© 2006 The Airway Course Rapid Sequence Intubation.

© 2006 The Airway Course

Rapid Sequence Intubation




Why are you here?

‘Don’t be afraid’

Control the situation; don’t let the situation control you!!



Outline

• What is RSI?• Where does it fit in?• Technique• RSI Pharmacology



Paralytic and NonParalytic RSI

• Paralytic: use of a NeuroMuscular Blocking (NMB) drug in addition to an Induction agent

• NonParalytic: induction agent only




Definition

The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness

and motor paralysis for tracheal intubation.




Definition






Definition






Definition






Definition Assumes:

• Patient has a full stomach• No interposed ventilation• Preoxygenation• Sellick’s maneuver



Outline




Universal EMS Airway Algorithm

RSI

FailedAirway

Algorithm

Difficult Airway

Algorithm

CrashAirway

AlgorithmNeeds Intubation

Difficult Airway?

Agonal/Unresponsive?

Yes

Yes

No

No

Fails

Fails

Fails



Outline





The Seven Ps of RSIPreparation

Preoxygenation

Pretreatment

Paralysis with induction

Protection

Placement

Post-Intubation Management




The Sequence

Zero: the time of administration of

succinylcholine.



Rapid Sequence IntubationThe Sequence

Zero - 10 minutes

Preparation

• Difficult Airway: last chance• Plan approach• Assemble drugs and equipment• Establish access, monitoring

PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation




Zero - 5 minutes

Preoxygenation

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

The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation




Zero - 3 minutes

Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation

“LOAD the patient before intubation.”





Zero!!

Paralysis with induction

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





Zero + 30 seconds

Protection

• Sellick’s Maneuver• Position patient

• Do not bag unless SpO2 < 90%





Zero + 45 seconds

Placement

The Sequence

• Check mandible for flaccidity• Intubate, remove stylet

• Confirm tube placement - ETCO2

• Release Sellick’s maneuver





Zero + 90 seconds

Post-intubation Management

The Sequence

• Secure tube• Chest x-ray• Long acting sedation/paralysis• Establish ventilator parameters





The Seven Ps of RSI

PreparationPreoxygenationPretreatmentParalysis with inductionProtectionPlacementPost-Intubation Management

Summary



What if the intubation attempt is not successful?

What is a failed attempt versus a failed airway?

Rapid Sequence IntubationFailed Attempt



Rapid Sequence IntubationFailed Attempt

• bag/mask ventilation• think about the six attributes:

operator optimum sniff position BURP paralysis length of blade type of blade




• The first rescue from failed intubation is bagging• The first rescue from failed bagging is better bagging

Failed Attempt

Rescue Maneuvers




Speeding Up RSI



Rapid Sequence IntubationSpeeding Up RSI

Accelerated RSI:• preoxygenation for 8 VC breaths• shorten pre-treatment interval

Immediate RSI: • preoxygenation for 8 VC breaths• omit pre-treatment



Outline




RSI Pharmacology

• Two pharmacologic decision points Pretreatment Paralysis and Induction




Zero - 3 minutes

Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation

“LOAD the patient before intubation.”




PATIENTS AT RISK• Larynx, trachea, carina are richly innervated •Intubation is intensely stimulating

Sympathetic Discharge (RSRL) ICP response (not 2o catecholamines) ICP response to SCh Bronchospastic response Bradycardia (in children)



PATIENTS AT RISK• Intracranial pathology “tight brain”• Cardiovascular disease “tight heart” “shear pressure”• Reactive airways disease “tight lungs”• Children



LIDOCAINE

• Increased intracranial pressure Blunts ICP response to stimulation

• Bronchospasm/reactive airways

1.5 mg/kg



LIDOCAINE

1.5 mg/kg

Tight Brain Tight Lungs



OPIOID

Fentanyl 3 g/kgBlunts catecholamine release

• Cardiovascular disease• Intracranial hypertension

May give slowly over 1-3 minutes!! Caution if dependent on sympathetic drive



OPIOID

Fentanyl 3 g/kg

Tight Heart/Shear Pressure Tight Brain



ATROPINE

0.02 mg/kg(minimum dose 0.1 mg)

• Children < 10 years who will receive SCh• Standby for second dose of SCh



DEFASCICULATION

Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg

• Intracranial hypertension



DEFASCICULATION

Tight Brain

Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg



INDUCTION AGENTS



INDUCTION AGENTS HEALTHY, STABLE PATIENTS

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

“IV Push”



INDUCTION AGENTS COMPROMISED PATIENTS

• Etomidate 0.15-0.2 mg/kg• Midazolam 0.1 mg/kg• Ketamine 1 mg/kg• Propofol 0.5 mg/kg• Pentothal 1.5 mg/kg



INDUCTION AGENTSFor specific conditions

Reactive airways ketamine ICP etomidate, pentothal Hypotensive ketamine Operator preference



NEUROMUSCULAR BLOCKING AGENTS



NEUROMUSCULAR BLOCKING AGENTS

• Depolarizing - succinylcholine • Competitive (nondepolarizing)

• Aminosteroids (“…onium”)• Benzylisoquinolines (“…curi”)



Succinylcholine has one very, very lethal side effect…

Fatal Hyperkalemia

Succinylcholine is a universally safe drug.

No-one is too sick to get succinylcholine.



SuccinylcholineHyperkalemia

• Receptor Upregulation Burns, crush, prolonged ICU care UMN lesions, including stroke spinal cord injury MS, ALS, other denervations

• Myopathic Processes Muscular dystrophy Rare idiopathic

Mortality 11%

Mortality 30%

Gronert: Anesthesiology 94:523-529, 2001.



USE OF NONDEPOLARIZERS

• Pretreatment (Defasciculation)

• Rapid sequence intubation rocuronium 1 mg/kg vecuronium 0.01 mg/kg+0.15 mg/kg




Fin



Positive Pressure (Ventilation)



Negative Pressure (Inspiration)





Valve Effect: Inspiration





© 2006 The Airway Course Rapid Sequence Intubation.

Documents

intubation management

tracheal intubation

fails slide

potent sedative agent

minutes preoxygenation

induction agent nonparalytic

motor paralysis

simultaneous administration