Rapid Sequence Intubation What Every Emergency physician Must Know

Rapid Sequence Intubation

What Every Emergency physician Must Know

Abdullah ALsakkaEM Consultant KKUH

What do the following have in common?

37 year old asthmatic man in extremis

22 year old overdose patient - barely arouses to pain

30 year old multiple trauma patient 67 year old man in cardiogenic shock 80 year old woman in refractory

pulmonary edema

Key Questions:Objectives

• What exactly is “RSI”?• Why use drugs?• Can I mitigate adverse effects?• What induction agent do I use?• What NMBA do I use?

Key Questions



Definition

The virtually simultaneous administration of a potent sedative agent and a

neuromuscular blocking agent to induce unconsciousness and motor paralysis for

tracheal intubation.

History

1979 first series of ED intubations – Taryle, 1979

1982 first series of intubations using succinylcholine in the ED – Thompson, 1982

History

1997 ACEP RSI policy statement:

“physicians performing RSI should possess training, knowledge, and experience in the techniques and pharmacologic agents used to perform

RSI”

“NMBA and appropriate sedative and induction agents should be immediately available in the ED and accessible to all physicians who perform RSI in the ED”

Reaffirmed, 2000


Definition Incorporates:

• Patient has a full stomach• Preoxygenation• No interposed ventilation• 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

The Evidence

Prospective observational and retrospective studies National Emergency Airway Registry (NEAR)

Series of > 6000 ED intubations 26 teaching hospitals 88.1% adult and 81.1% pediatric intubations

performed by the EP

The Evidence

METHOD FEQUENCY(%)

SUCCESS(%)

RSI 69.5% 98.7%

NO MEDS** PRE/FULL ARREST

17.3% 94.9%

SEDATION 6.8% 90.2%

NASAL 5.1% 87.2%

“NEAR” data:

Walls et. al., 1999-2000

ABSTRACT

The Evidence

EXPERIENCE PGY 3 PGY 2 PGY 1 STAFFINTUBATIONS

%73.5 17.8 2.6 6.2 *

* ½ RESIDENT * ½ RESIDENT FAILUREFAILURE

Sakles et. al. , 1998

Success rate: 99.4% with RSI vs. 91.4% with Sedation

The Evidence 1999 Li et. al. prospective airway data 3 months prior and 6 months post implementation of an

RSI protocol Results:

METHOD COMPLICATIONS

RSI n=166 28%

WITHOUT PARALYSIS

n=67

78%*

* 15% aspiration, 28% airway trauma, 3% death – NOT SEEN IN THE RSI GROUP

RSI

What are the contraindications to RSI?

RSI

The predicted difficult airway

Inexperience

Inadequate difficult airway tools and techniques


The Seven Ps of RSI

PreparationPreoxygenationPretreatmentParalysis with inductionPositioning Placement with proofPost-Intubation Management


The Sequence

Zero: the time of administration

of succinylcholine.

Zero - 10 minutes

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


The Sequence

Rapid Sequence IntubationThe Difficult Airway Rule

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

Airway Anatomy

Airway Anatomy

Pediatric Airway

Occipital prominence Nasal vs muoth breathing Dentition Adenoid tissue and friable

mucosa Aryepiglottic folds more

midline Epiglottic shape (longer,

narrower, stiffer) Laryngeal position (anterior)

Vocal cords (anterior angle)

Epiglottic vagal innervation

Lung compliance Diaphragmatic muscle

fibre type Increased metabolic rate Narrowest point is at

cricoid

Rapid Sequence IntubationThe Difficult Airway Rule

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

Airway Assessment

Airway Assessment

Airway Assessment

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

From: Benumoff

Zero - 3 minutes

Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation

“LOAD the patient before intubation.”


The Sequence

Zero!!

Paralysis with induction

• Induction agent IV push • Neuromuscular blocking agent IV push


The Sequence


1. INDUCTION

2. PRESSURE

3. PARALYSIS

INTUBATION


Zero + 30 seconds

Protection

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

The Sequence

Sellick Maneuver

CRICOID PRESSURE IN EMERGENCY RAPID SEQUENCE INTUBATION

CONCLUSIONS: Although application of cricoid pressure has been described as the "linchpin of RSI" and has come to be a widely accepted practice, there is no clear evidence to suggest that it reduces the risk of aspiration during RSI.

Butler, J., Emerg Med J 22:815, November 2005

LARYNGEAL VIEW DURING LARYNGOSCOPY: A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE, BACKWARD-UPWARD-RIGHTWARD PRESSURE, AND BIMANUAL LARYNGOSCOPY

CONCLUSIONS: bimanual laryngoscopy was more effective than cricoid pressure or the BURP maneuver in improving laryngoscopic visualization for intubation

Levitan, R.M., et al, Ann Emerg Med 27(6):548, June 2006

Zero + 45 seconds

Placement

• Check mandible for flaccidity• Intubate, remove stylet• Confirm tube placement - ET CO2

• Release Sellick’s maneuver


The Sequence

‘BURP’ Technique

Blade (type, size, placement)

Confirmation of Tube Position Visualize through cords ETCO2 Listen over stomach Compliance with bagging B/S over chest Esophageal detector device Bilateral chest rise Tube condensation Sats improve Bronchoscope CXR (lateral)

Zero + 90 seconds

Post-intubation Management

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


The Sequence

Summary

The Seven Ps of RSI

PreparationPreoxygenationPretreatmentParalysis with inductionProtectionPlacementPost-Intubation Management


• The first rescue from failed intubation is bagging

• The first rescue from failed bagging is better bagging

Rescue Maneuvers


Failed Attempt

Key Questions


Why use drugs?

