Paleerat Jariyakanjana, MDEmergency Physician

Naresuan University Hospital

Rapid Sequence Intubation

Decision to Intubate

1) Failure to maintain or protect the airway

2) failure of ventilation or oxygenation3) the patient’s anticipated clinical

course and likelihood of deterioration

Administration of a potent sedative (induction) agent and an NMBA without interposed assisted ventilation

positive-pressure ventilation

air to pass into the stomach

gastric distention

risk of regurgitation & aspiration

Requires preoxygenation phasepermits pharmacologic control of the

physiologic responses to laryngoscopy and intubation, mitigating potential adverse effects Increase ICP sympathetic discharge

Preparation

assessed for intubation difficultydetermining dosages and sequence

of drugs, tube size, and laryngoscope type, blade and size

continuous cardiac monitoring and pulse oximetry

≥1 good-quality IV linesRedundancy is always desirable in

case of equipment or IV access failure.

Preparation

Preoxygenation

100% oxygen for 3 minutes of normal, tidal volume breathing

normal, healthy adult establishes an adequate oxygen reservoir to permit 8 minutes of apnea before oxygen desaturation to less than 90% occurs

“no bagging”time is insufficient

8 vital capacity breaths using high-flow oxygen

Pretreatment

drugs are before administration of the succinylcholine & induction agent

mitigate the effects of laryngoscopy and intubation on the patient’s presenting or comorbid conditions

Intubation sympathetic discharge elevation of ICP reactive bronchospasm Bradycardia: children

Pretreatment

Paralysis with Induction

rapid IV pushimmediately followed by rapid

administration of intubating dose of NMBA

wait 45 s from the time the succinylcholine is given to allow sufficient paralysis to occur

Paralysis with Induction

Tintinalli's Emergency Medicine, 7e

Paralysis with Induction

Tintinalli's Emergency Medicine, 7e

Paralysis with Induction

Tintinalli's Emergency Medicine, 7e

Positioning

The patient should be positioned for intubation as consciousness is lost.

Sniffing position: head extension, neck flexion

Positioning

Sellick’s maneuver application of firm backward-directed pressure

over the cricoid cartilage minimize the risk of passive regurgitation and,

hence, aspirationafter administration of the induction

agent and NMBA BMV should not be initiated unless O2 sat ≤ 90%

Placement of Tube

assessed most easily by moving the mandible to test for absence of muscle tone

O2 sat is approaching 90%, the pt may be ventilated

When BMV is performed, Sellick’s maneuver is advisable

As soon as the ETT is placed, the cuff should be inflated and its position confirmed

Postintubation Management

CXRuse of long-acting NMBAs (e.g.,

pancuronium, vecuronium) toward optimal management using opioid analgesics and sedative agents to facilitate mechanical ventilation

ANY QUESTIONS?