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 Ps

Preparation: T-10

  

Positioning

 

Preoxygenation: T-5 Premedication: T-3

Paralysis:T-0 Placement of tube: T+45 Post management: T+2

Preparation

Preparation


Evaluate

LEMON

     

Equipment Check Positioning Drug Selection IVs, 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 patients 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, cerebroprotective 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 (46) 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) Pancuronium (Pavulon) Vecuronium (Norcuron) Atracurium (Tracrium) Rocuronium (Zemuron) Mivacurium (Mivacron)

Nondepolarizing Agents

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 Average increase in potassium of 0.5-1 mEq/L Burns, crush injuries, spinal cord injuries, neuromuscular disorders, chronic renal failure

Hyperkalemia

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!