Rapid Sequence Intubation in Emergency

Adapted from source

OBJECTIVES
To understand why we use Rapid Sequence Intubation To help you plan for a Rapid Sequence Intubation To help you identify the potentially difficult airway To learn some pharmacology behind airway management To demonstrate the failed airway algorithm we use in ED To introduce the Fastrach Intubating LMA

Definition
The virtually simultaneous administration, after pre oxygenation, of a potent sedative agent and a neuromuscular blocking agent to facilitate rapid tracheal intubation of a potentially non fasted patient without interposed positive-pressure ventilation.

Indications for RSI
‡ Inability to maintain an adequate airway ‡ Inability to maintain adequate oxygenation or ventilation ‡ Anticipated airway obstruction or special situations

Aspiration
‡ the entry of secretions or foreign material into the trachea and lungs ‡ lungs are normally protected against aspiration by a series of protective reflexes such as coughing and swallowing ‡ small volumes of gastric acid contents can fatally damage delicate lung tissue or lead to bronchopneumonia

BEFORE WE GO FURTHER Important Assumptions and Contraindications
‡ We are assuming that Intubation is indicated, is anticipated to be successful and, if we fail, ventilation is expected to be successful !! ‡ We are assuming there is no tracheal / laryngeal injury or disruption or massive facial trauma

‡ ie : We do not anticipate a difficult airway
‡ Alternatives exist such as awake nasal intubation with local anaesthesia and sedation by a specialist Anaesthetist

The Seven P·s of RSI
‡ Preparation ‡ Pre oxygenation ‡ Pre treatment
‡ Paralysis with induction

‡ Positioning + Protection ‡ Placement with proof
‡ Post-Intubation Management

1: Preparation ² Intubation Equipment
Bag and mask (check size) 2 laryngoscope handles 2 laryngoscope blades (Test light bulb) 2 endotracheal tubes (Test cuff + lubricate)

Stylet + Bougie Syringe (10 ml) OP/NP airway Working suction Functioning ETCO2

(Adult women (Adult men

7.0-8.0mm) 7.5-8.5mm)

Rescue device

M.A.L.E.S
‡ Magill's + Mask ‡ Airway + Assistant ‡ Laryngoscope + Lubrication ‡ Endotracheal tube + ETC02 ‡ Stylet (Bougie) + Syringe + Suction !

1: Preparation Airway Assessment
(You don t want to be a L.E.M.O.N)

‡ Look externally ‡ Evaluate 3-3-2 ‡ Mallampati ‡ Obstruction ‡ Neck

Look Externally
Is this patient likely to be a

Difficult BVM Ventilation ? Difficult Laryngoscopy / Intubation ? Difficult Surgical Airway ?
B O N E S = Beard = Obesity = No teeth = Elderly = Snores = Severe facial injuries (burns, mid face fractures or trauma)

Evaluate (3-3-2 Rule)
3 x fingers between upper and lower incisor teeth

3 x fingers between the mental protuberance of the mandible and hyoid bone

2 x fingers between thyroid cartilage notch and the mandible or floor of the mouth

Mallampati Classification
I Tonsillar pillars and fauces visible II Upper portion of pillars and uvula visible III Base of uvula / soft palate visible IV Only tongue and hard palate visible Ask patient s to open their mouth and stick their tongue out
Correlates with laryngoscopy classification but not as sensitive in predicting grades 3 and 4 intubations

Obstruction
‡ Epiglottis ‡ Abscess ‡ Burn ‡ Trauma ‡ Tumor

Neck
‡ Possible cervical spine injury ‡ In line immobilization OR collar on/off

‡ Rheumatoid arthritis ‡ Ankylosing spondylitis

Prepare Yourself and Staff and Establish a Plan
What if I can·t open the patients mouth? What if I can·t find the cords? What if I can·t pass the tube? What if I can·t ventilate the patient?

