emergency rapid sequence intubation: a “how and when to” guide
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Emergency Rapid Sequence Intubation: A “How and When To” Guide. Pat Melanson, MD, FRCPC Department of Emergency Medicine Division of Critical Care Medicine Royal Victoria Hospital. Rapid Sequence Intubation : Definition. - PowerPoint PPT PresentationTRANSCRIPT
Emergency RSI
Emergency Rapid Sequence Intubation:
A “How and When To” Guide
Pat Melanson, MD, FRCPCDepartment of Emergency
MedicineDivision of Critical Care Medicine
Royal Victoria Hospital
Emergency RSI
Rapid Sequence Intubation :Definition
• The near simultaneous administration of a sedative-hypnotic agent and a neuromuscular blocker in the presence of continuous cricoid pressure to facilitate endotracheal intubation and minimize risk of aspiration
• modifications are made depending upon the clinical scenario
Emergency RSI
A Brief History of Emergency RSI intubation of the newly/nearly dead
(prehistoric) techniques adapted from anesthetists in Case
Room and “crash” full-stomach induction's (exploration)
rapid dissemination of RSI teaching to emergency physicians (proselytism)
evidence-based research supporting safety and advantages of emergency RSI (enlightenment)
increasingly sophisticated techniques and methodology critically evaluated (postmodern)
Emergency RSI
Intubation Dilemmas:
• Intubate Awake or Asleep• Oral or Nasal• Laryngoscopy or Blind Intubation• To Paralyze or Not
Emergency RSI
Oral Intubation Without Drugs
• Reserved for the completely unconscious, unresponsive, pulseless and apneic
• Arrest situations only• The “ CRASH AIRWAY”
Emergency RSI
Oral Intubation with Sedation
• proponents argue use of BZ or opioids
–improves airway access
–decreases patient resistance
–avoids risks of NMB• Generally obtunds patient to point of loss of
protective reflexes and respiratory drive• lower success rate, higher complications
compared with RSI
Emergency RSI
Oral Intubation with Sedation
• “ In general, the technique of administering a potent sedative agent to obtund the patient’s responses and permit intubation in the absence of NMB is hazardous and to be discouraged… is not an appropriate alternative to properly conducted RSI and affords neither the success rate or the minimal complication rate of RSI.”
– RM Walls, page 4, Chapter 1, Rosen
Emergency RSI
Oral Intubation with Sedation
“ The avoidance of NMB actually creates a more hazardous situation for the patient and this practice should no longer be considered an appropriate method for emergency department ET intubation.”
RM Walls, page 8, Chapter 1, Rosen
Emergency RSI
Oral Intubation with Sedation:Use for the Anticipated Difficult Airway
• if time permits
–topical anesthesia
–careful titrated sedation
–avoid obtundation• ‘Awake” intubation technique
Emergency RSI
Blind Nasal Intubation
• success rates 65 - 80 % in most series• high complication rates
–epistaxis
–pharyngeal/ esophageal perforations
–increased incidence of O2 desats• Considered second line approach only• reserved for when RSI contraindicated• The “ DIFFICULT AIRWAY”
Emergency RSI
Approach to Airway Management: Algorithms
Is intubation indicated ?Is this a Crash Airway situation ?Is this a potentially Difficult Airway?
Difficult laryngoscopy ?Difficult Bag -Mask Ventilation?
Is RSI appropriate ?Is this a Failed Airway?
Emergency RSI
Emergency Airway Concerns
• “full” stomach• minimal respiratory reserve• hemodynamic instability• acute myocardial ischemia• increased intracranial pressure• C-spine injury• The “Difficult” Airway
Laryngoscopy bag-mask difficulty
Emergency RSI
Advantages of RSI facilitates and expedites endotracheal
intubation increased success rate decreased time to intubation
minimizes trauma during laryngoscopy minimizes hypoxia and hypercapnia minimizes risk of aspiration minimizes hemodynamic effects of
intubation
Emergency RSI
Disadvantages of RSI operator assumes complete
responsibility for oxygenation, ventilation and airway patency
irreversible commitment (burnt bridges)
adverse effects of medications ?? increases surgical airway rate
no evidence
Emergency RSI
Rapid Sequence Intubation: Principles
• Emergency intubation is indicated• The patient has a “full” stomach• Intubation is predicted to be successful• If intubation fails, ventilation is predicted
to be successful• Consists of a series of planned discrete
steps
Emergency RSI
Principles of RSI Competing demands:
Minimizing risk of aspiration vs. risk of hypoxia Preoxygenation:
ideally avoid BMV-PPV to minimize aspiration adequate N2 washout (5 min 100% O2 ) gives
oxygen reservoir providing several minutes of O2 supply despite apnea
4 assisted PPV breaths prior to paralysis pulse oximetry essential ANTICIPATE the O2 trend!
