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Rapid Sequence Intubation. Otto Sabando DO FACOEP Program Director Emergency Medicine Residency St. Joseph’s Regional Medical Center Paterson NJ. Objectives. Overview of Rapid sequence induction (RSI) RSI Procedure Pretreatment agents Induction agents Paralytic medications

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rapid sequence intubation

Rapid Sequence Intubation

Otto Sabando DO FACOEP

Program Director

Emergency Medicine Residency

St. Joseph’s Regional Medical Center

Paterson NJ

  • Overview of Rapid sequence induction (RSI)
  • RSI Procedure
  • Pretreatment agents
  • Induction agents
  • Paralytic medications
  • Case studies: “Pitfalls”
  • Questions
overview of rsi
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
overview of rsi1
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
overview of rsi2
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
overview of rsi3
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
overview of rsi4
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%
overview of rsi5
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
overview of rsi6
Overview of RSI
  • Further prospective evaluations
    • Prehospital physiology
    • Notation of preexisting aspiration
    • Better prospective studies!
rsi procedure
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,
rsi procedure1
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
rsi procedure2
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
rsi procedure3
RSI Procedure
  • Principal contraindication:
    • Any condition preventing mask ventilation or intubation
pretreatment agents
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
pretreatment agents1
Pretreatment agents
  • To be effective, pretreatment agents should be given 3-5min prior to RSI
    • Not practical at times
pretreatment agents2
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
induction agents
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
induction agents1
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
induction agents2
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)
induction agents3
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
induction agents4
Induction agents
  • Side effects
    • Direct myocardial depression leading to hypotension especially in the elderly
induction agents5
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
induction agents6
Induction agents
  • Side effects:
    • Chest wall rigidity (>15µg/kg IV)
    • ICP variable
    • Respiratory depression (seen with other sedatives)
induction agents7
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
induction agents8
Induction agents
  • Side effects
    • Myocardial depression leading to hypotension (MAP decrease by 40mm/hg)
    • Decreased respiratory drive
    • Lanrygospasm
paralytic medications
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
paralytic medications1
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
paralytic medications2

Major burns

Muscle trauma

Crush injuries



Narrow angle glaucoma

Renal failure

Neurologic disorder

Spinal cord injury

Guillian-Barre Syndrome

Children with undiagnosed myopathies?

Paralytic Medications
paralytic medications3
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.
paralytic medications4
Paralytic Medications
  • Competitive agents that block the effects of acetylcholine at the neuromuscular junction
    • Rocuronium is the alternative medication when succinylcholine is contraindicated
paralytic medications5
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
paralytic medications6
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
case 1
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
case 2
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
case 3
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
  • 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
  • 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
  • Propofol
  • barbiturate

1.5 mg/kg

Suppresses cough

Suppress ICP?

Decrease pressor response secondary to intubation?

Use with paralytics?