Rapid Sequence Intubation

John Bradley, MD Metropolitan Hospital

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Lessons from Skydiving
Levitan RM. Patient safety in emergency airway management and rapid sequence intubation: metaphorical lessons from skydiving. Ann Emerg Med. 2003;42:81-87. 2003;42:81-

‡ Redundancy of safety (primary and backup chute) ‡ Planned stepwise approach to deploy 1ary chute Simple, fast, easy backup chute deployment ‡ Attention to monitoring: exit plane at correct altitude, altimeter determines when to deploy backup chute ‡ Equipment vigilance
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Overview
Rapid Sequence Intubation
Airway Assessment The Difficult Airway The Failed Airway Airway Options Your Approach

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Rapid Sequence Intubation (RSI)
‡ ‡ ‡ ‡ ‡ ‡ ‡ Definition Assumptions Goals Indications Contraindications Alternatives Procedure
± Steps ± Pharmacology
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RSI Definition
‡ The administration of a potent induction agent followed immediately by a rapid acting neuromuscular blocker (NMB) to render unconsciousness and motor paralysis for tracheal intubation

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RSI Assumptions

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RSI Assumptions
‡ ‡ ‡ ‡ Intubation is indicated The stomach is full Intubation is anticipated to be successful If intubation fails, ventilation is expected to be successful

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RSI Goals
‡ ‡ Optimize intubation conditions Minimize aspiration risk by avoiding positive pressure ventilation until after intubation is accomplished

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Indications for Tracheal Intubation

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Indications for Tracheal Intubation
Inability to maintain an airway Inability to maintain adequate oxygenation and ventilation Anticipated airway obstruction / Special situations

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RSI Contraindications

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RSI Contraindications
‡ ‡ ‡ ‡ Tracheal / laryngeal injury / disruption S/P Laryngectomy Massive facial trauma Anticipated difficult airway

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RSI Alternatives
‡ Awake oral intubation with local anesthesia and sedation ‡ Blind nasotracheal intubation (BNTI)

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RSI
The 7 Ps

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RSI
The 7 Ps ‡ ‡ ‡ ‡ ‡ ‡ ‡ Preparation Preoxygenation Pretreatment Paralysis with induction Protection with positioning Placement with proof Post-intubation management
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RSI Timeline
Time Zero - 10 min Zero - 5 min Zero - 3 min Zero Zero + 20-30 sec Zero + 45-60 sec Zero + 60-90 sec Action Preparation Preoxygenation Pretreatment Paralysis with induction Protection with positioning Placement with proof Post-intubation management

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RSI Compressed Timeline
‡ Concurrent preparation and preoxygenation ‡ Accelerated (2 min)
± Shorten preoxygenation to 30 sec with 8 vital capacity breaths (VC) method ± Shorten pretreatment interval from 3 min to 2 min

‡ Immediate
± Eliminate pretreatment ± Preoxygenate with 8 VC breaths
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Preparation
‡ Patient
± Discussion, airway assessment, IV access ± Positioning

‡ Equipment
± Airway, monitoring, failed airway ± Blade type and size, ETT size ± OP airway, placement confirmation device ± Cuff integrity and stylet, laryngoscope fxn

‡ Personnel
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Airway Assessment (LEMON)
‡ ‡ ‡ ‡ ‡ ‡ Look externally Evaluate 3-3-2 Mallampati Obstruction Neck (Pediatrics)

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Look Externally
‡ Difficult BVM Ventilation ? ‡ Difficult Laryngoscopy / Intubation ? ‡ Difficult Surgical Airway ?

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Difficult BVM Ventilation (BONES)
‡ ‡ ‡ ‡ ‡ ‡ Beard Obesity No teeth (Elderly) (Snores) Severe facial burns / angioedema / trauma
± Unstable midface and/or mandible

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Difficult Laryngoscopy / Intubation
‡ ‡ ‡ ‡ ‡ ‡ (Severe facial burns / angioedema / trauma) Buck teeth Jay Leno Micronathia Down¶s syndrome FLK

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Difficult Surgical Airway (SHORT)
‡ ‡ ‡ ‡ ‡ Surgery Hematoma or infection Obesity Radiation Tumor (including goiter)

‡ Anatomic variability ‡ Females
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Evaluate (3(3-3-2 Rule)
‡ 3 finger breadths between upper lower teeth
±Ability to visualize

‡ 3 finger breadths between the mandible and hyoid bone
±< 3: suggests anterior larynx ±Greater: axes malalignment

‡ 2 finger breadths between thyroid cartilage notch and the mandible or floor of the mouth
±Cephalad larynx
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Mallampati Classification
I II III IV Tonsillar pillars and fauces visible Upper portion of pillars and uvula visible Base of uvula / soft palate visible Only tongue and hard palate visible

