Rapid Sequence Intubation - PowerPoint PPT Presentation

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

• 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

• 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

• 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

• 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

• 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%

• 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

• Further prospective evaluations
• Prehospital physiology
• Notation of preexisting aspiration
• Better prospective studies!

• 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,

• 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

• 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

• Principal contraindication:
• Any condition preventing mask ventilation or intubation

• 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

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

• 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

• 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

• 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

• 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)

• 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

• Side effects
• Direct myocardial depression leading to hypotension especially in the elderly

• 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

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

• 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

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

• 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

• 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

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?

• 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.

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

• 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

• 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

• 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

• 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

• 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?