Rapid Sequence Intubation:drugs and concepts

Decision to Intubate

• Failure to maintain/protect airway• Failure to ventilate/oxygenate• Condition present or therapy required that mandates

intubation

Once you have decided that the patient requires tracheal integration the primary goal is to secure the airway quickly and as

safely as possible to assure adequate oxygenation and ventilation

Rapid Sequence Intubation

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.

Rapid Sequence Intubation

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.

Rapid Sequence Intubation

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.

Rapid Sequence Intubation

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.

Rapid Sequence Intubation

Definition Assumes:

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

Rapid Sequence Intubation

The Seven Ps of RSIPreparation

Preoxygenation

Pretreatment

Paralysis with induction

Protection

Placement

Post-Intubation Management

Rapid Sequence Intubation

The Sequence

Zero: the time of administration of

paralytic

Rapid Sequence IntubationThe Sequence

Zero - 10 minutes

Preparation

• Plan your approach ahead of time!!• Assemble drugs and equipment• Establish access, monitoring• CHECKLIST!!

PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

Rapid Sequence Intubation

Zero - 5 minutes

Preoxygenation• De-Nitrogenate patient’s lungs- 8 VC BREATHS or 3 minutes

• Provides essential apnea time• Apnea time varies • NO DESAT- 15L nasal cannula• 15L NRB• If sats <95% -> BVM with 15cmH20 PEEP

The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

Rapid Sequence Intubation

Zero - 5 minutes

Preoxygenation• De-Nitrogenate patient’s lungs• Provides essential apnea time• Apnea time varies • NO DESAT-maintain airway open/HOB 30°• 15L nasal cannula• 15L NRB• If sats <95% -> BVM with 15cmH20 CPAP/PEEP

The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

“Rule of 15s”

Rapid Sequence Intubation

Zero - 5 minutes

Preoxygenation• De-Nitrogenate patient’s lungs• Provides essential apnea time• Apnea time varies • NO DESAT• 15L nasal cannula• 15L NRB• If sats <95% -> BVM/PEEPval/CPAP @ 15cmH20

The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

Rule of 15s

DSI: Delayed Sequence Intubation

The Basics:

“A procedural sedation, where the procedure is

pre-oxygenation”

* From EMCrit.org

Ph kills

• Pseudo- NIV with vent (not biPAP)- RR0• Give RSI meds• Give breaths (RR12) during apnea time for 1

minute –slow,controlled breaths with jaw thrust• Intubate, set vent to RR 30

Rapid Sequence Intubation

Zero - 3 minutes

Pretreatment• Fentanyl 5 mcg/kg• for high ICP/Vascular with elevated BP

• Scopolamine 0.4 mg• for amnesia in hypotensive patient intubation

•INOPRESSOR /IVFS- PDPS/Norepi gtt

The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

Rapid Sequence Intubation

Zero!!

Paralysis with induction

• Induction agent• Ketamine 2 mg/kg• Etomidate 0.3 mg/kg• Propofol 1.5-3 mg/kg

• Paralytic agent• Rocuronium 1.2 mg/kg• Succinylcholine 1.5-2.0 mg/kg

The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

Ketamine

Ketamine• Dissociative sedative and analgesic

• Dissociates the CNS from outside stimuli by “disconnecting” thalamocortical and limbic systems

• Produces trancelike cataleptic state

• Maintain protective airway reflexes• Very rapid onset - first pass effect• low dose gives analgesia 0.2 mg/kg• Moderate dose give analgesia and anxiolysis 0.5 mg/kg IV• High Doses give amnesia and disassociation IV dose 1.5-

2 mg/kg IV)

Ketamine- Cautions• Central adrenergic release, premedication with depressants (benzos) or

fentanyl will probably blunt this response.• MAP increased ~25 mmHg• Probably has neuroprotective effect by NDMA antagonism, so no issues

with elevated ICP patients-stroke and head injury• True laryngospasm is exceedingly rare, probably just tongue obstruction. 

