1. Rapid Sequence induction

2. Why Intubate? Airway protection – pre-transfer, burns Decreased GCS – Caution! Patient requires ventilatory assistance Need for hyperventilation Hyperthermia – paralyse

3. Pre intubation Four P’s: Preparation, preoxygenation, position, plan Have your equipment ready Optimise oxygenation – individual for each patient Position the patient correctly Have a plan, have a plan B, have a plan C. Communicate these with the team

4. Preparation Adequate assistance: Airway nurse, drugs nurse, SMO/consultant Physiological monitoring – include ETCO2 Check equipment: –Laryngoscope + VL –IV line –ETT –Bougie/stylet

5. Pre-oxygenation Standard pre-oxygenation should give 8 minutes in well adults, 5 minutes in sick adults, 2.5 minutes in obese adults We can do better!

6. What not to do

7. ??

8. Better

9. More Better + NP at 3-4 litres when awake, 15 litres as soon as asleep

10. Even Better? Probably not, but NIV is certainly reasonable

11. Position Normal weight – “sniffing” – flex at lower C spine, extend at C1 Overweight – “ramp” – Tragus level with sternomanubrial angle Children…

12. Plan Have a plan and two backup plans Communicate them. E.G.: –First I will trial intubation with direct laryngoscopy and a bougie –Then VL with bougie –Then LMA –Then surgical airway You can alter your plan – but always change something before you have another attempt

13. Drugs – general principles Think about them –adjust drugs and dose to patients My standard is rocuronium 1.2mg/kg and ketamine 1.5mg/kg Most of the other consultants use propofol, opiate and sux.

14. Rocuronium Non depolarising muscle relaxant No fasciculations – prolongs time to desat Lasts 20-30 minutes Reversed with sugammadex – never happens Fewer contraindications than suxamethonium

15. When to use sux Seizures/status – wears off quicker, you can see them fit

16. Cricoid pressure Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961; 2: 404–406. I don’t use it Consider bimanual manipulation if needed.

17. Bougie or stylet? Use one or the other Stylet may be more traumatic, bougie is slightly more complicated. Bougie requires a well trained airway nurse. Do not take out the laryngoscope!

18. Tube’s in. Now what? Check position – listen, ETCO2, CXR Secure tube Sedation – draw up before intubation if possible NGT IDC Head up 30 degrees

19. Ventilator settings (not COPD) SIMV/VC – do not worry about other modes for now Vt around 6-8mg/kg Rate around 14 PEEP 5 FiO2 – start at 100% and titrate down until sats <100%

20. Vantilator settings (COPD/asthma) SIMV/VC Vt 8mL/kg Rate 10 PEEP 0 IE ratio 1:4-5

21. Ventilator troubles If an alarm goes off, a breath is probably not given! Take the patient off the vent and bag them High pressures Hypoxia Hypotension These are for another lecture