Patient¶s mouth open, tongue sticking out Correlates with laryngoscopy classification, but not as sensitive in grades 3 and 4«
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Laryngoscopic Classification
‡ Grade I Entire glottis visible ‡ Grade II Arytenoid cartilage and posterior glottis visible ‡ Grade III Epiglottis only visible ‡ Grade IV Tongue or soft palate visible ‡ Grade III and IV are considered difficult intubations (about 5% of OR cases) ‡ Visualization predicts intubation success

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Obstruction
‡ ‡ ‡ ‡ ‡ ‡ Angioedema Epiglottis Abscess Burn Trauma Tumor

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Neck
‡ Possible cervical spine injury ‡ Rheumatoid arthritis ‡ Ankylosing spondylitis

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High Risk Patients
‡ ‡ ‡ ‡ ASA Class III and higher Chronic pulmonary or cardiac disease Fever, volume depletion, current URI Airway assessment suggestive

‡ Consider OR, anesthesia consult and/or awake intubation
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ETT Size and Depth
‡ Size
± Females 7.5-8; Males 8-8.5 ± Broslow tape, little finger diameter ± 4 + age/4

‡ Depth
± Females - 21 cm; Males - 23 cm ± Broslow tape, markings on ETT ± ETT size x 3 (cm); age + 10
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Preoxygenation
‡ Establish an O2 reservoir in the lungs & body
± Essential to ³no bagging´ principle of RSI ± Function residual capacity is primary reservoir ± Permits several minutes of apnea without desaturation

‡ 100% O2 via nonrebreather for 5 minutes OR 8 VC breaths with 100% O2 via bag/mask
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Pretreatment (LOAD)

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Pretreatment (LOAD)
‡ Mitigate adverse effects of laryngoscopy ‡ Lidocaine 1.5 mg/kg
± Airway bronchospasm / cough reflex ± Increased ICP

‡ Opiates (Fentanyl 3-6 mcg/kg)
± Increased ICP, aortic dissection, ruptured aortic or IC aneurysm, ischemic heart disease ± Blunts reflex sympathetic response to laryngoscopy ± Not recommended under age 1
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Pretreatment (LOAD)
‡ Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg)
± Children <= 10 yo ± Blunts vagal response to laryngoscopy

‡ Defasiculation (with succinylcholine)
± Increased ICP ± 1/10th dose of a non-depolarizing NMB ± Not indicated under age 5

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Paralysis with Induction
‡ Rapid IV administration of sedation followed immediately by rapid administration of a neuromuscular blocking agent

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Protection and Positioning
‡ Sellick¶s maneuver
± Firm pressure (10 #) ± Maintain until placement confirmation and cuff inflation

‡ Positioning
± Keep the pillow to maximize POGO ± Height of bed, height in bed

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Placement with Proof
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Test for jaw flaccidity Extend head on neck Gentle controlled technique Blade entry on right, sweep tongue to left Lift handle up and away Suction prn Insert into esophagus, then slowly withdraw Visualize vocal cords Watch ETT pass through vocal cords Check ETT depth Never let go of the tube! Inflate cuff Auscultation
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Placement with Proof
‡ Confirm tracheal placement
± Direct visualization plus either ± EtCO2 detector or ± Esophageal detector
‡ Preferred in cardiopulmonary arrest

‡ Confirm depth (cords > bronchus)
± Auscultation ± CXR
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PostPost-Intubation Management
‡ Secure ETT ‡ Reassess VS ‡ PCXR for depth of placement ‡ Bradycardia / Hypoxia -> Nontracheal tube placement until proven otherwise (DOPE) ‡ Hypertension->inadequate sedation/analgesia ‡ Hypotension
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PostPost-intubation Management
(Hypotension) ‡ Tension PTX
± High PIP, hard to bag, decreased BS, hypoxia ± Immediate thoracostomy

‡ Decreased venous return
± High PIPs 2ndary to high intrathoracic pressure ± Fluids, bronchodilators, ± Increase expiratory time, decrease TV

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PostPost-intubation Management
(Hypotension) ‡ Induction agent
± Other causes excluded ± Fluid bolus, consider reversal agent, expectant

‡ Cardiogenic
± Usually a compromised pt ± Check EKG, exclude other causes ± Fluid bolus (caution), pressors

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Medications
‡ Pretreatment drugs (LOAD)
± Lidocaine ± Opiates ± Atropine ± Defasiculation

‡ Sedation ‡ Paralysis

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Sedation
‡ ‡ ‡ ‡ ‡ Midazolam Etomidate Methohexital / Thiopental Ketamine Propofol

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Neuromuscular Blocking Agents
‡ Noncompetitive depolarizer
± Succinylcholine (Anectine)