Inevitably resolves with airway positioning.• The intraocular pressure increase has only been reported in animals• Avoid in hyperthyroid states due to catecholamine release

Etomidate• ultra–short-acting nonbarbiturate hypnotic• No analgesic effect• Dose: 0.2-0.3 mg/kg IV

– Onset: > 1min– Duration: 3-5 mins

Etomidate

• it causes adrenal suppression which may be linked to increased mortality in septic patients (though many argue that etomidate is safe)

• it is unreliable as an induction agent in reduced doses (even in shocked patients)

• Good hemodynamic profile

Propofol

• potent, ultra–short-acting sedation and anesthesia• It is a phenolic compound, and its mechanism of

action is unknown, but it is thought to mediate GABA activity

• Propofol has no analgesic properties• It is associated with rapid deepening of a

sedation level to that of general anesthesia

Propofol

• Dose 0.5-1 mg/kg IV loading dose ; repeat 0.5 mg/kg q3-5 mins until desired depth of sedation

• Onset: < 1 min• Duration 3-10 mins

Adverse effects

• Hypoventilation/apnea- preO2!!, ETCO2!!• Cardiovascular collapse/hypotension

– Exacerbated in patients who are volume depleted• Give IVFs up front

Ketofol• Best of both worlds !

Deep sedation of propofol (HR BP)

+Dissociation, analgesia, maintenance of airway reflexes

and sympathomimetic effects of ketamine

= Hemodynamically balanced sedation agent

TBW

IBW

IBW

TBW

TBW

Rapid Sequence Intubation

Zero + 30 seconds

Protection

• Position patient- ear to sternal notch, face parallel

• Do not bag unless SpO2 < 90%

The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

Rapid Sequence Intubation

Zero + 45 seconds

Placement

The Sequence

• Intubate, remove stylet• Confirm tube placement - ETCO2

PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

Rapid Sequence Intubation

Zero + 90 seconds

Post-intubation Management

The Sequence

• Secure tube• Fentanyl push then drip OR• Dilaudid pushes• Sedation if necessary- propofol, ketamine or midazolam• Establish ventilator parameters

PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation

NEUROMUSCULAR BLOCKING AGENTS

NEUROMUSCULAR BLOCKING AGENTS

• Depolarizing - succinylcholine • Competitive (nondepolarizing)

• eg rocuronium, vecuronium

•Succinylcholine is a universally safe drug.

•No-one is too sick to get succinylcholine………

Succinylcholine has one very, very lethal side effect…

Fatal Hyperkalemia

SuccinylcholineHyperkalemia

• Motor endplate proliferation burns, crush injuries stroke spinal cord injury MS, ALS, other denervations

• Myopathies Muscular dystrophy

Mortality 11%

Mortality 30%

Does Sux SUCK ?

or

Does Roc ROCK?

Sux vs Roc• Succinylcholine

– Used in 82% ED RSI– Faster onset to ETI

conditions?– Onset = 60 sec– Duration = 3-15 min– Benefit:Stat

epilepticus;ICH/stroke evals

– Adverse effects• K- do we know pts at risk?• rhabdo• ICP and IOP• Masseter spasm• Malignant hyperthermia

• Rocuronium– Onset = 45-60 sec (at 1.2

mg/kg)– Duration 30-90 min– Longer duration of safe apnea

vs. sux (preox!)– Reversal in 2mins with

Suggamadex?– Adverse effects

• None• Prolonged paralysis?• What if I can’t intubate?• What if I can’t ventilate?

Rapid Sequence Intubation

The Seven Ps of RSI

PreparationPreoxygenationPretreatmentParalysis with inductionProtectionPlacementPost-Intubation Management

Summary

Review…….

•Plan Ahead•Use checklist

Denitrogenate

Preoxygenate

Apneic oxygenation

pretreat

Dose smart

QUESTIONS??