rapid sequence intubation erik d. barton, md, ms, mba

Rapid Sequence Intubation

Erik D. Barton, MD, MS, MBA University of Utah Affiliated Emergency

Medicine Residency Program

The Decision to Intubate

Four Reasons for Intubation

• Establish, maintain or protect airway• Failure to ventilate• Failure to oxygenate• Anticipated clinical course

http://www.utah.edu/index.html

Sagarin, Barton, et al, Ann Emer Med, 2005

First Provider Intubations

Sagarin, Barton, et al, Ann Emer Med, 2005

Rescue Intubations


Definition

The virtually simultaneous administration of a potent sedative

agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal

intubation.


Just like Skydiving….

Skydiving is lethal unless one deploys a parachute…

RSI is lethal unless you rescue the airway!



Just like Skydiving….

– Redundancy of safety (primary & backup)

– Planned, stepwise approach to primary system

– Simple, fast backup system

– Attention to monitoring

– Equipment vigilance

Levitan, RM. Ann Emerg Med. 2003;42:81-87.




Definition Incorporates:

• Every patient has a full stomach• Preoxygenation• No interposed ventilations• Sellick’s maneuver



Advantages of RSI

• Rapid control of the airway• Minimizes risk of aspiration• Highest success rates• Lowest complication rates• Optimal intubating conditions• Adaptable to patient condition • Can mitigate adverse effects



The Six Ps of RSI

PreparationPreoxygenationPretreatmentParalysis with SedationProtectionPlacement



The Sequence

Zero:

the time of administration of succinylcholine.

Rapid Sequence IntubationThe Sequence

Zero - 10 minutes

Preparation

• Assess airway difficulty (LEMON)• Plan approach• Assemble drugs and equipment• Establish access• Establish monitoring

Rapid Sequence IntubationThe Difficult Airway Rule

L ook externallyE valuate 3-3-2M allampatiO bstruction?N eck mobility


Zero - 5 minutes

Preoxygenation

• 100% oxygen for five minutes• 8 vital capacity breaths• Provides essential apnea time• Apnea time varies

The Sequence

Rapid Sequence IntubationTime to Desaturation


Zero - 3 minutes

Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation

“LOAD the patient before intubation.”

The Sequence

THE AIRWAY COURSE

National Emergency Airway Management Course

PRETREATMENT AGENTS

THE AIRWAY COURSE


• L idocaine• O pioid• A tropine• D efasciculation

Give 3 minutes before SCh

PRETREATMENT AGENTS

THE AIRWAY COURSE


PRETREATMENT AGENTS

1.5 mg/kg

• Increased intracranial pressure• Bronchospasm

LIDOCAINE

THE AIRWAY COURSE


PRETREATMENT AGENTS

OPIOID

Fentanyl 3 g/kg

• Cardiovascular disease• Intracranial hypertension

Caution: sympathetic drive

THE AIRWAY COURSE


PRETREATMENT AGENTS

ATROPINE

0.01 mg/kg

• Children < 10 years who receive Sch

THE AIRWAY COURSE


PRETREATMENT AGENTS

10% of the paralyzing dose:• Vecuronium (0.01 mg/kg)• Pancuronium (0.01 mg/kg)• Rocuronium (0.06 mg/kg)

• Intracranial hypertension

DEFASCICULATION

THE AIRWAY COURSE


INDUCTION AGENTS

THE AIRWAY COURSE


INDUCTION AGENTS

HEALTHY, STABLE PATIENTS

• Etomidate 0.3 mg/kg• Midazolam 0.2 mg/kg• Ketamine 1.5 mg/kg• Propofol 1 mg/kg• Pentothal 3 mg/kg

THE AIRWAY COURSE


COMPROMISED/UNSTABLE PATIENTS

• Etomidate 0.1 mg/kg• Midazolam 0.1 mg/kg• Ketamine 1 mg/kg• Propofol 0.5 mg/kg• Pentothal 1.5 mg/kg

INDUCTION AGENTS

THE AIRWAY COURSE


INDUCTION AGENTS

FOR SPECIFIC CONDITIONS

Reactive airways ketamineICP etomidate, pentothalHypotensive ketamineOperator preference


Zero!!

Paralysis with sedation

• Induction agent IV push • Succinylcholine 1.5 mg/kg IVP

Entering the red zone...

The Sequence

THE AIRWAY COURSE


NEUROMUSCULAR BLOCKADE

Depolarizing • succinylcholine

Competitive (nondepolarizing)

• Aminosteroids• Benzylisoquinolines


Succinylcholine

• Still the ED NMB of choice• Rapid effect• Short duration• Generally well tolerated• A few important side effects


THE AIRWAY COURSE



SUCCINYLCHOLINE• Rapid onset / brief duration• May ICP• Fatal hyperkalemia• burns beyond day one• active neuromuscular disease• crush injuries• intra-abdominal sepsis (7D)

THE AIRWAY COURSE



Aminosteroids Benzylisoquinolines

• atracurium• cisatracurium• mivacurium• metocurine • DTC

• rocuronium• pancuronium• vecuronium• rapacuronium

THE AIRWAY COURSE



Summary

• SCh for RSI• Competitive for pre-treatment• Rocuronium for competitive RSI


Zero + 30 seconds

Protection

• Sellick’s Maneuver• Position patient• Do not bag unless S O < 90%p 2

The Sequence


Zero + 45 seconds

Placement

The Sequence

• Check mandible for flaccidity• Intubate, remove stylet• Confirm tube placement - E CO• Release Sellick’s maneuver• Long acting agents/ventilator

t 2


Failed Attempt

• Plan in advance• Systematic approach essential• Equipment• Training

…remember “Skydiving!!”

