Rapid Sequence Intubation
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Rapid Sequence IntubationRapid Sequence Intubation
Khalid Al-Ansari, FRCP(C), FAAP(PEM)
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ObjectivesObjectives
Definition and goals of RSISteps of RSIControversies Protocol for RSI
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DefinitionDefinition
The virtually simultaneous administration, after preoxygenation, of potent sedative agent and rapidly acting neuromuscular blocking agent to facilitate rapid tracheal intubation without interposed mechanical ventilation.
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Goals of RSIGoals of RSI
RSI produce excellent intubating condition 45 to 60 seconds after administration of neuromuscular blocking agent.
Complete jaw relaxation.Open and immobile vocal cords.No coughing or diaphragmatic
movements in response to intubation.Decrease Complication like aspiration.Control of agitation.
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RSIRSI
Intubation using RSI was more successful on first attempt (78%) compare to NOM (47%) p=<0.01 or SED (44%) p=<0.05
Sagarin et
al. pediatr Emerg care 2002
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Steps of RSISteps of RSI
7 PsPreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.
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PreparationPreparation
One of the most important step to success.
Equipment (Monitors, suction, O2, bag-valve mask, oral airway, ETT, stylet, laryngoscope blade, CO2 detector).
MedicationPersonnel.
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RSI - PreparationRSI - Preparation
S O A P MES Suction (Yankauer)O Oxygen A Airway (BVM set up,
lryngoscope, ETT, stylet, Magill forceps, tape)
P Pharmacology (drugs including reversal agents)
ME: Monitoring equipment
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PreparationPreparation
Short History + AMPLE Evaluate for difficult airway L E M O N:1. Look2. Mallampati classification3. Obstruction ( stridor, drolling, muffled
sound)4. Neck mobility ( collar)
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Mallampati classificationMallampati classification
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Look externallyLook externally
facial, cervical or neck trauma.MicrognathiaDysmorphic facial featuresSmall mouth, large tongueShort neck
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Normal Looking Kid – Normal Looking Kid – Right?Right?
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Pierre Robin SyndromePierre Robin Syndrome
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Steps of RSISteps of RSI
PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.
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PreoxygenationPreoxygenation
While preparing equipmentIt essential to the no bagging
principle.Aim to establish an O2 reservoir
within the lungs and body tissue.By 100% O2 via non-rebreather
face mask.For 3-5 minutes.
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QuizQuiz
In healthy 70 kg adult if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.
A- more than 9 minutes B- 7-8 minutes C- 4-6 minutes D- less than 4 minutes
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QuizQuiz
In healthy 70 kg adult if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.
A- more than 9 minutes B- 7-8 minutes C- 4-6 minutes D- less than 4 minutes
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QuizQuiz
In healthy 10 kg child if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.
A- > 8 minutes B- 6-8 minutes C- 3-4 minutes D- 1-2 minutes
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QuizQuiz
In healthy 10 kg child if fully preoxygenated and then paralyze how long will take to drop O2 sat from 100% to 90%.
A- > 8 minutes B- 6-8 minutes C- 3-4 minutes D- 1-2 minutes
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PreoxygenationPreoxygenation Anesthesiology: Volume 87(4) October 1997 Anesthesiology: Volume 87(4) October 1997
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Steps of RSISteps of RSI
PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.
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PremedicationPremedication
Aim to block the physiologic reflex response to airway manipulation and insertion of ETT.
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AtropineAtropine
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AtropineAtropine
To prevent Bradycardia.It should be given 1-2 min before
intubation.PALS recommendation: - Children less than 1 year of age. - Children age 1-5 years receiving Sch. - Children > 5 years receiving second
dose of Sch.
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AtropineAtropine
Bradycardia during intubation has 3 causes:
Vagal stimulation during laryngoscopy.
Succinylcholine administration Hypoxia
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FentanylFentanyl
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FentanylFentanyl
Blunt the reflex sympathetic response.
Used in pt with raised ICPDose: 1-2 Mcg/kgBe careful about BP and
respiratory depression.Add extra step
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LidocaineLidocaine
To blunt the rise in ICP associated with laryngoscopy and intubation.
Dose : 1-2 mg/kg 2-5 min before intubation
Evidence.
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Defasciculating Defasciculating
Non competitive N/M blocking agent ( rocuronium (0.06mg/kg).
