rapid sequence intubation

Rapid Sequence IntubationRapid Sequence Intubation

Khalid Al-Ansari, FRCP(C), FAAP(PEM)

ObjectivesObjectives

Definition and goals of RSISteps of RSIControversies Protocol for RSI

DefinitionDefinition

The virtually simultaneous administration, after preoxygenation, of potent sedative agent and rapidly acting neuromuscular blocking agent to facilitate rapid tracheal intubation without interposed mechanical ventilation.

Goals of RSIGoals of RSI

RSI produce excellent intubating condition 45 to 60 seconds after administration of neuromuscular blocking agent.

Complete jaw relaxation.Open and immobile vocal cords.No coughing or diaphragmatic

movements in response to intubation.Decrease Complication like aspiration.Control of agitation.

RSIRSI

Intubation using RSI was more successful on first attempt (78%) compare to NOM (47%) p=<0.01 or SED (44%) p=<0.05

Sagarin et

al. pediatr Emerg care 2002

Steps of RSISteps of RSI

7 PsPreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.

PreparationPreparation

One of the most important step to success.

Equipment (Monitors, suction, O2, bag-valve mask, oral airway, ETT, stylet, laryngoscope blade, CO2 detector).

MedicationPersonnel.

RSI - PreparationRSI - Preparation

S O A P MES Suction (Yankauer)O Oxygen A Airway (BVM set up,

lryngoscope, ETT, stylet, Magill forceps, tape)

P Pharmacology (drugs including reversal agents)

ME: Monitoring equipment

PreparationPreparation

Short History + AMPLE Evaluate for difficult airway L E M O N:1. Look2. Mallampati classification3. Obstruction ( stridor, drolling, muffled

sound)4. Neck mobility ( collar)

Mallampati classificationMallampati classification

Look externallyLook externally

facial, cervical or neck trauma.MicrognathiaDysmorphic facial featuresSmall mouth, large tongueShort neck

Normal Looking Kid – Normal Looking Kid – Right?Right?

Pierre Robin SyndromePierre Robin Syndrome

Steps of RSISteps of RSI

PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.

PreoxygenationPreoxygenation

While preparing equipmentIt essential to the no bagging

principle.Aim to establish an O2 reservoir

within the lungs and body tissue.By 100% O2 via non-rebreather

face mask.For 3-5 minutes.

QuizQuiz

In healthy 70 kg adult if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.

A- more than 9 minutes B- 7-8 minutes C- 4-6 minutes D- less than 4 minutes

QuizQuiz

In healthy 70 kg adult if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.

A- more than 9 minutes B- 7-8 minutes C- 4-6 minutes D- less than 4 minutes

QuizQuiz

In healthy 10 kg child if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.

A- > 8 minutes B- 6-8 minutes C- 3-4 minutes D- 1-2 minutes

QuizQuiz

In healthy 10 kg child if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.

A- > 8 minutes B- 6-8 minutes C- 3-4 minutes D- 1-2 minutes

PreoxygenationPreoxygenation Anesthesiology: Volume 87(4) October 1997 Anesthesiology: Volume 87(4) October 1997

Steps of RSISteps of RSI

PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.

PremedicationPremedication

Aim to block the physiologic reflex response to airway manipulation and insertion of ETT.

AtropineAtropine

AtropineAtropine

To prevent Bradycardia.It should be given 1-2 min before

intubation.PALS recommendation: - Children less than 1 year of age. - Children age 1-5 years receiving Sch. - Children > 5 years receiving second

dose of Sch.

AtropineAtropine

Bradycardia during intubation has 3 causes:

Vagal stimulation during laryngoscopy.

Succinylcholine administration Hypoxia

FentanylFentanyl

FentanylFentanyl

Blunt the reflex sympathetic response.

Used in pt with raised ICPDose: 1-2 Mcg/kgBe careful about BP and

respiratory depression.Add extra step

LidocaineLidocaine

To blunt the rise in ICP associated with laryngoscopy and intubation.

Dose : 1-2 mg/kg 2-5 min before intubation

Evidence.

Defasciculating Defasciculating

Non competitive N/M blocking agent ( rocuronium (0.06mg/kg).

