Rapid Sequence Intubation

Anthony G. Hillier, D.O.

EM Resident
St. John West Shore
Rapid Sequence Intubation

 The induction of a state of unconsciousness

with complete neuromuscular paralysis to
achieve intubation without interposed
mechanical ventilation in efforts to facilitate
the procedure and minimize risks of gastric
aspiration
Rapid Sequence Intubation
Indications

 Failure of airway maintenance/protection

- lost or diminished gag reflex
 Failure of oxygenation/ventilation
- pulmonary edema, COPD
 Anticipated clinical course
- multiple trauma, head injured
- intoxication, air transport
Rapid Sequence Intubation
“6 P’s”

 Preparation: T-10”  Paralysis:T-0

– Positioning  Placement of tube: T+45
 Preoxygenation: T-5”  Post management: T+2”
 Premedication: T-3”
Preparation
Preparation

 Evaluate
– LEMON
 Equipment Check
 Positioning
 Drug Selection
 IV’s, monitor, oximetry
 Ancillary Staff
 Anticipate alternative airway maneuver
Preparation

 LEMON
– L-look
– E-evaluate the 3-3-2 rule
– M-Mallampati
– O-Obstruction
– N-Neck mobility
PREOXYGENATION
Preoxygenation

 100% O2 for 5 minutes of 5 vital capacity

breaths can theoretically permit 3-5 minutes
of apnea before desaturation to less than
90% occurs
Downloaded from: Rosen's Emergency Medicine (on 6 August 2006 02:03 PM)
© 2005 Elsevier
Preoxygenation

 “nitrogen wash-out”
 Avoid bagging the patient if adequately
preoxygenated
PREMEDICATION
Premedication

 Goal is to blunt the patient’s physiologic

responses to intubation

 Minimizes bradycardia, hypoxemia,

cough/gag reflex, increases in intracranial,
intraocular, and intragastric pressures
Premedication

 Lidocaine
 Opioid
 Atropine
 Defasciculating doses “priming”
Lidocaine

 Thought to blunt the rise in intracranial

pressure associated with airway
manipulation and the use of depolarizing
neuromuscular blocking agents
 1.5-3.0 mg/kg (average 100mg) three
minutes prior to intubation
Atropine

 0.02 mg/kg, minimum 0.1 mg IV, max 1 mg,

three minutes prior to intubation
 Can minimize vagal effects, bradycardia and
secretions
 Infants and children < 8 years may develop
profound bradycardia during intubation
Defasciculating doses

 Decreases muscle fasiculations caused by

the depolarizing agents (succinylcholine)
 Attenuates rise in intracranial pressure
 Agents used are the non-depolarizing
blocking agents (vecuronium, pancuronium
etc.) usually 1/10 of standard dose
Sedation

 Sedative agents administered at doses

capable of producing unconsciousness with
little or no cardiovascular effects
 No ideal agent exists
 Sedation should nearly always be used when
paralyzing the patient
Sedation

 Barbiturates/hypnotics
 Non-barbiturate
 Neuroleptics
 Opiates
 Benzodiazepines
Barbiturates/Hypnotics

 Thiopental (Pentothal), Methohexital (Brevital)

 Short onset (10-20) seconds, duration 5-10
minutes
 May reduce intracranial pressure, cerebro-
protective
 Histamine release, hypotension, bronchospasm
Barbiturates/Hypnotics

 Etomidate (Amidate) a nonbarbiturate

hypnotic
 Decreases ICP/IOP
 Rapid onset, short duration
 Minimal hemodynamic effects
 No histamine release
 Increases seizure threshold
Etomidate

 No malignant hyperthermia reported

 Watch for myoclonus, vomiting
 May decrease cortisol synthesis (adrenal
insufficiency)
 Dose 0.3 mg/kg IV
Propofol

 Propofol (Diprivan), sedative hypnotic

 Extremely rapid onset (10 sec), duration of
10-15 minutes
 Decreases ICP
 Can cause profound hypotension
 Dose 1-3 mg/kg IV for induction
 Dose: 100-200 mcg/kg/min for maintenance
Ketamine

 Ketamine-dissociative anesthetic
 Rapid onset, short duration
 Potent bronchodilator, useful in asthmatics
 Increases ICP, IOP, IGP
 Contraindicated in head injuries
 Increases bronchial secretions
Ketamine

 “Emergence” phenomenon can occur though

rarely in children less than 10 years
 Emergence reactions occur in up to 50% of
adults
 Dose: 1-2 mg/kg
Opiates
Fentanyl

 Fentanyl
 Broad dose-response relationship
 Can be reversed with naloxone
 Fentanyl is rapid acting (<1 min), duration of
30 min
– Does not release histamine
Fentanyl

