succinylcholine.
Timimg:
1-2 min prior to inubation.

27. Pre-Treatment
Dose:
0.02 mg/kg IV (max 1 mg & min 0.1 mg too small doses can cause paradoxical bradycardia).

28. Pre-Treatment Disadvantages:
In too small doses can cause paradoxical bradycardia.
The effect of atropine on heart rate may persist for several hours and prevent the bradycardic response to hypoxemia.
Dilates the pupils, thus interfering with pupillary response to light as a means to evaluate a change in neurologic status once the patient is paralyzed.

29. Pre-Treatment Lidocaine:
Indicated in all p.ts to reduce the risk of increase in ICP associated with laryngoscopy and intubation (vagal nerve stimulation).
Timing:
2-5 min prior to intubation.
Dose:
1.5 mg/kg IV (max 100 mg)

30. Pretreatment Controversies:
Although widely used, there are no studies that assess the efficacy of lidocaine to improve neurologic outcome in patients undergoing RSI in acute brain traumatic injury.

31. Pre-treatment
In systematic review of studies of adult patients, Robinson et al, it showed conflicting results on the ability of lidocaine to blunt the increase in ICP in patients who were being intubated or undergoing endotrachial suctioning.

32. Premedication Groups of patients going for RSI can be divided into:
Head trauma without shock.
Shock.
Asthmatic.
Non of the above.

33. Premedication Agents: Etimodate. Thiopental. Ketamine. Propofol.
Midazolam.

34. Premedication Criteria to choose the sedative agent: Availability.
Institutional policy.
Familiarity.
Clinical advantages/disadvantages with respect to the clinical requirements of the patients.

35. Etimodate Onset of action: Duration: Intubation conditions:
< 1 min.
Duration:
10-20 min.
Intubation conditions:
75% success rate.
1st most common agent used in united states cuz it is hemodynamically neutral.

36. Etomidate
CNS:
Pros: lowers ICP, protective against generalized siezure activity.
Cons: lowers the threshold for convulsion in p.ts with focal siezure disorders.
CVS:
Pros: hemodynamically neutral.

37. Etimodate Adrenals: Effect:
Increase the risk of adrenal suppression leading to decrease in cortisol level (one prospective randomized controlled study of 31 adults compared etimodate and midazolam specifically to assess for adrenal function. It showed that although there was significant decrease in adrenal function in the 1st 4hr in etimodate group, there was no diffrence at 12 or 24hr and measured cortisol levels remained within normal ranges).

38. Etimodate Significance: If there is no alternative:
Not to be used in cases of sepsis or in patients known to have adrenal insufficiency.
If there is no alternative:
Give a single dose of corticosteroids.

39. Etimodate Preferred in: Better avoid in:
As a 1st choice unless contraindicated.
Better avoid in:
Focal siezure disorders.
Adrenal insufficiency.
Severe sepsis.

40. Thiopental Onset of action: Duration: Intubation conditions:
10-30 min.
Intubation conditions:
% success rate (better than etimodate).
The best success rate of 1st attempt in RSI.
2nd most common agent used in united states.

41. Thiopental CNS: CVS: Chest:
Pros: lowers ICP, anticonvulsant properties.
CVS:
Cons: hypotension (bradycardia and vasodilation).
Chest:
Cons: laryngo and bronchospasm (causes histamine release).

42. Thiopental Preferred in: Better avoid in:
Cases of ICP without hypotension.
Cases in which etimodate is contraindicated or not available and patient is hemodynamically stable.
Better avoid in:
Hemodynamically unstable patients.
Bronchial asthma patients.

43. Ketamine
Onset of action:
1 min.
Duration:
30-60 min.

44. Ketamine CNS: CVS: Chest:
Controversial: increases ICP (very weak data)
Pros: has anticonvulsant properties, increase cerebral perfusion.
CVS:
Cons: hypertension (tachcardia and vasoconstriction).
Chest:
Pros: bronchodilator.
Cons: laryngospasm.