Rescue Maneuvers


• The first rescue from failed intubation is bagging.

• The first rescue from failed bagging is better bagging.

• Rescue devices

Failed Attempt

Rescue Maneuvers

How do we know that RSI really works?


The “Science” of Airway Management

The problems…

• Self-reporting• Emergency conditions • Multiple factors influence each course:

• highly variable• operator dependent

• “Jargon” not standardized

Wang, HE. Acad Emerg Med. 2003;10:644-5.

6294 ED Intubations from the second report of the ongoing National Emergency Airway

Registry Study (NEAR II)

NEAR

Methods:

Prospective, observational study from 8/97 to 4/00 of 26 teaching hospitals in the U.S. during the second phase of the ongoing

National Emergency Airway Registry (NEAR II) study.

6294 Intubations from the National Emergency Airway Registry

Personnel Performing ED Intubations

Emergency MedicineInternal Med.OtherSurgeryPeds EM??Critical CarePedsFPEMT


Demographics of Cases:

Indication Cases Female Male Unknown

Trauma 1605 (22%) 349 (22%) 1059 (65%) 97 (3%)

Medical 4286 (72%) 1740 (40%) 2194 (51%) 352 (9%)

Not Provided 277 (6%) 84 (2%) 166 (3%) 27 (1%)

TOTAL 6294 (100%) 1642 (36%) 2545 (55%) 415 (9%)



Oral RSI 4377 (69%)Oral no meds 1088 (17%)Oral induction without paralysis 427 (7 %)Nasal awake with topical 206 (3%)Nasal no meds 69 (1%)Nasal induction without paralysis 45 Surgical cric/tracheotomy 39 (0.6%)Other 16Oral awake with topical 21 Unknown 5 TOTAL 6294

1st Course Success Rates:

Medical TraumaOral RSI 99.8% 97.7%Oral no meds 94.7% 96.3%Oral induction without paralysis 95.0% 93.7%Nasal awake with topical 97.2% 98.1%Nasal no meds 91.3% 45.4%Nasal induction without paralysis 97.0% 100%Oral awake with topical 93.7% N/AOther 50.0% 100%Surgical cricothyrotomy 60.0% 68.7%Unknown 50.0% N/ATOTAL 94.7% 96.2%



Success Rates by Intubator:

First pass OverallEM 84.7% 98.5%Anesthesia 93.5% 93.5%Other 64.9% 97.4%

Attending EM 90.2% 97.9%PGY 3 or 4 87.2% 98.4%PGY 1 or 2 77.5% 98.7%Other 81.1% 98.5%

NEAR

Other Studies:• Analysis of failed intubations and rescue techniques

- Bair, AE, et al. J Emerg Med. 2002;23:131-40.

• Sedative agents facilitate intubations with NMB

- Sivilotti, MLA, et al. Acad Emerg Med. 2003;10:612-20.

• Underdosing of midazolam in 92% of adults, 56% of kids - Sagarin, MJ, et al. Acad Emerg Med. 2003;10:329-38.

• Benchmarking intubation data for North American EM residents - Sagarin, MJ, et al. Ann Emerg Med. 2004.

• Golden Hour Data Systems project

• Prospectively collect data on all intubations in the field by air medical personnel

• 13 Helicopter and air ambulance companies in the U.S.

• “RSI” defined as the use of Suxx + an induction agent

Air Medical Research Collaborative (AMTC)

• Results:– Over 30,000 patient transports from 1998-2004– 2853 patients had intubations (9%)– RSI = 68% (1944 patients)– Non-RSI = 32% (909 patients)


Success Failure Total Success Rate

Trauma/Burn RSI (58%) 1542 115 1657 93.1%Trauma/Burn non-RSI (22%) 532 92 624 85.3%* Medical RSI (10%) 265 22 287 92.3%Medical non-RSI (9%) 238 30 268 88.8%

Total RSI (68%) 1807 137 1944 93.0%Total non-RSI (32%) 777 132 909 85.5%*

(*p<0.05) Surgical Cric/tracheotomy 45 (1.6%)


The Future:• Standardize the jargon• What is an intubation attempt?• Immediate vs. long-term complications

• Difficult airway assessments• Rapid and predictive• Universally applied



The Future:• Unbiased reporting systems• Large-scale data collection (web)• Standardized reporting tools• NEAR III and IV

• Data analysis• Trends and outcomes• New devices/technologies

Emergency medicine…

…the specialty that…

…ALWAYS…

…has customers!!

The End…

rapid sequence intubation erik d. barton, md, ms, mba

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