Rsi rapid sequence intubation what when where why how
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RSI: Rapid Sequence Intubation What, When, Where, Why & How. Michael T. Czarnecki, MD. 265. Objective. What is RSI? Discuss the “7 P’s” of RSI Review RSI pharmacologic agents Highlight current controversies with RSI. RSI Defined.

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RSI: Rapid Sequence Intubation What, When, Where, Why & How

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Rsi rapid sequence intubation what when where why how

RSI: Rapid Sequence IntubationWhat, When, Where, Why & How

Michael T. Czarnecki, MD

265


Objective

Objective

  • What is RSI?

  • Discuss the “7 P’s” of RSI

  • Review RSI pharmacologic agents

  • Highlight current controversies with RSI


Rsi defined

RSI Defined

“Virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation”


Why bother with rsi

Why Bother with RSI?

  • Rapid airway control

  • Less risk of aspiration

  • Highest success rates/lowest complications

    • More controlled

  • Optimal intubating conditions


What are the problems inherent to intubation

What are The Problems Inherent to Intubation?

  • Laryngoscopy and Intubation

    • Increased bronchospasm

    • Increased ICP

    • Increased catecholamine release


Beneficial effects of rsi

Beneficial Effects of RSI

  • “Tight Heads”

    • Intracranial pathology

  • “Tight Hearts” or “Tight Vessels”

    • Cardiovascular disease

  • “Tight Lungs”

    • Reactive airway disease


Assumptions in airway management

Assumptions in Airway Management

  • Pt. has a full stomach

  • Pt. is preoxygenated

  • Pts. do not receive BVM ventilation unless necessary to keep O2 sat. over 90%

  • Sellick’s maneuver always used


Rsi 7 p s

RSI: “7 P’s”

  • P = Preparation

  • P = Preoxygenation

  • P = Pretreatment

  • P = Paralysis with induction

  • P = Protection

  • P = Placement of the tube

  • P = Post-Intubation management


Rsi timeline

RSI: Timeline

T – 10 minutesPrepare

T – 5 minutesPreoxygenate

T – 3 minutesPretreat

T = 0Paralysis with induction

T + 30 secondsProtection

T + 45 secondsPlacement

T + 90 secondsPost-Intubation management


Preparation t 10 minutes

Preparation: T – 10 minutes

  • Prepare the patient

    • Monitoring/access

    • Positioning

    • Assess for difficult airway

      • “4 D’s”,“LEMON”, “BONES”, “SHORT”

      • Mallampati

  • Prepare your equipment

  • Prepare yourself (mental checklist)

  • Prepare your personnel


Difficult airway assessment

Difficult Airway Assessment

  • 4 D’s

    • Distortion, Disproportion, Dysmobility, Dentition

  • BONES

    • Beard, Obese, No teeth, Elderly, Snores (sleep apnea)

  • SHORT

    • Surgery (head/neck/jaw), Hematoma, Obese, Radiation, Tumor

  • LEMON

  • MALLAMPATI

  • Always have a “Rescue Airway” technique ready

JUMP AHEAD


Mallampati score

MALLAMPATI SCORE

Class I Class II Class III Class IV

JUMP BACK


60 second exam lemon

60-SECOND EXAM “LEMON”

  • Look for external difficulty

  • Evaluate using 3=3=2 rule

  • Mallampati (Class I & II)

  • Obstruction

  • Neck Mobility

  • 3 fingers fit in mouth

  • 3 fingers fit from mentum

    to hyoid cartilage

  • 2 fingers fit from mandible

    to top of thyroid cartilage

JUMP BACK


Rescue airways

Rescue Airways

  • Gum Elastic Bougie (GEB)

  • Laryngeal Mask Airway (LMA/ILMA)

  • Combitube

  • Surgical Cricothyrotomy

JUMP BACK


Preoxygenate t 5 minutes

Preoxygenate: T – 5 minutes

  • Provides reservoir of oxygen during apnea

  • If pt. spont. breathing – then NRB for 5’

    • Provides maximum of 70% FiO2

  • Avoid bagging the spont. breathing patient

    • If needed, use sellick & airway adjunct

    • 8 effective Vital Capacity breaths provides best preoxygenation


Pretreat t 3 minutes

Pretreat: T – 3 minutes

  • L - Lidocaine

  • O - Opiates

  • A - Atropine

  • D – Defasiculating Agent


Lidocaine 1 5 mg kg

Lidocaine (1.5 mg/kg)

  • Consider in “Tight Head” or “Tight Lungs”

    • Blunts ICP rise (??)

    • Suppress cough response

      • may blunt bronchospasm

      • may blunt sympathetic response

  • Does Lido help in head trauma?

    • No clinical trials have answered question

    • Not proven to change outcome

    • Little downside in using

Robinson, Emeg Med J 2001; 18:453


Opioids

Opioids

  • Fentanyl (3 mcg/kg slow IV over 3’)

    • Consider in “Tight Heads”, “Tight Heart”, & “Tight Vessels”

    • Beware: cautious use in pt’s dependent on sympathetic drive (aka, trauma)


Atropine

Atropine

  • Only needed in:

    • Children under 10 y.o.

    • Adults receiving 2nd dose of succinylcholine

  • 0.01 mg/kg IV push

    • Minumum dose: 0.1 mg


Defasiculating agent

Defasiculating Agent

  • Use any paralytic at 10% paralyzing dose

  • Consider in “Tight Heads”

  • Beware: may cause hypoventilation and frank paralysis – be prepared

  • Who needs defasiculation?