45. Ketamine Eyes: Salivation: IOP.
Cons: hypersalivation (better to pre-treat with atropine).

46. Ketamine Prefered in: Avoid in: Controversial:
Bronchial asthma, anaphylactic shock.
Avoid in:
Aortic dissection, abdominal aneurism or acute myocardial infarction.
Penetrating eye trauma.
HTN.
Controversial:
ICP.

47. Midazolam
Onset of action:
1-2 min.
Duration:
20-30 min.

48. Midazolam CNS: CVS: Chest: Pros: anticonvulsant properties.
Cons: hypotension.
Chest:
Cons: causes respiratory depression, so p.ts may develop apnea before receiving the paralytic agent which interferes with the effectiveness of pre-oxygenation.

49. Propofol
Onset of action:
10 s.
Duration:
10-15 m.

50. Propofol CNS: CVS: Other:
Pros: anticoncvulsant properties, lowers ICP.
CVS:
Cons: hypotension (vasodilatation and bradycardia).
Other:
It contains egg lecithen, egg yolk phospholipids and soybean oil.

51. Premedication No ideal sedative exists for every RSI situation.
Etomidate or thiopental for the uncomplicated patient undergoing RSI.

52. Premedication Hypotension: Increased ICP:
Etimodate or ketamine (especially in septic shock).
Increased ICP:
Any agent but thiopental and midazolam are not preferred cuz they decrease the mean arterial pressure leading to decrease in cerebral perfusion pressure.

53. Premedication Hypotension with head injury: Status asthmaticus:
Etimodate or ketamine.
Status asthmaticus:
Ketamine or etimodate.
Status epilepticus:
Thiopental, midazolam or etimodate (especially if hemodynamically unstable).

54. Paralysis Agents: Depolaryzing: Non-depolaryzing: Succinylcholine.
Vecuronium.
Rocuronium.
Pancuronium.

55. Succinylcholine Onset of action: Duration:
3-8 min.
1st most commonly used paralytic agent cuz of its rapid onset of action and short duration of paralysis.

56. Succinylcholine Action:
Mimics the effect of acetylcholine at the nicotinic cholinergic receptor, causing continuous depolarization of the muscle membrane. This inhibits repolarization, resulting in paralysis.

57. Succinylcholine S.E Bradycardia: Patients at risk: Recommendation:
Children < 5 yrs receiving succinylcholine.
Children receiving a second dose of succinylcholine.
Recommendation:
Pre-treating with atropine.

58. Succinylcholine S.E
Malignant hyperthermia can be triggered by succinylcholine.
Elevated ICP and IOP:
Recommendation:
Pre-treat with lidocane.

59. Succinylcholine S.E Hyperkalemia: Patients at risk:
Myopathies (such as Duchenne or Becker’s dystrophy). Succinylcholine interacts with the unstable muscle membrane causing rhabdomyolysis and rapid increase in serum potassium.

60. Succinylcholine S.E
Conditions resulting in up-regulation of skeletal muscle acetylcholine receptors (such as motor neuron lesions, muscle injury, muscle disuse, or muscle atrophy) → exaggerated efflux of potassium from the muscle occurs after depolarization. The increase in number of receptors usually occurs within 2-3 days following an injury.

61. Succinylcholine S.E Recommendation:
To minimize the hyperkalemia it is recommended to give a defasciculating dose of a non-depolarizing agent 2 min before the administration of succinylcholine.
In a small randomized controlled study, 45 children, 3–15 years old, were pretreated with either saline or a nondepolarizing paralytic agent, and then treated with succinylcholine. While there was no difference in the amount of fasciculations, the rise in serum potassium levels was significantly less when pretreated with a nondepolarizing agent (0.45 mmol/L for saline group vs. 0.0 for nondepolarizing agent group).

62. Succinylcholine Absolute contraindications: Chronic myopathies.
Denervating NM disease.
48-72hrs post burns, crush injuries, or acute denervating event.
H/O malignant hyperthermia.
Pre-existing hyperkalemia.
Renal failure.

