1. Rapid Sequence Intubation Otto Sabando DO FACOEP Program Director Emergency Medicine Residency St. Joseph’s Regional Medical Center Paterson NJ

2. Objectives • Overview of Rapid sequence induction (RSI) • RSI Procedure • Pretreatment agents • Induction agents • Paralytic medications • Case studies: “Pitfalls” • Questions

3. Overview of RSI • 1979, Taryle and colleagues reported complications in 24 of 43 patients needing an emergent airway • Improvement of house officer training • More liberal use of procedures used in the OR

4. Overview of RSI • Objectives: • Immediate airway control necessitating induction of anesthesia and muscle relaxation • Provision of anesthesia and sedation to the awake patient • Minimization of intubation adverse effects, including systemic and intracranial hypertension

5. Overview of RSI • Prehospital? • In non-cardiac arrest patients, overall RSI success rate 92%-98%. Comparable to ED settings • Without a full compliment of medications, success rate are ~60% as in ED settings • i.e.: Patient combative, intact gag reflex, preexisting muscle tone

6. Overview of RSI • Impact of prehospital intubations on outcome….Controversial! • Gausche and Colleagues • Comparison bag-mask ventilation and endotracheal intubation for critically ill and injured pediatric patients • 820 subjects, no paralytics and sedation used • 57% intubation success rate • Similar outcomes for both study groups

7. Overview of RSI • Winchell and Hoyt • Retrospective review of 1092 blunt trauma patients with GCS score of less than 9 • Prehospital intubation reduced mortality from 36% to 26% (impact on most severely injured) • Endotracheal intubation without medications had success rate of 66%

8. Overview of RSI • Bochicchio and colleagues • Compared brain injured patient outcomes in patients with and without prehospital RSI • Pre-hospital RSI • Higher mortality rate and more ventilator days • Equivalence of the patient groups upon paramedic arrival is unknown • Study suggest that prehospital RSI and intubation may adversely affect outcomes

9. Overview of RSI • Further prospective evaluations • Prehospital physiology • Notation of preexisting aspiration • Better prospective studies!

10. RSI Procedure • Preoxygenate with 100% NRB if the patient is spontaneously breathing • No positive pressure ventilations • Intravenous line: Preferably 2 lines 20 gauge or larger in adults • Cardiac monitor, pulse oximetry, and Capnography • Prepare equipment: suction, difficult airway cart,

11. RSI Procedure • Explain the procedure: Document neurologic status • Sedative agent • Defasciculating agent, lidocaine, and or atropine • Perform Sellick maneuver • Neuromuscular agent • Intubate trachea and release Sellick maneuver • Confirm placement

12. RSI Procedure • Sample Rapid Sequence Intubation Using Etomidate and Succinylcholine: Timed Step • Zero minus 10 min Preparation • Zero minus 5 min Preoxygenation 100% oxygen for 3 min or eight vital capacity breaths • Zero minus 3 min Pretreatment  as indicated "LOAD“ • Zero Paralysis with induction   Etomidate, 0.3 mg/kg   Succinylcholine, 1.5 mg/kg • Zero plus 45 sec Placement   Sellick's maneuver   Laryngoscopy and intubation   End-tidal carbon dioxide confirmation • Zero plus 2 min Post-intubation management   Midazolam 0.1 mg/kg, plus   Pancuronium, 0.1 mg/kg, or   Vecuronium, 0.1 mg/kg

14. RSI Procedure • Principal contraindication: • Any condition preventing mask ventilation or intubation

15. Pretreatment agents • Goal: Attenuate pathophysiologic responses to Laryngoscopy and intubation • Reflex sympathetic response • Increase in heart rate and blood pressure • Children: vagal response predominates • Bradycardia • Laryngeal stimulation • Lanrygospasm, cough, and bronchospasm

16. Pretreatment agents • To be effective, pretreatment agents should be given 3-5min prior to RSI • Not practical at times