Emergency RSI
Principles of RSI (cont) Minimizing gastric distention
avoidance of BMV-PPV cricoid pressure
–caudal to thyroid cartilage–complete ring esophageal occlusion– release if vomiting occurs–maintain until ETT position confirmed
minimize peak pressures if BMV-PPV immediate ID of esophageal intubation
Emergency RSI
Typical Emergency RSI: Time Course
time 0:00
2:002:15
3:003:20
5:00
100% O2, iv access, monitor, oximetry assemble equipment, meds and team thiopental 3mg/kg iv succinylcholine 1.5mg/kg iv cricoid pressure with LOC; no bagging laryngoscopy after fasciculations tube position confirmed and secured positive pressure ventilation begins To CT/lavage/OR/etc. O2 sat 100% throughout
Emergency RSI
Drugs used for RSI: Overview
Essential:ParalyticSedative/ Induction agent
Optional:DefasciculantModulators of
hemodynamics/ICP/etc.
Emergency RSI
Emergency RSI: Selecting the PatientIs RSI contraindicated?
Absolute: Cardiopulmonary arrest
present/imminent Operator inexperience
Relative: Anticipated technical difficulties with
laryngoscopy and/or intubation Anticipated difficulty with BVM
Emergency RSI
Emergency RSI: Selecting the Paralytic
Neuromuscular blocking agents
Depolarizing:Succinylcholine
Non-depolarizing:VecuroniumRocuronium
Emergency RSI
Emergency RSI: Selecting the Paralytic
Is succinylcholine contraindicated? NO: choose succinylcholine YES: choose rocuronium (or vecuronium)
If using SUX, is atropine needed?atropine 0.02mg/kg (.15mg-.5mg) 2min before
If using SUX, is a defasciculant desired?
10% dose of non-depolarizing agent 2 min prior
Emergency RSI
Succinylcholine ( Anectine) dose: 1.5 mg/kg onset : 45 - 60 seconds duration : 6 to 10 min (3 to 15) disadvantages :
ACh analog - bradycardia fasciculations hyperkalemia ( K+ release) malignant hyperthermia
Emergency RSI
Succinylcholine : Contraindications
• Hyperkalemia - renal failure• Active neuromuscular disease with
functional denervation
• ( 6 days to 6 months)• Extensive burns, crush injuries• Malignant hyperthermia• Pseudocholinesterase deficiency• Organophosphate poisoning
Emergency RSI
Succinylcholine : Complications
• Inability to secure airway• Increased vagal tone ( second dose )• Histamine release ( rare )• Increased ICP/ IOP/ gastric pressure• Myalgias• Hyperkalemia with burns, NM disease• Malignant hyperthermia
Emergency RSI
Vecuronium ( Norcuron )
• dose : 0.1 - 0.2 mg/kg• action : 120 secs to 60 minutes• “prime” with 1/10 dose 2 min prior
• onset in 90 secs• advantages :
• non-depolarizing• neutral hemodynamics• hepatic clearance
Emergency RSI
Rocuronium ( Zemuron )
• dose : 0.6 - 1.2 mg/kg• onset : 60 -90 secs• advantages :
• almost as rapid as SUX• disadvantages
• less rapid in elderly• long duration
Emergency RSI
Emergency RSI: Selecting the Sedative
Thiopental
Ketamine
MidazolamPropofol
Etomidate(nothing)
????
??
??