• Blunt perception and recall• Make intubation easier• Mitigate adverse responses• Improve patient condition

Key Questions


WHAT CAUSES THE RESPONSE?

• Laryngoscopy and intubation cause bronchospasm

ICP catecholamines

• Succinylcholine causes ICP

PATIENTS AT RISK

• Intracranial pathology “tight brain”• Cardiovascular disease “tight heart” “floppy heart”• Reactive airways disease “tight lungs”

• Pretreatment: L.O.A.D.

• Induction agents

ATTENUATING THE RESPONSE

L.O.A.D.• L idocaine• O pioid• A tropine no longer use• D efasciculation no

The Pretreatment drugs for RSIGive 3 minutes before SCh

LIDOCAINE

1.5 mg/kg

• Increased intracranial pressure• Bronchospasm

OPIOID

Fentanyl 3 g/kgMay give slowly over 3 minutes

• Cardiovascular disease• Intracranial hypertension

Caution if dependent on sympathetic drive

Atropine

•No longer recommended

DEFASCICULATION

•No longer recommended

Key Questions


PHARMACOLOGIC INDUCTION

GOAL: INDUCTION OF UNCONSCIOUSNESS Doses dependent on:

Weight Hemodynamics Level of consciousness age

Etomidate Imidazole derivative ACTION

Sedative-hypnotic INDICATION

Hemodynamic instability Respiratory compromise increased ICP

DOSE 0.3 mg/kg iv

ADVERSE EFFECTS Adrenal suppression No analgesia property Pain on injection

Etomidate does cause adrenal insufficiency?

Not clear this affects overall survival

Barbiturates Sodium thiopental ACTION

GABAergic INDICATION

Increased ICP DOSE

3-5 mg/kg ADVERSE EFFECT

Negative inotrope and venodialtor (+) histamine release Apnea No analgesic property

Benzodiazepines Midazolam ACTION

GABAergic INDICATIONS

Cerebroprotective Amnesia Anxiolysis Muscle relaxation

DOSE 0.1 - 0.3 mg/kg (induction)

ADVERSE EFFECT Negative inotrope No analgesia property

Ketamine Phencyclidine derivative ACTION

Induces a cataleptic state INDICATION

Obstructive airway disease Hemodynamic instability Analgesia

DOSE 1-2 mg/kg

ADVERSE EFFECTS Myocardial depressant, induces tachycardia (via SNS) Unpleasant emergence

Ketamine in Head Injury Can you use ketamine in head injured patients?

• Critical review of literature

• Included 79 studies

• May improve cerebral perfusion

Neuroprotective

• No negative effects, possibly beneficial

Himmelseher S, et al. Anesth Analg 2005;101:524

Propofol Alkylphenol ACTION

Hypnotic, mechanism unknown (GABA) INDICATION

Increased ICP or IOP Amnesia Status epilepticus

DOSE 1-3 mg/kg

ADVERSE EFFECT Decreases cerebral perfusion myocardial and respiratory depression Venodilation Pain on injection No analgesic property

INDUCTION AGENTS HEALTHY, STABLE PATIENTS

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

“IV Push”

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

INDUCTION AGENTS COMPROMISED, UNSTABLE PATIENTS

INDUCTION AGENTS Special Circumstances

Reactive airways ketamineICP etomidate/pentothalHypotensive ketamine/etomidate

Operator preference

Key Questions


NEUROMUSCULAR BLOCKING AGENTS

• Depolarizing - succinylcholine • Competitive (nondepolarizing)

• Aminosteroids•Rocuronium, vecuronium

• Benzylisoquinolines•Curare

•Benzylisoquinoliniums•Atracurium, mivacurium

SUCCINYLCHOLINE

• Rapid onset / brief duration• May ICP• Fatal hyperkalemia

• burns beyond day one• active neuromuscular disease• crush injuries• intra-abdominal sepsis

USE OF NONDEPOLARIZERS

• Pretreatment no more use

• Rapid sequence intubation rocuronium

• Maintaining paralysis for ventilation


37 year old asthmatic man in extremis 22 year old overdose patient - barely

arouses to pain 30 year old multiple trauma patient 67 year old man in cardiogenic shock 80 year old woman in refractory

pulmonary edema


All should be intubated with RSI in the absence of identified difficult airway attributes


Questions ?

• Walls RM, et al: Manual of Emergency Airway Management, LWW, 2004

Rapid Sequence Intubation What Every Emergency physician Must Know

Documents

rsi protocolresults

rapid sequence intubationwhat

airway trauma

use drugs

year old asthmatic man

ed thompson

series of intubations

induction agents