17. Pretreatment agents • Pretreatment Agents for Rapid Sequence Intubation (LOAD) • Lidocaine: in a dose of 1.5 mg/kg, used to mitigate bronchospasm in patients with reactive airways disease and to attenuate ICP response to Laryngoscopy and intubation in patients with elevated ICP • Opioid: Fentanyl, in a dose of 3 μg/kg, attenuates the sympathetic response to Laryngoscopy and intubation and should be used in patients with ischemic coronary disease, intracranial hemorrhage, elevated ICP, or aortic dissection • Atropine: 0.02 mg/kg is given to prevent bradycardia in children ≤ 10 years old who are receiving succinylcholine for intubation • Defasciculation: a Defasciculating dose (1/10 of the paralyzing dose) of a competitive neuromuscular blocker is given to patients with elevated ICP who will be receiving succinylcholine to mitigate succinylcholine-induced elevation of ICP

19. Induction agents • Ketamine: 1-2mg/kg, onset 1min, duration 5 min • Phencyclidine derivative • Potent bronchodilator • Status asthmaticus • Hypertension, increased ICP • Increase secretions • Atropine to offset • Emergence phenomenon • Contraindications • Elderly “Cautious” • Head injury (ICP increase), increase IOP

20. Induction agents • Etomidate: 0.3mg/kg.Onset <1min, duration 10-20min. • Non-barbiturate, non-receptor hypnotic • Water and lipid soluble and reaches the brain quickly • Sedation comparable to barbiturates • Acts on CNS to stimulate ∂-aminobutyric acid receptors and depress the RAS • No analgesic activity

21. Induction agents • Decreases cerebral oxygen consumption, cerebral blood flow and ICP • Best used in patients with head injury and hypovolemia • Side effects • Nausea, vomiting, myoclonus • Inhibition of adrenal cortical function (not really seen with one dose induction)

22. Induction agents • Propofol : 0.5-1.5mg/kg IV onset 20-40 seconds, duration 8-15 minutes • Highly lipophylic • Alkylphenol sedative-hypnotic • Has amnestic effect but no analgesic effects • Dose dependant depression of consciousness ranging from light sedation to coma • Lowers intracranial pressure • Anti seizure effects

23. Induction agents • Side effects • Direct myocardial depression leading to hypotension especially in the elderly

24. Induction agents • Opioids • Not first line selections • Fentanyl: 3-10µg/kg IV. Onset 1-2min, duration 20-30min • Highly lipophylic, rapid serum clearance, high potency, and minimal histamine release • 50-100 times more patent than morphine • Best used for hypotensive patients in pain

25. Induction agents • Side effects: • Chest wall rigidity (>15µg/kg IV) • ICP variable • Respiratory depression (seen with other sedatives)

26. Induction agents • Barbiturates: • Thiopental: 3-5mg/kg IV. Onset 30-60sec. Duration 10-30 minutes • Methohexital (brevital): 1mg/kg IV. Onset <1min. Duration 5-7 min. • CNS depressant that leads to deep sedation and coma • Best indication is for status epilepticus, ICP related to trauma or HTN emergency

27. Induction agents • Side effects • Myocardial depression leading to hypotension (MAP decrease by 40mm/hg) • Decreased respiratory drive • Lanrygospasm

29. Paralytic Medications • Depolarizing agents • Succinylcholine: 1-1.5mg/kg. Onset 45-60sec, duration 5-9 min. • Most commonly used agent for paralysis • Chemical structure similar to acetylcholine • Depolarize postjuctional neuromuscular membrane • Rapidly hydrolyzed by pseudocholiesterase

30. Paralytic Medications • Complications: • Bradyarrythmias • Masseter spasm • ICP?, IOP, increase intragastric pressure • Malignant hyperthermia • Tx: Dantrolene • Hyperkalemia • Increase 0.5mEq/ml • Histamine release • Fasciculation induced musculoskeletal trauma • Prevent by using defisciulating dose of nondepolorizing agent (10% of normal dose) • Prolonged apnea with pseudocholinesterase deficiency