‡ Competitive nondepolarizer Benzylisoquinolinium group
± Atracurium (Tracrium), cisatracurium (Nimbex), mivacurium (Mivacron)

Aminosteroid group
± Pancuronium (Pavulon), vecuronium (Norcuron), rocuronium (Zemuron)
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Succinylcholine (SCh) (Anectine)
‡ Rapid onset (45 seconds) and short duration of action (<= 10 minutes) ‡ Mechanism of action ‡ Metabolism ‡ Sequence of action ‡ Dosing

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SCh Adverse Effects

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SCh Adverse Effects
‡ ‡ ‡ ‡ Malignant hyperthermia Masseter spasm Hyperkalemia Increased ICP / Increased IOP
± Fasciculations
‡ Bradycardia (peds) ‡ Prolonged NMB ‡ Hypotension (histamine release, (-) inotrope)

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SCh Contraindications

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SCh Contraindications
‡ Personal or FH of malignant hyperthermia ‡ ‡ ‡ ‡ ‡ Known or suspected hyperkalemia > 24 hours post-burn (>10% BSA, 1-2 yrs) > 1 week post crush injury (60-90 days) > 1 week post SCI or CVA (6 months) Neuromuscular disease (indefinite)
± MS, ALS, muscular dystrophy

‡ Anticipated difficult airway
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Competitive, Nondepolarizing NMB
‡ ‡ ‡ ‡ ‡ Most commonly utilized post-intubation No CIs other than the difficult airway Disadvantage is longer onset and duration Metabolism variable Higher dose reduces time to paralysis but prolongs time to recovery

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Competitive, Nondepolarizing NMB
‡ Aminosteroid group dose not cause histamine release ‡ Reversible with AChesterase inhibitor
± Requires 40% spontaneous recovery

‡ Consider administering sedation shortly after administering vecuronium or pancuronium for RSI

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Competitive, Nondepolarizing NMB
‡ ‡ ‡ ‡ ‡ Rapacurium off the market Rocuronium (0.6-1.2 mg/kg) Mivacurium (0.15 mg/kg) Vecuronium (0.3 mg/kg) Pancuronium (0.1 mg/kg)

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Awake Oral Intubation
‡ Upper airway distortion is anticipated ‡ Prepare the patient ‡ Anesthetize the airway
± ± ± ± Lidocaine 4% 4 cc / neosynephrine 0.5% 1cc OR Lidocaine 2% w/EPI 5cc / Lidocaine 2% Plain 5 cc Via nebulizer for 10 minutes OR Lidocaine spray

‡ Sedation (Midazolam or Etomidate +/- Fentanyl)
± Onset 3-5 minutes

‡ Perform laryngoscopy ‡ Immediate intubation / consider RSI / surgical airway
± Can the epiglottis be visualized? ± Is an abnormal glottis anticipated?
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Pediatrics
‡ ‡ ‡ ‡ ‡ Relatively large tongue / more oral secretions High tracheal opening (C1 > C4,5 adult) Large occiput Cricoid ring is narrowest portion Large tonsils and adenoids and greater angle between epiglottis and larygeal opening ‡ Minimal cricothyroid membrane until age ¾ ‡ Small relative FRC ‡ Basal oxygen consumption twice the adult rate
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Pediatrics
‡ Appropriately sized equipment (Broslow) ‡ Positioning
± Avoid hyperextension ± May need to elevate shoulders

‡ Effective BVM
± C-grip / good seal ± Squeeze, release, release ± Tidal volume ± Cricoid pressure
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Pediatrics
‡ ‡ ‡ ‡ ‡ ‡ ‡ Atropine < age 10 Avoid fentanyl < age, use cautiously Lower barbituate dose per kg No defasciculation < age 5 / 20 kg Succinylcholine dose Straight blade Uncuffed ETT < age 8
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Pediatrics
‡ ‡ ‡ ‡ ‡ ‡ No BNTI < age 10 Adult EtCO2 detector > 15 kg Securing the tube Place NGT or OGT early Orotracheal intubation for better security No surgical cricothyroidotomy < age 10

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The Second Attempt
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Learn from your first attempt (experience) Blade type or size (Use Mac as a Miller) ETT size Sellick¶s technique / stylet BURP Reposition the head and neck Chest pressure looking for air bubble Monitor VS, interposed BVM ventilation Find the epiglottis Call for help
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The Bottom Line
The Broslow Tape / Cart Get the trachea intubated efficiently Have a plan Have a back-up plan Call for help early Airway assessment is an integral part of RSI and procedural sedation ‡ Practice, practice, practice ‡ ‡ ‡ ‡ ‡ ‡
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Resources
‡ Manual of Emergency Airway Management by Ron Walls et al ‡ Airway Courses

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