1. Rapid Sequence Intubation
Otto Sabando DO FACOEP
Program Director
Emergency Medicine Residency
St. Joseph’s Regional Medical Center
Paterson NJ

2. Objectives Overview of Rapid sequence induction (RSI) RSI Procedure
Pretreatment agents
Induction agents
Paralytic medications
Case studies: “Pitfalls”
Questions

3. Overview of RSI
1979, Taryle and colleagues reported complications in 24 of 43 patients needing an emergent airway
Improvement of house officer training
More liberal use of procedures used in the OR

4. Overview of RSI Objectives:
Immediate airway control necessitating induction of anesthesia and muscle relaxation
Provision of anesthesia and sedation to the awake patient
Minimization of intubation adverse effects, including systemic and intracranial hypertension

5. Overview of RSI Prehospital?
In non-cardiac arrest patients, overall RSI success rate 92%-98%. Comparable to ED settings
Without a full compliment of medications, success rate are ~60% as in ED settings
i.e.: Patient combative, intact gag reflex, preexisting muscle tone

6. Overview of RSI
Impact of prehospital intubations on outcome….Controversial!
Gausche and Colleagues
Comparison bag-mask ventilation and endotracheal intubation for critically ill and injured pediatric patients
820 subjects, no paralytics and sedation used
57% intubation success rate
Similar outcomes for both study groups

7. Overview of RSI Winchell and Hoyt
Retrospective review of 1092 blunt trauma patients with GCS score of less than 9
Prehospital intubation reduced mortality from 36% to 26% (impact on most severely injured)
Endotracheal intubation without medications had success rate of 66%

8. Overview of RSI Bochicchio and colleagues
Compared brain injured patient outcomes in patients with and without prehospital RSI
Pre-hospital RSI
Higher mortality rate and more ventilator days
Equivalence of the patient groups upon paramedic arrival is unknown
Study suggest that prehospital RSI and intubation may adversely affect outcomes

9. Overview of RSI Further prospective evaluations Prehospital physiology
Notation of preexisting aspiration
Better prospective studies!

10. RSI Procedure
Preoxygenate with 100% NRB if the patient is spontaneously breathing
No positive pressure ventilations
Intravenous line: Preferably 2 lines 20 gauge or larger in adults
Cardiac monitor, pulse oximetry, and Capnography
Prepare equipment: suction, difficult airway cart,

11. RSI Procedure Explain the procedure: Document neurologic status
Sedative agent
Defasciculating agent, lidocaine, and or atropine
Perform Sellick maneuver
Neuromuscular agent
Intubate trachea and release Sellick maneuver
Confirm placement

12. RSI Procedure
Sample Rapid Sequence Intubation Using Etomidate and Succinylcholine: Timed Step
Zero minus 10 min Preparation
Zero minus 5 min Preoxygenation 100% oxygen for 3 min or eight vital capacity breaths
Zero minus 3 min Pretreatment   as indicated "LOAD“
Zero Paralysis with induction   Etomidate, 0.3 mg/kg   Succinylcholine, 1.5 mg/kg
Zero plus 45 sec Placement   Sellick's maneuver   Laryngoscopy and intubation   End-tidal carbon dioxide confirmation
Zero plus 2 min Post-intubation management   Midazolam 0.1 mg/kg, plus   Pancuronium, 0.1 mg/kg, or   Vecuronium, 0.1 mg/kg

14. RSI Procedure Principal contraindication:
Any condition preventing mask ventilation or intubation

15. Pretreatment agents
Goal: Attenuate pathophysiologic responses to Laryngoscopy and intubation
Reflex sympathetic response
Increase in heart rate and blood pressure
Children: vagal response predominates
Bradycardia
Laryngeal stimulation
Lanrygospasm, cough, and bronchospasm

16. Pretreatment agents
To be effective, pretreatment agents should be given 3-5min prior to RSI
Not practical at times

17. Pretreatment agents
Pretreatment Agents for Rapid Sequence Intubation (LOAD)
Lidocaine: in a dose of 1.5 mg/kg, used to mitigate bronchospasm in patients with reactive airways disease and to attenuate ICP response to Laryngoscopy and intubation in patients with elevated ICP
Opioid: Fentanyl, in a dose of 3 μg/kg, attenuates the sympathetic response to Laryngoscopy and intubation and should be used in patients with ischemic coronary disease, intracranial hemorrhage, elevated ICP, or aortic dissection
Atropine: 0.02 mg/kg is given to prevent bradycardia in children ≤ 10 years old who are receiving succinylcholine for intubation
Defasciculation: a Defasciculating dose (1/10 of the paralyzing dose) of a competitive neuromuscular blocker is given to patients with elevated ICP who will be receiving succinylcholine to mitigate succinylcholine-induced elevation of ICP

19. Induction agents Ketamine: 1-2mg/kg, onset 1min, duration 5 min
Phencyclidine derivative
Potent bronchodilator
Status asthmaticus
Hypertension, increased ICP
Increase secretions
Atropine to offset
Emergence phenomenon
Contraindications
Elderly “Cautious”
Head injury (ICP increase), increase IOP

20. Induction agents
Etomidate: 0.3mg/kg.Onset <1min, duration 10-20min.
Non-barbiturate, non-receptor hypnotic
Water and lipid soluble and reaches the brain quickly
Sedation comparable to barbiturates
Acts on CNS to stimulate ∂-aminobutyric acid receptors and depress the RAS
No analgesic activity

21. Induction agents
Decreases cerebral oxygen consumption, cerebral blood flow and ICP
Best used in patients with head injury and hypovolemia
Side effects
Nausea, vomiting, myoclonus
Inhibition of adrenal cortical function (not really seen with one dose induction)