10% of normal paralyzing dose.3 min before intubation.In pt. with raised ICP receiving

Sch for paralysis.No evidence to support it’s use in

RSI.Add extra step.

Steps of RSISteps of RSI

PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.

SedationSedation

Aim to rapidly make the pts unconscious to eliminate pt awareness of being paralyzed and intubated and facilitate the intuabtion.

The choice depend on: - Shock - Head trauma - bronchoconstriction

ThiopentaleThiopentale

BarbiturateDose 2-4mg/kgOnset: 30-60 seconds Duration : 10-30minSide effects: decrease cardiac output,

hypotension, broncho & laryngo spasm.

Contraindication: Porphyria, Barbiturate sensitivity, Asthma (caution in decreased BP)

KetamineKetamine

Non barbiturate dissociative agentDose: 1-2mg/kgOnset:<2minutesDuration: 10-30minutesMaintain BP & bronchodilator Side effects: Inrease BP, hallucination,

increase secreations, laryngospasm & emergence reaction.

Contraindication: raised IOP, psyhosis &hypertension.

MidazolamMidazolam

Benzodiazepine Dose 0.1-0.3mg/kgOnset: 30-60 seconds Duration : 30-60minSide effects: Respiratory

depression & hypotension.

EtomidateEtomidate

Imidazole Non barbiturate hypnoticDose: 0.3mg/kgOnset:<1minuteDuration: 10-30minutesHemodynamic stability.Side effects: Adrenal suppression,

myoclonus & trismus.Contraindication: Adrenal insufficiency

& focal seizure.

Sedation Sedation

Etomidate used in 42% of pediatric RSI in US.

Thiopental used in 22% .Benzodiazepine used in ~ 18%

(90% Midazolam)

Sagarin et al, pediatr Emer Care 2002;18

N/M blocking agentsN/M blocking agentspediatr Emerg Care 2000;16(6):441pediatr Emerg Care 2000;16(6):441

N/M blocking agentsN/M blocking agents

Sch contraindicationHyperkalemia ( renal failure) Myopathy Malignant hyperthermia> 3-5 days of burns, crush injury,

Denervation due to stroke or spinal cord injury.

Steps of RSISteps of RSI

PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.

Protection Protection

Sellick’s maneuver ( cricoid pressure )Thumb and long fingers applying

posterior pressure to occlude the esophagus against the anterior surface of the vertebral body to prevent passive regurgitation of gastric content

Initiated after sedation given and maintained throughout the entire intubation sequence until ETT placed and verified.

Steps of RSISteps of RSI

PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.

Placement with proofPlacement with proof

45 seconds – 60 seconds after administration of N/M blocking agent

Intubation should be performed.Tube placement should be

checked ( auscultation, end tidal CO2 detector and CXR)

Post intubation Post intubation managementmanagement

ETT must be taped in place.Low BP should be RxCXRLong term sedation and paralysis - Midazolam infusion - pancuronium or vecuronium

0.1mg/kg. Opioid analgesia if needed.

Time Action

0 Assess if appropriate for RSI

0-3 minutes Pre-oxygenateObtain IV access (2 preferable) Assemble necessary equipment and personnel Draw up medications

3-5 minutes Continue to pre-oxygenate Premedicate

Atropine (< 1 year, 1 through 5 years if receiving succinylcholine, and adolescents receiving a second dose of succinylcholine)

Fentanyl (for substantial head trauma)

5-6 minutes Administer sedation

No shock, head injury or asthma

Shock, no head trauma no asthma

Head trauma, no shock, no asthma

Asthma, no shock no head trauma

Thiopental Etomidate

Etomidate, ketamine Consider no sedation

Thiopental Etomidate

Ketamine Etomidate

Apply cricoid pressure

Administer neuromuscular blockade agent

Succinylcholine (preferred, except when contraindicated) OrRocuronimum

6-7 minutes (one minute after NMB agent administered) Perform orotracheal intubation

Remove cricoid pressure when tracheal intubation confirmed (including CO2 detection)

Consider need for more sedation/paralysis

Take home messageTake home message

Preparation is one of the most important step for success.

Try to identify difficult airway.Preoxygenate with no bagging

principle.Back up plan.

Thank YouThank You