Difficult intubation caused by an immature upper airway in ...
© 2006 The Airway Course Rapid Sequence Intubation.
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Transcript of © 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!!
© 2006 The Airway Course
Rapid Sequence Intubation
Outline
• What is RSI?• Where does it fit in?• Technique• RSI Pharmacology
© 2006 The Airway Course
Rapid Sequence Intubation
Paralytic and NonParalytic RSI
• Paralytic: use of a NeuroMuscular Blocking (NMB) drug in addition to an Induction agent
• NonParalytic: induction agent only
© 2006 The Airway Course
Rapid Sequence 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.
© 2006 The Airway Course
Rapid Sequence 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.
© 2006 The Airway Course
Rapid Sequence 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.
© 2006 The Airway Course
Rapid Sequence 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.
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Definition Assumes:
• Patient has a full stomach• No interposed ventilation• Preoxygenation• Sellick’s maneuver
© 2006 The Airway Course
Rapid Sequence Intubation
Outline
• What is RSI?• Where does it fit in?• Technique• RSI Pharmacology
© 2006 The Airway Course
Rapid Sequence Intubation
Universal EMS Airway Algorithm
RSI
FailedAirway
Algorithm
Difficult Airway
Algorithm
CrashAirway
AlgorithmNeeds Intubation
Difficult Airway?
Agonal/Unresponsive?
Yes
Yes
No
No
Fails
Fails
Fails
© 2006 The Airway Course
Rapid Sequence Intubation
Outline
• What is RSI?• Where does it fit in?• Technique• RSI Pharmacology
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
The Seven Ps of RSIPreparation
Preoxygenation
Pretreatment
Paralysis with induction
Protection
Placement
Post-Intubation Management
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
The Sequence
Zero: the time of administration of
succinylcholine.
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence IntubationThe Sequence
Zero - 10 minutes
Preparation
• Difficult Airway: last chance• Plan approach• Assemble drugs and equipment• Establish access, monitoring
PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Zero - 5 minutes
Preoxygenation
• 100% oxygen for three minutes• 8 vital capacity breaths• Provides essential apnea time• Apnea time varies
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Zero - 3 minutes
Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation
“LOAD the patient before intubation.”
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Zero!!
Paralysis with induction
• Induction agent IV push • Succinylcholine 1.5 mg/kg IVP
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Zero + 30 seconds
Protection
• Sellick’s Maneuver• Position patient
• Do not bag unless SpO2 < 90%
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Zero + 45 seconds
Placement
The Sequence
• Check mandible for flaccidity• Intubate, remove stylet
• Confirm tube placement - ETCO2
• Release Sellick’s maneuver
PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Zero + 90 seconds
Post-intubation Management
The Sequence
• Secure tube• Chest x-ray• Long acting sedation/paralysis• Establish ventilator parameters
PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
The Seven Ps of RSI
PreparationPreoxygenationPretreatmentParalysis with inductionProtectionPlacementPost-Intubation Management
Summary
© 2006 The Airway Course
Rapid Sequence Intubation
What if the intubation attempt is not successful?
What is a failed attempt versus a failed airway?
Rapid Sequence IntubationFailed Attempt
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence IntubationFailed Attempt
• bag/mask ventilation• think about the six attributes:
operator optimum sniff position BURP paralysis length of blade type of blade
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
• The first rescue from failed intubation is bagging• The first rescue from failed bagging is better bagging
Failed Attempt
Rescue Maneuvers
© 2006 The Airway Course
Rapid Sequence Intubation
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
© 2006 The Airway Course
Rapid Sequence Intubation
Outline
• What is RSI?• Where does it fit in?• Technique• RSI Pharmacology
© 2006 The Airway Course
Rapid Sequence Intubation
RSI Pharmacology
• Two pharmacologic decision points Pretreatment Paralysis and Induction
© 2006 The Airway Course
Rapid Sequence Intubation
Rapid Sequence Intubation
Zero - 3 minutes
Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation
“LOAD the patient before intubation.”
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
© 2006 The Airway Course
Rapid Sequence 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)
© 2006 The Airway Course
Rapid Sequence Intubation
PATIENTS AT RISK• Intracranial pathology “tight brain”• Cardiovascular disease “tight heart” “shear pressure”• Reactive airways disease “tight lungs”• Children
© 2006 The Airway Course
Rapid Sequence Intubation
LIDOCAINE
• Increased intracranial pressure Blunts ICP response to stimulation
• Bronchospasm/reactive airways
1.5 mg/kg
© 2006 The Airway Course
Rapid Sequence Intubation
OPIOID
Fentanyl 3 g/kgBlunts catecholamine release
• Cardiovascular disease• Intracranial hypertension
May give slowly over 1-3 minutes!! Caution if dependent on sympathetic drive
© 2006 The Airway Course
Rapid Sequence Intubation
OPIOID
Fentanyl 3 g/kg
Tight Heart/Shear Pressure Tight Brain
© 2006 The Airway Course
Rapid Sequence Intubation
ATROPINE
0.02 mg/kg(minimum dose 0.1 mg)
• Children < 10 years who will receive SCh• Standby for second dose of SCh
© 2006 The Airway Course
Rapid Sequence Intubation
DEFASCICULATION
Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg
• Intracranial hypertension
© 2006 The Airway Course
Rapid Sequence Intubation
DEFASCICULATION
Tight Brain
Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg
© 2006 The Airway Course
Rapid Sequence Intubation
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”
© 2006 The Airway Course
Rapid Sequence Intubation
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
© 2006 The Airway Course
Rapid Sequence Intubation
INDUCTION AGENTSFor specific conditions
Reactive airways ketamine ICP etomidate, pentothal Hypotensive ketamine Operator preference
© 2006 The Airway Course
Rapid Sequence Intubation
NEUROMUSCULAR BLOCKING AGENTS
• Depolarizing - succinylcholine • Competitive (nondepolarizing)
• Aminosteroids (“…onium”)• Benzylisoquinolines (“…curi”)
© 2006 The Airway Course
Rapid Sequence Intubation
Succinylcholine has one very, very lethal side effect…
Fatal Hyperkalemia
Succinylcholine is a universally safe drug.
No-one is too sick to get succinylcholine.
© 2006 The Airway Course
Rapid Sequence Intubation
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.
© 2006 The Airway Course
Rapid Sequence Intubation
USE OF NONDEPOLARIZERS
• Pretreatment (Defasciculation)
• Rapid sequence intubation rocuronium 1 mg/kg vecuronium 0.01 mg/kg+0.15 mg/kg