Rapid Sequence ion Edited

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Rapid Sequence Intubation

in Emergency

Adapted from source


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OBJECTIVES

To understand why we use Rapid Sequence Intubation

To help you plan for a Rapid Sequence Intubation

To help you identify the potentially difficult airway

To learn some pharmacology behind airway management

To demonstrate the failed airway algorithm we use in ED

To introduce the Fastrach Intubating LMA


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Definition

The virtually simultaneous administration,

after pre oxygenation, of a potent sedative

agent and a neuromuscular blocking agent

to facilitate rapid tracheal intubation of a

potentially non fasted patient without

interposed positive-pressure ventilation.


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Indications for RSI

Inability to maintain an adequate airway

Inability to maintain adequate oxygenation orventilation

Anticipated airway obstruction or special situations


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Aspiration

the entry of secretions or foreign material into thetrachea and lungs

lungs are normally protected against aspiration bya series ofprotective reflexessuch as coughing andswallowing

small volumes of gastric acid contents can fatallydamage delicate lung tissue or lead tobronchopneumonia


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BEFORE WE GOFURTHER

Important Assumptions and Contraindications

We are assuming that Intubation is indicated, is anticipated to be successful

and, if we fail, ventilation is expected to be successful !!

We are assuming there is no tracheal / laryngeal injury or disruption or

massive facial trauma

ie : We do not anticipate a difficult airway

Alternatives exist such as awake nasal intubation with local anaesthesia and

sedation by a specialist Anaesthetist


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The Seven Ps of RSI

Preparation

Pre oxygenation

Pre treatment Paralysis with induction

Positioning + Protection

Placement with proof

Post-Intubation Management


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1: PreparationIntubation Equipment

Stylet + Bougie

Syringe (10 ml)

OP/NP airway

Working suction

Functioning ETCO2

Rescue device

Bag and mask (check size)

2 laryngoscope handles

2 laryngoscope blades(Test light bulb)

2 endotracheal tubes

(Test cuff + lubricate)

(Adult women 7.0-8.0mm)

(Adult men 7.5-8.5mm)


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M.A.L.E.S Magill's

+ Mask

Airway

+ Assistant

Laryngoscope

+ Lubrication

Endotracheal tube

+ ETC02

Stylet (Bougie)

+ Syringe

+ Suction !


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Look Externally

Is this patient likely to be a

Difficult BVM Ventilation ?

Difficult Laryngoscopy / Intubation ?

Difficult Surgical Airway ?

B = Beard

O = ObesityN = No teethE = ElderlyS = Snores

= Severe facial injuries

(burns, mid face fractures or trauma)


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Evaluate (3-3-2 Rule)

3 x fingers between upper and lower incisor teeth

3 x fingers between the mental protuberance of the

mandible and hyoid bone

2 x fingers between thyroid cartilage notch

and the mandible or floor of the mouth


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Mallampati Classification

I Tonsillar pillars and fauces visible

II Upper portion of pillars and uvula visible

III Base of uvula / soft palate visible

IV Only tongue and hard palate visible

Ask patients to open their mouth

and stick their tongue out

Correlates with laryngoscopy classification but not as sensitive in

predicting grades 3 and 4 intubations


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Obstruction

Epiglottis

Abscess

Burn

Trauma

Tumor


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Neck

Possible cervical spine injury

In line immobilization OR collar on/off

Rheumatoid arthritis

Ankylosing spondylitis


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Prepare Yourself and Staff

and Establish a Plan

What if I cant open the patientsmouth?

What if I cant find the cords?

What if I cant pass the tube?

What if I cant ventilate the patient?


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Time Zero in 5 minutes

2: Pre oxygenation

100% oxygen for three minutes

8 vital capacity breaths

Provides essential apnoea time

Apnoea time will vary with patient physiology


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Brain Teaser 1:

How long is the apnoea time?