Emergency RSI
Thiopental ( Pentothal ) dose : 1- 5 mg/kg action : 20 sec to 5 minutes advantages
ultrafast, short duration neuroprotective, anticonvulsant familiar
disadvantages hypotension ( myocardial depression, vd) ultrashort duration ( 3 - 5 minutes ) demyelination in porphyria chemical endarteritis, thrombosis
Emergency RSI
Midazolam ( Versed ) dose : 0.1 - 0.4 mg/kg action : 2 min to 120 minutes advantages:
wide therapeutic index amnesia
disadvantages variable dose response slower onset suboptimal effect at lower doses negative inotrope, vasodilation
Emergency RSI
Ketamine ( Ketalar ) dose : 1 - 2 mg/kg action : 30 secs to 15 minutes advantages :
bronchodilation supports BP
disadvantages : increases ICP and IOP salivation emergence reactions
Emergency RSI
Propofol ( Diprivan ) dose : 0.5 - 2.5 mg/kg (20-40mg q10 s) action : 20 sec to 5 minutes advantages :
ultrarapid neuroprotective
disadvantages hypotension, bradycardia ultrashort duration
Emergency RSI
Etomidate ( Amidate ) dose ; 0.3 mg/kg action : 1 minute to 10 minutes advantages :
hemodynamically neutral neuroprotective
disadvantages : unfamiliar vomiting cortisol suppression
Emergency RSI
Emergency RSI: Selecting the Sedative
Identify Primary Concern:
Hemodynamics: fentanyl, ketamine, etomidate
Neuroprotection: thiopental, propofol (midazolam)
Bronchodilation: ketamine Speed: thiopental, propofol
(ketamine)
Emergency RSI
Emergency RSI: Selecting the Sedative
Identify any Secondary Concerns:
Hemodynamics: beware thiopental, propofol (midazolam)
Neuroprotection: avoid ketamine (??) Speed: beware midazolam Patient given naloxone: avoid fentanyl Specific contraindications (e.g. porphyria):
avoid drug
Emergency RSI
The “Intubation Reflex “
• Catecholamine release in response to laryngeal manipulation
• Tachycardia, hypertension, raised ICP• Attenuated by beta-blockers, fentanyl• ICP rise possibly attenuated by lidocaine• Midazolam and thiopental have no effect
Emergency RSI
Emergency RSI: Selecting optional medications
Increased ICP: Lidocaine Bronchospasm : Lidocaine Tachycardia harmful: fentanyl
(esmolol) 3 min before atropine if child receiving Sux defasciculant “priming” dose of neuromuscular
blocking agent topical/regional anesthetics
Emergency RSI
Emergency RSI Checklist: Flight planning
Move patient to resuscitation suite Assemble personnel 100% O2 Patient too unstable for RSI => intubate ASAP Inadequate ventilation/sat <90% => BMV Select drugs and doses, delegate “Drug Nurse” Cardiac monitor, BP cuff, O2 sat continuously IV running in limb contralateral to BP cuff Cleared to taxi
Emergency RSI
Emergency RSI Checklist: Taxiing
C-Spine? OK: pillow/folded sheet under head?: designate assistant in-line stabilization
Check ETT and lubricate (+/- stylet) Check laryngoscope (and other airway device prn) Yankauer suction on and under mattress (to right) Final neuro assessment (AVPU, posturing, pupils) Baseline HR, BP, O2 sat Review drugs, doses and sequence with Drug Nurse Cleared for take-off
Emergency RSI
Emergency RSI Checklist: Take-off
0:003:00
3:15
4:00
4:30
5:00-15:00
administer optional drugs administer sedative administer paralytic cricoid pressure with loss of ciliary reflex BMV if hypercapnia deleterious/sat <90% laryngoscopy once fully relaxed BURP to visualize larynx Confirm ETT placement and secure Ventilator settings Treat fluctuations in VS as indicated CXR
time (mm:ss)
Emergency RSI
Rapid Sequence Intubation :Procedure
