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Rapid Sequence Rapid Sequence IntubationIntubationJohn Bradley, MDJohn Bradley, MD

Metropolitan HospitalMetropolitan HospitalMay 30, 2012May 30, 2012

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Lessons from SkydivingLessons from SkydivingLevitan RM. Patient safety in emergency airway management and rapid sequence Levitan RM. Patient safety in emergency airway management and rapid sequence intubation: metaphorical lessons from skydiving. intubation: metaphorical lessons from skydiving. Ann Emerg Med. Ann Emerg Med. 2003;42:812003;42:81--87.87.

• Redundancy of safety (primary and backup chute)

• Planned stepwise approach to deploy 1ary chute Simple, fast, easy backup chute deployment

• Attention to monitoring: exit plane at correct altitude, altimeter determines when to deploy backup chute

• Equipment vigilance

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OverviewOverview

Rapid Sequence Intubation

Airway AssessmentThe Difficult AirwayThe Failed AirwayAirway OptionsYour Approach

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Rapid Sequence Intubation (RSI)Rapid Sequence Intubation (RSI)

• Definition• Assumptions• Goals• Indications• Contraindications• Alternatives• Procedure

– Steps– Pharmacology

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RSI DefinitionRSI Definition

• The administration of a potent induction agent followed immediately by a rapid acting neuromuscular blocker (NMB) to render unconsciousness and motor paralysis for tracheal intubation

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RSI AssumptionsRSI Assumptions

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RSI AssumptionsRSI Assumptions

• Intubation is indicated• The stomach is full• Intubation is anticipated to be successful• If intubation fails, ventilation is expected to

be successful

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RSI GoalsRSI Goals

• Optimize intubation conditions

• Minimize aspiration risk by avoiding positive pressure ventilation until after intubation is accomplished

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Indications for Tracheal IntubationIndications for Tracheal Intubation

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Indications for Tracheal IntubationIndications for Tracheal Intubation

Inability to maintain an airwayInability to maintain adequate oxygenation

and ventilationAnticipated airway obstruction /

Special situations

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RSI ContraindicationsRSI Contraindications

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RSI ContraindicationsRSI Contraindications

• Tracheal / laryngeal injury / disruption• S/P Laryngectomy• Massive facial trauma• Anticipated difficult airway

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RSI AlternativesRSI Alternatives

• Awake oral intubation with local anesthesia and sedation

• Blind nasotracheal intubation (BNTI)

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RSIRSIThe 7 PsThe 7 Ps

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RSIRSIThe 7 PsThe 7 Ps

• Preparation• Preoxygenation• Pretreatment• Paralysis with induction• Protection with positioning• Placement with proof• Post-intubation management

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RSI TimelineRSI TimelineTime ActionZero - 10 min PreparationZero - 5 min PreoxygenationZero - 3 min PretreatmentZero Paralysis with inductionZero + 20-30 sec Protection with positioningZero + 45-60 sec Placement with proofZero + 60-90 sec Post-intubation management

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RSI Compressed TimelineRSI Compressed Timeline

• Concurrent preparation and preoxygenation• Accelerated (2 min)

– Shorten preoxygenation to 30 sec with 8 vital capacity breaths (VC) method

– Shorten pretreatment interval from 3 min to 2 min

• Immediate – Eliminate pretreatment– Preoxygenate with 8 VC breaths

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PreparationPreparation

• Patient– Discussion, airway assessment, IV access– Positioning

• Equipment– Airway, monitoring, failed airway– Blade type and size, ETT size– OP airway, placement confirmation device– Cuff integrity and stylet, laryngoscope fxn

• Personnel

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Airway Assessment (LEMON)Airway Assessment (LEMON)

• Look externally• Evaluate 3-3-2• Mallampati• Obstruction• Neck• (Pediatrics)

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Look ExternallyLook Externally

• Difficult BVM Ventilation ?• Difficult Laryngoscopy / Intubation ?• Difficult Surgical Airway ?

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Difficult BVM VentilationDifficult BVM Ventilation(BONES)(BONES)

• Beard• Obesity• No teeth • (Elderly)• (Snores)• Severe facial burns / angioedema / trauma

– Unstable midface and/or mandible

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Difficult Laryngoscopy / Intubation Difficult Laryngoscopy / Intubation

• (Severe facial burns / angioedema / trauma)• Buck teeth• Jay Leno • Micronathia• Down’s syndrome• FLK

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Difficult Surgical AirwayDifficult Surgical Airway(SHORT)(SHORT)

• Surgery• Hematoma or infection• Obesity• Radiation• Tumor (including goiter)

• Anatomic variability• Females

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EvaluateEvaluate(3(3--33--2 Rule)2 Rule)

• 3 finger breadths between upper lower teeth –Ability to visualize

• 3 finger breadths between the mandible and hyoid bone–< 3: suggests anterior larynx–Greater: axes malalignment