63. Succinylcholine Relative contraindications: Increased IOP or ICP.
Patients with pseudocholinestrase deficiency (risk of prolonged duration).

64. Non-Depolarizing agents
Mode of action:
Induces muscle paralysis by competitive antagonism at the nicotinic cholinergic receptor.

65. Rocuronium Onset of action: Duration:
1-3 min.
Duration:
30-45 min.
The best alternative to succinylcholine cuz of its rapid onset of action and shorter duration of action when compared with the other non-depolarizing agents.

66. Rocuronium Rocuronium v.s succinylcholine:
Some clinicians prefer the disadvantage of rocuronium longer duration of action to the small but fatal risk of using succinylcholine.
Succinylcholine provides better intubating conditions than rocuronium. This can be compensated by giving higher doses of rocuronium but unfortunately, it is associated with longer duration of paralysis.

67. Placement of Tube When:
Once the child is apneic and the jaw can be easily opened (proper muscle relaxation).

68. Placement of Tube Confirmation of proper position:
Visualizing the ETT passing through the vocal cords.
Yellow color change in CO2 detector (the color might change even with esophageal intubation cuz of hyperinflation of the stomach when BMV is needed. The color might not change in case of prolonged cardiac arrest).

69. Placement of Tube Good wave form on the carbonograph (ETCO2 monitor).
Auscultation over the lungs and stomach.
Improvement in patient vital signs.

70. Post Intubation Management
Secure the ETT in position.
Initiate mechanical ventilation.
Chest radiograph.
Administer appropriate analgesia and sedation for patient comfort.

71. Complications
Adverse physiologic reactions (hypotension, bradycardia or increase ICP) secondary to vagal stimulation induced by direct laryngoscopy.
Failure of intubation in a patient who cannot be ventilated (the so called cannot intubate/cannot ventilate situation). A rescue airway techniques must be done.

72. Complications Side effects from the pharmacological agents.
Esophageal intubation.
Barotrauma (due to administration of excessive tidal volume) causing pneumothorax.
Mechanical trauma to the oral cavity and larynx during insertion or manipulation of the ETT or laryngoscope.

73. Complications Aspiration pneumonitis:
Usually patient comes with full stomach.
Sometimes cricoid pressure must be relieved and BMV must be initiated giving more chance for air to enter stomach and causes reflux.

74. Cricoid Pressure Benefit: When to apply:
Occlude the esophageal lumen, which reduces the risk of passive regurgitation, which reduces the risk of aspiration.
When to apply:
Once the sedative and paralytic agents are administered until the endotracheal intubation is confirmed.

75. Cricoid Pressure Risks (remove once you have one of the following):
Difficulty viewing the larynx during intubation.
Airway obstruction when ventilation is required.
Movement of the cervical spine in patients with unstable fractures.
Esophageal injury in patients who are actively vomiting.

77. Difficult Airway Can be assessed by the following methods (LEMON):
L: Look externally.
E: Evaluate the rule.
M: Mallampati classification.
O: Obstruction.
N: Neck mobility.

78. Difficult Airway Look externally for difficulty in the following:
Positioning:
Prominent or misshapen occiput, short neck or poor neck mobility.
Bag mask ventilation:
Facial anomalies, facial trauma (including burns).

79. Difficult Airway Laryngoscopy: Intubation:
Small mouth, small mandible, abnormal palate, large tongue.
Intubation:
Signs of upper airway obstruction (hoarseness, stridor, drooling).

80. Difficult Airway Evaluate 3-3-2 rule:
3: patient is able to insert 3 of his or her own fingers between his teeth.
3: can accommodate 3 of his her own fingers breadth between his or her hyoid bone and the mentum.
2: can accommodate 2 of his her own fingers between his or her hyoid bone and the thyroid cartilage.

82. Mallampati classification

83. Difficult Airway Obstruction look for 3 signs: Neck mobility:
Drooling (inability to swallow secretions).
Stridor.
Hoarsness.
Neck mobility:
Inability to move the neck makes it a difficult airway.