31. Contraindications: Major burns Muscle trauma Crush injuries Myopathies Rhabdomyolysis Narrow angle glaucoma Renal failure Neurologic disorder Spinal cord injury Guillian-Barre Syndrome Children with undiagnosed myopathies? Paralytic Medications

32. Paralytic Medications • Nondepolorizing agents: • Vecuronium 0.08 mg/kg-0.15mg/kg, 0.15-0.28mg/kg. Onset 2-4min, duration 25-120min • Rocuronium 0.6mg/kg. Onset 1-3min. Duration 30-45 min • Atracurium 0.4-0.5mg/kg. Onset 2-3min. Duration 25-45 min. • Pancuronium 0.1mg/kg. Onset 2-5min. Duration 40-60 min.

33. Paralytic Medications • Competitive agents that block the effects of acetylcholine at the neuromuscular junction • Rocuronium is the alternative medication when succinylcholine is contraindicated

34. Paralytic Medications • Reversal agents: • Mostly in OR anesthetized patients, rarely used in the ED setting • Neostigmine 0.02mg-0.04mg slow IVP • Additional doses of 0.01 to 0.02 mg/kg slow IVP can be given if reversal is incomplete • Total dose not to exceed 5mg in an adult • Give atropine 0.01mg/kg to block cholinergic effects of Neostigmine • Max adult dose 1mg • Minimum pediatric dose 0.1mg

35. Paralytic Medications • Complications • Vecuronium • Prolonged recovery time in elderly and obese patients or hepatorenal dysfunction • Rocuronium • Tachycardia • Atracurium • Hypotension, histamine release, bronchospasm • Pancuronium • Hypertension, tachycardia, histamine release

36. Cases

37. Case 1 • A 24 y.o. male with a medical history of asthma is short of breath secondary to his asthma. You note that the patient is hypoxic and getting tired. • Which RSI Medications for sedation would be best for this case? • Answer

38. Case 2 • A patient is hit in the head by a bat. His GCS is 8. You decide to RSI this patient as he is combative and altered. Which medications would be best in this situation? • Sedative • Paralytic • adjunct

39. Case 3 • A 45 y.o. male in respiratory distress with crush injuries to his legs needs to be intubated. Which of the following paralytics are indicated in this case? • Succinylcholine • Rocuronium • Vecuronium • Pancuronium

40. Questions

41. References • Yano M, et al: Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 64:651, 1986 • Kirkegaard-Nielsen H, et al: Rapid tracheal intubation with rocuronium. Anesthesiology 91:131, 1999 • Schneider RE, Caro D: Pretreatment agents. In Walls RM, et al (eds): Manual of Emergency Airway Management. Philadelphia, Lippincott Williams & Wilkins, 2004 • Gausche M. Lewis RJ, Stratton SJ et al. Effect of out of Hospital Pediatric Endotracheal Intubation on Survival and Neurologic Outcome: A controlled Clinical Trial. JAMA 283:783,2000 • Bochicchio GV, Ilahi O,Joshi M et al. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutly lethal traumatic brain injury. J Trauma 54:307, 2003 • Winchell RJ, Hoyt DB: Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 132:592, 1997

42. References • Roberts and Hedges. Clinical Procedures in Emergency Medicine. Edition 4. Saunders, 2004 • Tintnalli J et al. Emergency Medicien: A comprehensive study guide. Edition 6. McGraw Hill, 2004 • Rosen’s Emergency Medicine: Concept in Clinical Practice. Edition 6. Elsevier, 2006

44. Etomidate • Propofol • barbiturate

45. Lidocaine 1.5 mg/kg Suppresses cough Suppress ICP? Decrease pressor response secondary to intubation? Use with paralytics?