• 2 finger breadths between thyroid cartilage notch and the mandible or floor of the mouth–Cephalad larynx

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Mallampati ClassificationMallampati Classification

I Tonsillar pillars and fauces visibleII Upper portion of pillars and uvula visibleIII Base of uvula / soft palate visibleIV Only tongue and hard palate visible

Patient’s mouth open, tongue sticking outCorrelates with laryngoscopy classification,

but not as sensitive in grades 3 and 4…

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Laryngoscopic ClassificationLaryngoscopic Classification

• Grade I Entire glottis visible• Grade II Arytenoid cartilage and

posterior glottis visible• Grade III Epiglottis only visible• Grade IV Tongue or soft palate visible

• Grade III and IV are considered difficult intubations (about 5% of OR cases)

• Visualization predicts intubation success

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ObstructionObstruction

• Angioedema• Epiglottis• Abscess• Burn• Trauma• Tumor

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NeckNeck

• Possible cervical spine injury• Rheumatoid arthritis• Ankylosing spondylitis

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High Risk PatientsHigh Risk Patients

• ASA Class III and higher• Chronic pulmonary or cardiac disease• Fever, volume depletion, current URI• Airway assessment suggestive

• Consider OR, anesthesia consult and/or awake intubation

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ETT Size and DepthETT Size and Depth

• Size– Females 7.5-8; Males 8-8.5– Broslow tape, little finger diameter– 4 + age/4

• Depth– Females - 21 cm; Males - 23 cm– Broslow tape, markings on ETT– ETT size x 3 (cm); age + 10

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PreoxygenationPreoxygenation

• Establish an O2 reservoir in the lungs & body– Essential to “no bagging” principle of RSI– Function residual capacity is primary reservoir– Permits several minutes of apnea without

desaturation• 100% O2 via nonrebreather for 5 minutes

OR8 VC breaths with 100% O2 via bag/mask

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Pretreatment (LOAD)Pretreatment (LOAD)

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Pretreatment (LOAD)Pretreatment (LOAD)• Mitigate adverse effects of laryngoscopy• Lidocaine 1.5 mg/kg

– Airway bronchospasm / cough reflex– Increased ICP

• Opiates (Fentanyl 3-6 mcg/kg)– Increased ICP, aortic dissection, ruptured

aortic or IC aneurysm, ischemic heart disease– Blunts reflex sympathetic response to

laryngoscopy– Not recommended under age 1

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Pretreatment (LOAD)Pretreatment (LOAD)

• Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg)– Children <= 10 yo– Blunts vagal response to laryngoscopy

• Defasiculation (with succinylcholine)– Increased ICP– 1/10th dose of a non-depolarizing NMB– Not indicated under age 5

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Paralysis with InductionParalysis with Induction

• Rapid IV administration of sedation followed immediately by rapid administration of a neuromuscular blocking agent

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Protection and PositioningProtection and Positioning

• Sellick’s maneuver– Firm pressure (10 #)– Maintain until placement confirmation and cuff

inflation• Positioning

– Keep the pillow to maximize POGO– Height of bed, height in bed

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Placement with ProofPlacement with Proof• Test for jaw flaccidity• Extend head on neck• Gentle controlled technique• Blade entry on right, sweep tongue to left• Lift handle up and away• Suction prn• Insert into esophagus, then slowly withdraw• Visualize vocal cords• Watch ETT pass through vocal cords• Check ETT depth• Never let go of the tube!• Inflate cuff• Auscultation

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Placement with ProofPlacement with Proof

• Confirm tracheal placement – Direct visualization plus either– EtCO2 detector or– Esophageal detector

• Preferred in cardiopulmonary arrest

• Confirm depth (cords > bronchus)– Auscultation – CXR

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PostPost--Intubation ManagementIntubation Management

• Secure ETT• Reassess VS• PCXR for depth of placement

• Bradycardia / Hypoxia -> Nontracheal tubeplacement until proven otherwise (DOPE)

• Hypertension->inadequate sedation/analgesia• Hypotension

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PostPost--intubation Managementintubation Management(Hypotension)(Hypotension)

• Tension PTX– High PIP, hard to bag, decreased BS, hypoxia– Immediate thoracostomy

• Decreased venous return– High PIPs 2ndary to high intrathoracic pressure– Fluids, bronchodilators, – Increase expiratory time, decrease TV

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PostPost--intubation Managementintubation Management(Hypotension)(Hypotension)

• Induction agent– Other causes excluded– Fluid bolus, consider reversal agent, expectant

• Cardiogenic– Usually a compromised pt– Check EKG, exclude other causes– Fluid bolus (caution), pressors

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MedicationsMedications

• Pretreatment drugs (LOAD)– Lidocaine– Opiates– Atropine– Defasiculation

• Sedation• Paralysis

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SedationSedation

• Midazolam• Etomidate• Methohexital / Thiopental• Ketamine• Propofol

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Neuromuscular Blocking AgentsNeuromuscular Blocking Agents• Noncompetitive depolarizer