    • Helps mitigate ICP rise with succinylcholine

    • Not really useful in any other ICU situation


Paralysis with induction t 0

Paralysis with Induction: T = 0

  • Tailor inducing agent to specific needs

    • Barbituates

    • Etomidate

    • Midazolam

    • Ketamine

    • Propofol

JUMP AHEAD


Barbituates

Barbituates

  • Decreases GABA dissociation at receptor

  • Rapid onset sedation

  • Decreases ICP

  • Hypotension (especially in hypovolemia)

  • Choices:

    • Thiopental, pentobarbital, methohexital

      Overall – Etomidate is better that Barbs

JUMP BACK


Thiopental

Thiopental

  • Onset 15 seconds, duration 3-5 minutes

  • Cardiac depressant, venodilator

    • Hypotension

  • Dose depedent on pt. profile

    • Euvolemic adult (3-5 mg/kg IV)

    • Hypovolemic adult (1-3 mg/kg IV)

JUMP BACK


Etomidate

Etomidate

  • Nonnarcotic, nonbarbituate, nonanalgesic

  • Minimal cardio effects, lowers ICP

  • Is it the ideal agent for RSI?

    • May cause critical adrenal suppression

      • Inhibits adrenal mitochondrial hydroxylase activity

      • Occurs after both single bolus and infusions

      • Infusions incr. ICU death rate & incr. infections

    • Clinical significance is unclear

      • Randomized, controlled trials on outcomes needed

Malerba, et al: Intensive Care Med 2005


Etomidate con t

Etomidate (con’t)

  • Induction dose: 0.2 – 0.3 mg/kg IV

  • Onset: 20 – 30 seconds

  • Duration: 7 – 15 minutes

  • May cause myoclonic jerking, hiccups, injection pain, N/V (also on emergence)

  • Risk for adrenal insufficiency incr. 12-fold

Jackson, Chest 2005 MarMurray, Chest 2005 Mar; 127:707-709

JUMP BACK


Midazolam

Midazolam

  • Nonanalgesic sedative, anxiolytic, amnestic

  • Respiratory depressant and hypotension

    • Give slow IV

    • Give ½ the dose in elderly or COPD

  • Rapid onset (< 1 minute)

  • Induction dose (0.1 - 0.3 mg/kg) DIFFERENTthan sedation dose (0.01 – 0.03 mg/kg)

    • In RSI, 92% of adults are underdosed

Sagarin, et al: Acad Emerg Med 2003 Apr; 10:329-38

JUMP BACK


Ketamine 1 2 mg kg

Ketamine (1 – 2 mg/kg)

  • Dissociative, analgesic, amnestic

  • Causes catecholamine release

    • Incr. BP, HR, ICP, Laryngospasm risk

  • Bronchodilator →induction agent in asthma

  • Onset: 15 – 30 seconds

  • Duration: 10 – 15 minutes

JUMP BACK


Propofol 0 5 1 2 mg kg white magic milk of amnesia

Propofol(0.5 – 1.2 mg/kg)(white magic, milk of amnesia)

  • Sedative-hypnotic

  • Cardiac depressant, venodilator

    • Hypotension

    • Decr. ICP at expense of CPP

JUMP BACK


Nmbs neuromuscular blocking agents

NMBs: Neuromuscular Blocking Agents

  • Depolarizing

    • Succinylcholine

  • Non-Depolarizing

    • Pan/Vec/Atra/Rocuronium

  • Potential Problems

    • Inadequate pre-intubation neuro exam

    • Failure to sedate

    • Inadequate pre-treatment or inadequate dosing

    • Aspiration and Dysrhythmias

    • Failed intubation → surgical airway needed


Succinylcholine 1 5 2 0 mg kg

Succinylcholine(1.5 – 2.0 mg/kg)

  • Onset: 15 – 30 sec; Duration: 5 – 12 min

  • Contraindications:

    • FHx malignant hyperthermia, burns, crush injuries, progressing neuromuscular disease

  • Side Effects:

    • Brady, hyper-K+, fasciculations, MH

      • ↓HR: pretreat all kids; adults 2nd dose with atropine

      • ↑K+: peaks in 5’, resolves in 15’

        • Treat like any hyperkalemia case

  • Use actual-body weight for dose

Rose, et al: Anesth Analg 2000


Non depolarizing nmbs

Non-depolarizing NMBs

  • Longer duration than SUX, onset about equal

  • Aminosteroid compounds

    • Pan/Vec/Rocuronium

  • Benzylisoquinolinum compounds

    • Atracuronium


Rocuronium

Rocuronium

  • Is it equivalent to SUX?

    • Meta-analysis 1600 pts → equivalent in:

      • Acceptable conditions for intubation

      • Rates of intubation success

        • But SUX is BEST at creating EXCELLENT conditions

Perry, AEM 2002


Rsi timeline1

RSI: Timeline

T – 10 minutesPrepare

T – 5 minutesPreoxygenate

T – 3 minutesPretreat

T = 0Paralysis with induction

T + 30 secondsProtection

T + 45 secondsPlacement

T + 90 secondsPost-Intubation management


Rsi rapid sequence intubation what when where why how

  • Align the 3 axes – critical for success

  • Sellick’s maneuver


Rsi rapid sequence intubation what when where why how

  • Confirm placement/review CXR

  • Secure tube

  • Vent Settings

  • Administer sedation

  • Maintain paralysis if indicated

    And…..


Don t ever forget the 7 ps

Don’t Ever Forget the “7 Ps”

  • P = Preparation

  • P = Preoxygenation

  • P = Pretreatment

  • P = Paralysis with induction

  • P = Protection

  • P = Placement of the tube

  • P = Post-Intubation management


Rsi rapid sequence intubation what when where why how

WHEN IN DOUBT, PULL IT OUT!


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