A healthy young ED doctor is fully pre oxygenated

with 100% oxygen and SUX is administered.

How long until their SpO2 drops below 90%?

A. 60 - 90 seconds

B. 91 - 180 seconds

C. 181 - 360 seconds

D. > 360 seconds


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Brainteaser 2:

Which fully pre oxygenated patient

desaturates quicker?

A. Normal healthy 47 yr old 70 kg male

B. 60 yr old 80 kg male with moderate COPD

C.

14 month old hell on wheels toddler

D. 22 yr old 55kg intoxicated female OD


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Time Zero in 3 minutes

3: Pre treatment

Laryngoscopy causes stimulation of afferentreceptors in the posterior pharynx, hypopharynx

and larynx

Reflexes can cause:

Increased intracranial pressure (ICP)

Stimulation of upper & lower respiratory tractincreasing airway resistance.

Stimulation of autonomic nervous system, withincrease heart rate and BP


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Laryngoscopy Effects

CNS response to airway stimulation

Increase cerebral metabolic demand

Increase cerebral blood flow

Increase ICP if intracranial elastance is

compromised


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Respiratory system response

Upper airway reflexes lead to

laryngospasm & coughing

Coughing may cause increase in ICP

Lower airway reflexes can lead to an

increase in airway resistance bronchospasm


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Cardiovascular system response

Overall increase in heart rate and blood pressure

up to twice normal limits

Can be detrimental in patients with myocardial

ischemia, aortic or intracerebral aneurysm

or any penetrating trauma where increase in shear

pressure may reactivate previous haemorrhage

Increase in blood pressure may cause significant

increase in ICP if auto-regulation is lost


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PATIENTS AT RISK

Intracranial pathology

tight brain

Cardiovascular disease

tight heart

Reactive airways disease

tight lungs


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FENTANYL

FENTANYL 1 - 3 mcg/kg given slowly over 1 minute

Attenuates normal physiologic & pathophysiologicalreflex responses caused by airway manipulation during

laryngoscopy and insertion of an ETT

Caution: Contraindicated in patients overtly hypotensive anddependent on sympathetic tone

( can use Fentanyl 1mg/kg OR occasionally lignocaine )


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Brain Teaser 3:

Aspiration is always a risk with intubation and canlead to significant morbidity and mortality

From the answers below which patient has a high risk ofaspiration ?

A. A 60 yr old male with acute respiratory distress and

subacute bowel obstruction

B. A 28 yr old 34 week pregnant women with preeclampsia

C. A 6 yr old given morphine in ED and now 4 hours postdisplaced supracondylar fracture

D. A 45 yr old presenting to ED with GCS 8/15 following OD

of unknown quantity of amitriptylline

E. All of the above


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Time ZERO !!!

4: Paralysis with Induction

Near simultaneous administration ofintravenous Induction agent and

Neuromuscular blocker

Both given as iv pushes with large saline flush


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Induction Agents

The Ideal agent would quickly render patientsunconsciousness, and amnesic and maintain stablecerebral perfusion, cardiovascular stability and be

reversible with no side effects

Does NOT exist !!

Different agents have advantages and disadvantages

We try to use them to suit our clinical needs


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ETOMIDATE 0.3 mg/kg

Primary choice as induction agent in emergency RSI

Rapid onset, hemodynamic stability, positive CNS results

and rapid recovery

No contraindications

(widely used overseas !!!)

Attenuates elevated ICP by decreasing cerebral

blood flow and metabolic oxygen demand

Second only to ketamine regarding haemodynamic

stability of induction agents

Half-dose for haemodynamic instability (shock)


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PROPOFOL 1-2 mg/kg

A highly lipid soluble and highly potent intravenous

sedative hypnotic agent

Does cause significant hypotension

Contraindication

- Elderly patients ( reduce dose to 0.5 mg/kg )

- Hypovolaemic patients ( preload with fluids )

Onset of action = 30 seconds from start administration

Duration of action = 3 to 5 minutes


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MIDAZOLAM 0.05 0.1 mg/kg

A short acting benzodiazepine sedative hypnotic agent

NOT IDEAL BUT SAFE

- Risk of Awareness !