10% of normal paralyzing dose.3 min before intubation.In pt. with raised ICP receiving
Sch for paralysis.No evidence to support it’s use in
RSI.Add extra step.
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Steps of RSISteps of RSI
PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.
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SedationSedation
Aim to rapidly make the pts unconscious to eliminate pt awareness of being paralyzed and intubated and facilitate the intuabtion.
The choice depend on: - Shock - Head trauma - bronchoconstriction
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ThiopentaleThiopentale
BarbiturateDose 2-4mg/kgOnset: 30-60 seconds Duration : 10-30minSide effects: decrease cardiac output,
hypotension, broncho & laryngo spasm.
Contraindication: Porphyria, Barbiturate sensitivity, Asthma (caution in decreased BP)
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KetamineKetamine
Non barbiturate dissociative agentDose: 1-2mg/kgOnset:<2minutesDuration: 10-30minutesMaintain BP & bronchodilator Side effects: Inrease BP, hallucination,
increase secreations, laryngospasm & emergence reaction.
Contraindication: raised IOP, psyhosis &hypertension.
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MidazolamMidazolam
Benzodiazepine Dose 0.1-0.3mg/kgOnset: 30-60 seconds Duration : 30-60minSide effects: Respiratory
depression & hypotension.
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EtomidateEtomidate
Imidazole Non barbiturate hypnoticDose: 0.3mg/kgOnset:<1minuteDuration: 10-30minutesHemodynamic stability.Side effects: Adrenal suppression,
myoclonus & trismus.Contraindication: Adrenal insufficiency
& focal seizure.
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Sedation Sedation
Etomidate used in 42% of pediatric RSI in US.
Thiopental used in 22% .Benzodiazepine used in ~ 18%
(90% Midazolam)
Sagarin et al, pediatr Emer Care 2002;18
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N/M blocking agentsN/M blocking agentspediatr Emerg Care 2000;16(6):441pediatr Emerg Care 2000;16(6):441
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N/M blocking agentsN/M blocking agents
Sch contraindicationHyperkalemia ( renal failure) Myopathy Malignant hyperthermia> 3-5 days of burns, crush injury,
Denervation due to stroke or spinal cord injury.
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Steps of RSISteps of RSI
PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.
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Protection Protection
Sellick’s maneuver ( cricoid pressure )Thumb and long fingers applying
posterior pressure to occlude the esophagus against the anterior surface of the vertebral body to prevent passive regurgitation of gastric content
Initiated after sedation given and maintained throughout the entire intubation sequence until ETT placed and verified.
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Steps of RSISteps of RSI
PreparationPreoxygenationPremedicationParalysis/sedationProtection and positioningPlacement with proofPostintubation management.
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Placement with proofPlacement with proof
45 seconds – 60 seconds after administration of N/M blocking agent
Intubation should be performed.Tube placement should be
checked ( auscultation, end tidal CO2 detector and CXR)
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Post intubation Post intubation managementmanagement
ETT must be taped in place.Low BP should be RxCXRLong term sedation and paralysis - Midazolam infusion - pancuronium or vecuronium
0.1mg/kg. Opioid analgesia if needed.
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Time Action
0 Assess if appropriate for RSI
0-3 minutes Pre-oxygenateObtain IV access (2 preferable) Assemble necessary equipment and personnel Draw up medications
3-5 minutes Continue to pre-oxygenate Premedicate
Atropine (< 1 year, 1 through 5 years if receiving succinylcholine, and adolescents receiving a second dose of succinylcholine)
Fentanyl (for substantial head trauma)
5-6 minutes Administer sedation
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No shock, head injury or asthma
Shock, no head trauma no asthma
Head trauma, no shock, no asthma
Asthma, no shock no head trauma
Thiopental Etomidate
Etomidate, ketamine Consider no sedation
Thiopental Etomidate
Ketamine Etomidate
Apply cricoid pressure
Administer neuromuscular blockade agent
Succinylcholine (preferred, except when contraindicated) OrRocuronimum
6-7 minutes (one minute after NMB agent administered) Perform orotracheal intubation
Remove cricoid pressure when tracheal intubation confirmed (including CO2 detection)
Consider need for more sedation/paralysis
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Take home messageTake home message
Preparation is one of the most important step for success.
Try to identify difficult airway.Preoxygenate with no bagging
principle.Back up plan.
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Thank YouThank You