22. Induction agents
Propofol : mg/kg IV onset seconds, duration 8-15 minutes
Highly lipophylic
Alkylphenol sedative-hypnotic
Has amnestic effect but no analgesic effects
Dose dependant depression of consciousness ranging from light sedation to coma
Lowers intracranial pressure
Anti seizure effects

23. Induction agents Side effects
Direct myocardial depression leading to hypotension especially in the elderly

24. Induction agents Opioids Not first line selections
Fentanyl: 3-10µg/kg IV. Onset 1-2min, duration 20-30min
Highly lipophylic, rapid serum clearance, high potency, and minimal histamine release
times more patent than morphine
Best used for hypotensive patients in pain

25. Induction agents Side effects: Chest wall rigidity (>15µg/kg IV)
ICP variable
Respiratory depression (seen with other sedatives)

26. Induction agents Barbiturates:
Thiopental: 3-5mg/kg IV. Onset 30-60sec. Duration minutes
Methohexital (brevital): 1mg/kg IV. Onset <1min. Duration 5-7 min.
CNS depressant that leads to deep sedation and coma
Best indication is for status epilepticus, ICP related to trauma or HTN emergency

27. Induction agents Side effects
Myocardial depression leading to hypotension (MAP decrease by 40mm/hg)
Decreased respiratory drive
Lanrygospasm

29. Paralytic Medications
Depolarizing agents
Succinylcholine: 1-1.5mg/kg. Onset 45-60sec, duration 5-9 min.
Most commonly used agent for paralysis
Chemical structure similar to acetylcholine
Depolarize postjuctional neuromuscular membrane
Rapidly hydrolyzed by pseudocholiesterase

30. Paralytic Medications
Complications:
Bradyarrythmias
Masseter spasm
ICP?, IOP, increase intragastric pressure
Malignant hyperthermia
Tx: Dantrolene
Hyperkalemia
Increase 0.5mEq/ml
Histamine release
Fasciculation induced musculoskeletal trauma
Prevent by using defisciulating dose of nondepolorizing agent (10% of normal dose)
Prolonged apnea with pseudocholinesterase deficiency

31. Paralytic Medications
Contraindications:
Major burns
Muscle trauma
Crush injuries
Myopathies
Rhabdomyolysis
Narrow angle glaucoma
Renal failure
Neurologic disorder
Spinal cord injury
Guillian-Barre Syndrome
Children with undiagnosed myopathies?

32. Paralytic Medications
Nondepolorizing agents:
Vecuronium 0.08 mg/kg-0.15mg/kg, mg/kg. Onset 2-4min, duration min
Rocuronium 0.6mg/kg. Onset 1-3min. Duration min
Atracurium mg/kg. Onset 2-3min. Duration min.
Pancuronium 0.1mg/kg. Onset 2-5min. Duration min.

33. Paralytic Medications
Competitive agents that block the effects of acetylcholine at the neuromuscular junction
Rocuronium is the alternative medication when succinylcholine is contraindicated

34. Paralytic Medications
Reversal agents:
Mostly in OR anesthetized patients, rarely used in the ED setting
Neostigmine 0.02mg-0.04mg slow IVP
Additional doses of 0.01 to 0.02 mg/kg slow IVP can be given if reversal is incomplete
Total dose not to exceed 5mg in an adult
Give atropine 0.01mg/kg to block cholinergic effects of Neostigmine
Max adult dose 1mg
Minimum pediatric dose 0.1mg

35. Paralytic Medications
Complications
Vecuronium
Prolonged recovery time in elderly and obese patients or hepatorenal dysfunction
Rocuronium
Tachycardia
Atracurium
Hypotension, histamine release, bronchospasm
Pancuronium
Hypertension, tachycardia, histamine release

36. Cases

37. Case 1
A 24 y.o. male with a medical history of asthma is short of breath secondary to his asthma. You note that the patient is hypoxic and getting tired.
Which RSI Medications for sedation would be best for this case?
Answer

38. Case 2
A patient is hit in the head by a bat. His GCS is 8. You decide to RSI this patient as he is combative and altered. Which medications would be best in this situation?
Sedative
Paralytic
adjunct

39. Case 3
A 45 y.o. male in respiratory distress with crush injuries to his legs needs to be intubated. Which of the following paralytics are indicated in this case?
Succinylcholine
Rocuronium
Vecuronium
Pancuronium

40. Questions

41. References
Yano M, et al: Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 64:651, 1986
Kirkegaard-Nielsen H, et al: Rapid tracheal intubation with rocuronium. Anesthesiology 91:131, 1999
Schneider RE, Caro D: Pretreatment agents. In Walls RM, et al (eds): Manual of Emergency Airway Management. Philadelphia, Lippincott Williams & Wilkins, 2004
Gausche M. Lewis RJ, Stratton SJ et al. Effect of out of Hospital Pediatric Endotracheal Intubation on Survival and Neurologic Outcome: A controlled Clinical Trial. JAMA 283:783,2000
Bochicchio GV, Ilahi O,Joshi M et al. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutly lethal traumatic brain injury. J Trauma 54:307, 2003
Winchell RJ, Hoyt DB: Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 132:592, 1997

42. References
Roberts and Hedges. Clinical Procedures in Emergency Medicine. Edition 4. Saunders, 2004
Tintnalli J et al. Emergency Medicien: A comprehensive study guide. Edition 6. McGraw Hill, 2004
Rosen’s Emergency Medicine: Concept in Clinical Practice. Edition 6. Elsevier, 2006

44. Etomidate
Propofol
barbiturate

45. Lidocaine 1.5 mg/kg Suppresses cough Suppress ICP?
Decrease pressor response secondary to intubation?
Use with paralytics?