 May decrease tachycardia and hypertension

associated with intubation
 Seizures and chest wall rigidity have been
reported
 Dose: 2-10 mcg/kg IV
Morphine Sulfate

 Longer onset (3-5) minutes and duration (4-

6) hours
 May not blunt the rise in ICP, hypertension
and tachycardia as well as fentanyl
 Dose 0.1-0.2 mg/kg IV
 Histamine release
Benzodiazepines
Benzodiazepines

 Midazolam, Diazepam, Lorazepam

 Provide excellent amnesia and sedation
 Broad dose-response relationship
 Reversed with Flumazenil (Romazicon)
 Doses required are higher for RSI than for
general sedation
Midazolam

 Slower onset (3-5) min than the

barbiturate/hypnotic agents
 Considered short-acting (30-60 min)
 Does not increase ICP
 Causes respiratory and cardiovascular
depression
 Dose: 0.1-0.4mg/kg IV
Diazepam and Lorazepam

 Moderate/long acting agents

 Longer onset time than midazolam
 May be more beneficial post-intubation for
sedation
Paralysis
Neuromuscular Blocking Agents

 Chemical paralysis facilitates intubation by

allowing visualization of the vocal cords and
optimizing intubating condition
 Only CONTRAINDICATION is anticipated
difficult airway
– Mallampati Class
– Thyromental Distance
Depolarizing Agents

 Exert their affect by binding with

acetylcholine receptors at the neuromuscular
junction, causing sustained depolarization of
the muscle cell
Nondepolarizing

 Bind to acetylcholine receptors in a

competitive, non-stimulatory manner, no
receptor depolarization
 Histamine release
 Agents can be reversed with edrophonium or
neostigmine
 Caution with myasthenia gravis
 Depolarizing agents
– Succinylcholine (Anectine)
 Nondepolarizing Agents
– Pancuronium (Pavulon)
– Vecuronium (Norcuron)
– Atracurium (Tracrium)
– Rocuronium (Zemuron)
– Mivacurium (Mivacron)
Succinylcholine

 Stimulates nicotinic/muscarinic cholinergic

receptors
 Gold standard for 50 years
 Onset 45 seconds, duration 8-10 minutes
 Dose: (adults 1.5 mg/kg IV)
 Children 2.0 mg/kg IV
 Inactivated by pseudocholinesterase
Succinylcholine cont

 Prolonged paralysis seen with:

– Pregnancy
– Liver disease
– Malignancies
– Cytotoxic drugs
– Certain antibiotics
– Cholinesterase inhibitors
– Organophosphate poisoning
Succinylcholine

 Adverse reactions
– Muscle fasiculations
– Hyperkalemia
– Bradycardia
– Prolonged neuromuscular blockade
– Trismus
– Malignant hyperthermia
Depolarizing Agents

 Muscle fasiculations
– Thought to increase ICP/IOP/IGP
– Causes muscle pain
– Minimized by “priming” dose of NMB
 Hyperkalemia
– Average increase in potassium of 0.5-1 mEq/L
– Burns, crush injuries, spinal cord injuries,
neuromuscular disorders, chronic renal failure
Depolarizing agents

 Bradycardia
– Most common in children <10 years due to higher
vagal tone
– Also with repeated doses of succinylcholine
– Premedicate with atropine
Depolarizing Agents

 Malignant hyperthermia
– From excessive calcium influx through open
channels
– Genetic predisposition
– Rapid temperature, rhabdomyolysis, muscle
rigidity, DIC
– 60% mortality
– Treatment: IV Dantrolene
Depolarizing Agents

 Trismus (Masseter spasm)

– Usually in children
– Unknown cause
– Treat with a nondepolarizing NMB
Pancuronium

 Long-acting agent (45-90 min)

 Slow onset (1-5 min)
 Renal excretion
 Vagolytic tachyarrythmias common
 Dose: 0.10-0.15 mg/kg IV
Vecuronium

 Duration of 30-60 min

 Onset of 1-4 min
 Hypotension may occur from loss of venous
return and sympathetic blockade
 Mostly biliary excretion
 Dose 0.1 mg/kg
 “priming dose” 0.01 mg/kg
Rocuronium

 Has the shortest onset of the

nondepolarizing agents (1-3 min)
 Duration 30-45 min
 Tachycardia can occur
 Dose: 0.6-1.2 mg/kg
Placement of Endotracheal Tube
Placement of Tube

 Allow medications to work and assure complete

neuromuscular blockade of the patient
 Maintain Sellick maneuver until cuff inflated
 Ventilate with bag-valve mask if unsuccessful
 Additional doses of sedatives/NMB may be
necessary
 Confirm tube placement
Post Intubation
Post Intubation Management

 Secure tube
 Continuous pulse oximetry
 Reassess vital signs frequently
 Obtain chest x-ray, ABG
 Restrain patient
 Consider long term sedation
Questions??

Thank You!