• Pre-intubation assessment• Pre-oxygenate• Prepare• Premedicate• Paralyze with Induction• Pressure on cricoid• Place the tube• Post intubation assessment
Emergency RSI
Pre-oxygenate ( Time - 5 Minutes)
• 100 % oxygen for 5 minutes• 4 conscious deep breaths of 100 % O2• Fill FRC with reservoir of 100 % O2• Allows 3 to 5 minutes of apnea• Essential to allow avoidance of bagging• If necessary bag with cricoid pressure
Emergency RSI
Preparation ( Time - 5 Minutes )
• ETT, stylet, blades, suction, BVM• Cardiac monitor, pulse oximeter, ETCO2• One ( preferably two ) iv lines• Drugs• Difficult airway kit including cric kit• Patient positioning
Emergency RSI
Pre-treatment/ Prime ( Time - 2 Minutes )
• Lidocaine 1.5 mg/kg iv• Defasciculating dose of non-
depolarizing NMB• Fentanyl 3- 5 mcg/kg• Atropine 0.02 mg/kg• ( The above agents are optional and given if there is a
specific indication and time permits)
Emergency RSI
Induction agent
–Thiopental 3 - 5 mg/kg
–Midazolam 0.1 - 0.4mg/kg
–Ketamine 1.5 - 2.0 mg/kg
–Propafol 0.5 - 2.0 mg/kg
–Etomidate 0.2 - 0.3 mg/kg
Emergency RSI
Paralyze ( Time Zero )• Succinylcholine 1.5 mg/kg iv• Allow 45 - 60 seconds for complete
muscle relaxation• Alternatives
–Vecuromium 0.1 - 0.2 mg/kg
–Rocuronium 0.6 - 1.2 mg/kg
Emergency RSI
Pressure
• Sellick maneuver• initiate upon loss of
consciousness• continue until ETT balloon
inflation• release if active vomiting
Emergency RSI
Place the Tube ( Time Zero + 45 Secs )
• Wait for optimal paralysis
• Confirm tube placement with ETCO2
Emergency RSI
Post-intubation Hypotension
• Loss of sympathetic drive• Myocardial infarction• Tension pneumothorax• Auto-peep
Emergency RSI
Difficult Airway Kit
• Multiple blades and ETTs• ETT guides ( stylets, bougé, light wand)• Emergency nonsurgical ventilation
( LMA, Combitube, TTJV )• Emergency surgical airway access
( cricothyroidotomy kit, cricotomes ) • ETT placement verification• Fiberoptic and retrograde intubation
Emergency RSI
Amitriptyline tripper
27 year old overdose benzos + TCAs 1 hour PTA.
Decreasing LOC (?ciliary reflex). HR 140 wide-complex regular, BP 90/50, RR 24,
O2 sat 99% on O2.
Emergency RSI
Walking at the scene
22 yr old multiple abdominal stab wounds 6” knife.
Evisceration, agitation and uncooperative.
HR 140, BP 90/50, RR 22, O2 sat 99% on O2.
Emergency RSI
Status asthmaticus severus
50 yr old asthmatic x years, never admitted O/N. SOB x 2d despite prednisone, antibiotics, and salbutamol q1h. Despite continuous salbutamol, epi s/c x 2, and SoluMedrol iv, begins to fatigue.
pH 7.22, pCO2 70, pO2 140.
Emergency RSI
Collapse at bank
38 year old male, standing in line at bank, complained of sudden severe HA and collapsed.
On arrival, HR 55 BP 170/100 RR 12 decorticate posturing.
Emergency RSI
NOT renal colic
68 year old male, hypertensive, no past history of urolithiasis, presents with R flank pain and hematuria. While you are booking the spiral CT, he complains of increasing back pain, then vomits. HR 140 BP 85/palp diaphoretic ++.
And then he gets worse.
Emergency RSI
Overdue for dialysis
68 yr old hemodialysis-dependent pt in florid pulmonary edema and decreasing LOC.
HR 120 reg, BP 220/120, O2 sat 85% on non-rebreather
15L/min.
Emergency RSI
Too much Nintendo
14 year old known epileptic on multiple meds, still seizing after diazepam, phenobarb and over 30 minutes in the ED.
160 100/50 37.2 99% sat. Small jaw.
Emergency RSI
“ I would especially commend the physician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.”
Hippocrates