– Succinylcholine (Anectine)• Competitive nondepolarizer

Benzylisoquinolinium group– Atracurium (Tracrium), cisatracurium (Nimbex),

mivacurium (Mivacron)Aminosteroid group

– Pancuronium (Pavulon), vecuronium (Norcuron), rocuronium (Zemuron)

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Succinylcholine (SCh) (Anectine)Succinylcholine (SCh) (Anectine)

• Rapid onset (45 seconds) and short duration of action (<= 10 minutes)

• Mechanism of action• Metabolism• Sequence of action• Dosing

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SCh Adverse EffectsSCh Adverse Effects

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SCh Adverse EffectsSCh Adverse Effects

• Malignant hyperthermia• Masseter spasm• Hyperkalemia• Increased ICP / Increased IOP

– Fasciculations• Bradycardia (peds)• Prolonged NMB• Hypotension (histamine release, (-) inotrope)

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SCh ContraindicationsSCh Contraindications

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SCh ContraindicationsSCh Contraindications• Personal or FH of malignant hyperthermia

• Known or suspected hyperkalemia • > 24 hours post-burn (>10% BSA, 1-2 yrs)• > 1 week post crush injury (60-90 days)• > 1 week post SCI or CVA (6 months)• Neuromuscular disease (indefinite)

– MS, ALS, muscular dystrophy

• Anticipated difficult airway

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Competitive, Nondepolarizing NMBCompetitive, Nondepolarizing NMB

• Most commonly utilized post-intubation• No CIs other than the difficult airway• Disadvantage is longer onset and duration• Metabolism variable• Higher dose reduces time to paralysis but

prolongs time to recovery

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Competitive, Nondepolarizing NMBCompetitive, Nondepolarizing NMB

• Aminosteroid group dose not cause histamine release

• Reversible with AChesterase inhibitor– Requires 40% spontaneous recovery

• Consider administering sedation shortly after administering vecuronium or pancuronium for RSI

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Competitive, Nondepolarizing NMBCompetitive, Nondepolarizing NMB

• Rapacurium off the market• Rocuronium (0.6-1.2 mg/kg)• Mivacurium (0.15 mg/kg)• Vecuronium (0.3 mg/kg)• Pancuronium (0.1 mg/kg)

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Awake Oral IntubationAwake Oral Intubation

• Upper airway distortion is anticipated• Prepare the patient• Anesthetize the airway

– Lidocaine 4% 4 cc / neosynephrine 0.5% 1cc OR– Lidocaine 2% w/EPI 5cc / Lidocaine 2% Plain 5 cc– Via nebulizer for 10 minutes OR– Lidocaine spray

• Sedation (Midazolam or Etomidate +/- Fentanyl)– Onset 3-5 minutes

• Perform laryngoscopy• Immediate intubation / consider RSI / surgical airway

– Can the epiglottis be visualized?– Is an abnormal glottis anticipated?

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PediatricsPediatrics

• Relatively large tongue / more oral secretions• High tracheal opening (C1 > C4,5 adult)• Large occiput • Cricoid ring is narrowest portion• Large tonsils and adenoids and greater angle

between epiglottis and larygeal opening• Minimal cricothyroid membrane until age ¾• Small relative FRC• Basal oxygen consumption twice the adult rate

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PediatricsPediatrics

• Appropriately sized equipment (Broslow)• Positioning

– Avoid hyperextension– May need to elevate shoulders

• Effective BVM– C-grip / good seal– Squeeze, release, release– Tidal volume– Cricoid pressure

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PediatricsPediatrics

• Atropine < age 10• Avoid fentanyl < age, use cautiously• Lower barbituate dose per kg• No defasciculation < age 5 / 20 kg• Succinylcholine dose• Straight blade• Uncuffed ETT < age 8

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PediatricsPediatrics

• No BNTI < age 10• Adult EtCO2 detector > 15 kg• Securing the tube• Place NGT or OGT early• Orotracheal intubation for better security• No surgical cricothyroidotomy < age 10

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The Second AttemptThe Second Attempt• Learn from your first attempt (experience)• Blade type or size (Use Mac as a Miller)• ETT size• Sellick’s technique / stylet• BURP • Reposition the head and neck• Chest pressure looking for air bubble• Monitor VS, interposed BVM ventilation• Find the epiglottis• Call for help

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The Bottom LineThe Bottom Line

• The Broslow Tape / Cart• Get the trachea intubated efficiently• Have a plan• Have a back-up plan• Call for help early• Airway assessment is an integral part of

RSI and procedural sedation • Practice, practice, practice

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ResourcesResources

• Manual of Emergency Airway Management by Ron Walls et al

• Airway Courses