Time Zero in 5 minutes

2: Pre oxygenation
100% oxygen for three minutes 8 vital capacity breaths Provides essential apnoea time
Apnoea time will vary with patient physiology

Brain Teaser 1: How long is the apnoea time?
A healthy young ED doctor is fully pre oxygenated with 100% oxygen and SUX is administered. How long until their SpO2 drops below 90%? A. 60 - 90 seconds B. 91 - 180 seconds C. 181 - 360 seconds D. > 360 seconds

Brainteaser 2: Which fully pre oxygenated patient desaturates quicker?
A. Normal healthy 47 yr old 70 kg male B. 60 yr old 80 kg male with moderate COPD C. 14 month old hell on wheels toddler D. 22 yr old 55kg intoxicated female OD

Time Zero in 3 minutes

3: Pre treatment
Laryngoscopy causes stimulation of afferent receptors in the posterior pharynx, hypopharynx and larynx
Reflexes can cause: Increased intracranial pressure (ICP) Stimulation of upper & lower respiratory tract increasing airway resistance. Stimulation of autonomic nervous system, with increase heart rate and BP

Laryngoscopy Effects
CNS response to airway stimulation Increase cerebral metabolic demand Increase cerebral blood flow Increase ICP if intracranial elastance is compromised

Laryngoscopy Effects
Respiratory system response Upper airway reflexes lead to laryngospasm & coughing Coughing may cause increase in ICP Lower airway reflexes can lead to an increase in airway resistance bronchospasm

Laryngoscopy Effects
Cardiovascular system response Overall increase in heart rate and blood pressure up to twice normal limits Can be detrimental in patients with myocardial ischemia, aortic or intracerebral aneurysm or any penetrating trauma where increase in shear pressure may reactivate previous haemorrhage Increase in blood pressure may cause significant increase in ICP if auto-regulation is lost

PATIENTS AT RISK
Intracranial pathology tight brain Cardiovascular disease tight heart Reactive airways disease tight lungs

FENTANYL
FENTANYL 1 - 3 mcg/kg given slowly over 1 minute

Attenuates normal physiologic & pathophysiological reflex responses caused by airway manipulation during laryngoscopy and insertion of an ETT

Caution: Contraindicated in patients overtly hypotensive
dependent on sympathetic tone ( can use Fentanyl 1mg/kg OR occasionally lignocaine )

and

Brain Teaser 3:
Aspiration is always a risk with intubation and can lead to significant morbidity and mortality ‡ From the answers below which patient has a high risk of aspiration ?
A. A 60 yr old male with acute respiratory distress and subacute bowel obstruction B. A 28 yr old 34 week pregnant women with preeclampsia C. A 6 yr old given morphine in ED and now 4 hours post displaced supracondylar fracture D. A 45 yr old presenting to ED with GCS 8/15 following OD of unknown quantity of amitriptylline E. All of the above

Time ZERO !!!

4: Paralysis with Induction
Near simultaneous administration of intravenous Induction agent and Neuromuscular blocker Both given as iv pushes with large saline flush

Induction Agents
‡ The µIdeal agent¶ would quickly render patients unconsciousness, and amnesic and maintain stable cerebral perfusion, cardiovascular stability and be reversible with no side effects Does NOT exist !!
Different agents have advantages and disadvantages

We try to use them to suit our clinical needs

ETOMIDATE
‡ 0.3 mg/kg

Primary choice as induction agent in emergency RSI Rapid onset, hemodynamic stability, positive CNS results and rapid recovery No contraindications (widely used overseas !!!) Attenuates elevated ICP by decreasing cerebral blood flow and metabolic oxygen demand Second only to ketamine regarding haemodynamic stability of induction agents Half-dose for haemodynamic instability (shock)

PROPOFOL
‡ 1-2 mg/kg

A highly lipid soluble and highly potent intravenous sedative hypnotic agent

Does cause significant hypotension
Contraindication - Elderly patients ( reduce dose to 0.5 mg/kg ) - Hypovolaemic patients ( preload with fluids ) Onset of action = 30 seconds from start administration Duration of action = 3 to 5 minutes

MIDAZOLAM
‡ 0.05 0.1 mg/kg

A short acting benzodiazepine sedative hypnotic agent

NOT IDEAL BUT SAFE - Risk of Awareness !