Effects can be reversed by Flumazenil (Annexate)

Onset of action = 2 MINUTES from start administration

Duration of action = 15 - 45 minutes


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KETAMINE 1.0 1.5 mg/kg

Phencyclidine (PCP) derivative

Does cause catecholamine release

Contraindication

- Closed head injury (elevated ICP)

- Ischaemic heart disease

May cause increase in upper airway secretions

Onset of action = 45 60 seconds

Duration of action = 20 30 minutes


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Induction Agents for Specific

Conditions

Reactive airways disease

Ketamine, Propofol, Midazolam

Increased intracranial pressure

- Propofol, Midazolam, ketamine, Thiopentone

Hypotensive patient

Ketamine, Midazolam


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NEUROMUSCULAR

BLOCKING AGENTS

Depolarizing

Suxamethonium

Non-depolarizing

Rocuronium

Vecuronium


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Suxamethonium

NMBA best suited for RSI in emergency

due to its rapid onset and quick recovery time

Contraindications

Personal or family history of malignant

hyperthermia

Significant, verified, hyperkalemia is an

absolute contraindication

End-stage renal disease / dialysis dependent

patients with unknown potassium level


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SUX Related Hyperkalemia

Receptor Up regulation

Burns, crush injury, spinal cord injury > 72hrs

UMN lesions, including stroke

MS, ALS, other denervation states

Prolonged ICU care

Myopathic Processes

Muscular dystrophy

Rare idiopathic

Mortality11%

Mortality30%


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SUXAMETHONIUM

Dosage

Adult = 1.5 mg/kg

Paediatric = 2.0 mg/kg

Neonatal = 3.0 mg/kg

Onset of action = 45 60 seconds

Duration of action = 7 10 minutes


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Non depolarising Agents

Rocuronium = 1 mg/kg ( INTUBATING DOSE )

Onset of action: 55 70 sec

Duration: 30 60 min

- Full recovery 1 2 hrs

Vecuronium = 0.1 mg/kg 0.15 mg/kg

Onset of action = 90 120 sec

Duration: 60 75 min

- Full recovery 1.5 2hrs


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Time Zero + 30 seconds

5:Positioning


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Time Zero + 45 seconds

6: Placement and Proof

Check mandible for flaccidity + end of fasciculation

Intubate, remove stylet / bougie and hold ETT

Confirm tube placement

Direct visualisation

ETCO2/ capnography

Bilateral breath sounds

Absent epigastric sounds


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Failed Attempt = oxygenate

1st step = can I bag/mask ventilate this patient ?

Think about the six attributes:

Operator

Optimum patient position

BURP

Paralysis

Length of blade

Type of blade

Rescue Manoeuvres

The first rescue from failed intubation is bagging

The first rescue from failed bagging is better bagging


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Zero + 90 seconds

7: Post-intubation Management

Secure tube / bite block

Monitor ETCO2 continuously

Arrange Chest x-ray

Start long acting sedation (+/- paralysis) 60mg morphine + 30mg midazolam up to 60mls in saline at 10ml/hr intermittent boluses of vecuronium (5mg) approx every 30 minutes

Establish ventilator parameters- tidal volume 7- 8 ml/kg at RR 12


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Rapid Sequence Intubation

Summary

Preparation (10 mins - zero)

Pre oxygenation (5 mins - zero)

Pre treatment (3 mins - zero)

Paralysis with induction (time zero)

Positioning (zero + 30 sec)

Placement (zero + 45 sec)

Post-tube management (zero + 90 sec)


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FASTRACH Intubating LMA


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VIDEO ??

http://www.youtube.com/watch?v=UA1wWm

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