Effects can be reversed by Flumazenil (Annexate)

Onset of action = 2 MINUTES from start administration Duration of action = 15 - 45 minutes

KETAMINE
‡ 1.0 1.5 mg/kg

Phencyclidine (PCP) derivative

Does cause catecholamine release
Contraindication - Closed head injury (elevated ICP) - Ischaemic heart disease May cause increase in upper airway secretions Onset of action = 45 60 seconds Duration of action = 20 30 minutes

Induction Agents for Specific Conditions
Reactive airways disease Ketamine, Propofol, Midazolam Increased intracranial pressure - Propofol, Midazolam, ketamine, Thiopentone Hypotensive patient Ketamine, Midazolam

NEUROMUSCULAR BLOCKING AGENTS
Depolarizing

Suxamethonium

Non-depolarizing
Rocuronium Vecuronium

Suxamethonium
NMBA best suited for RSI in emergency due to its rapid onset and quick recovery time

Contraindications
Personal or family history of malignant hyperthermia Significant, verified, hyperkalemia is an absolute contraindication End-stage renal disease / dialysis dependent patients with unknown potassium level

SUX Related Hyperkalemia
Receptor Up regulation
Burns, crush injury, spinal cord injury > 72hrs UMN lesions, including stroke MS, ALS, other denervation states Prolonged ICU care Mortality11%

Myopathic Processes
Mortality30% Muscular dystrophy Rare idiopathic

SUXAMETHONIUM
Dosage
Adult Paediatric Neonatal = 1.5 mg/kg = 2.0 mg/kg = 3.0 mg/kg

Onset of action

= 45 60 seconds

Duration of action = 7 10 minutes

Non depolarising Agents
Rocuronium = 1 mg/kg ( INTUBATING DOSE )
Onset of action: 55 70 sec Duration: 30 60 min - Full recovery 1 2 hrs

Vecuronium = 0.1 mg/kg 0.15 mg/kg
Onset of action = 90 120 sec Duration: 60 75 min

- Full recovery 1.5 2hrs

Time Zero + 30 seconds

‡ 5:Positioning

Time Zero + 45 seconds

6: Placement and Proof
Check mandible for flaccidity + end of fasciculation Intubate, remove stylet / bougie and µhold¶ ETT Confirm tube placement ± Direct visualisation ± ETCO2 / capnography ± Bilateral breath sounds ± Absent epigastric sounds

Failed Attempt = oxygenate
1st step = can I bag/mask ventilate this patient ?
Think about the six attributes: » » » » » » Operator Optimum patient position BURP Paralysis Length of blade Type of blade

Rescue Manoeuvres
‡ The first rescue from failed intubation is bagging

‡ The first rescue from failed bagging is better bagging

Zero + 90 seconds

7: Post-intubation Management
Secure tube / µbite block¶ Monitor ETCO2 continuously Arrange Chest x-ray Start long acting sedation (+/- paralysis)
± 60mg morphine + 30mg midazolam up to 60mls in saline at 10ml/hr ± intermittent boluses of vecuronium (5mg) approx every 30 minutes

Establish ventilator parameters - tidal volume 7- 8 ml/kg at RR 12

Rapid Sequence Intubation Summary
‡ Preparation ‡ Pre oxygenation ‡ Pre treatment ‡ Paralysis with induction ‡ Positioning ‡ Placement ‡ Post-tube management (10 mins - zero) (5 mins - zero) (3 mins - zero) (time zero) (zero + 30 sec) (zero + 45 sec) (zero + 90 sec)

FASTRACH Intubating LMA

VIDEO ??
‡ http://www.youtube.com/watch?v=UA1wWm ehuuI

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