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Rapid Sequence Intubation. Anthony G. Hillier, D.O. EM Resident St. John West Shore . Rapid Sequence Intubation.

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rapid sequence intubation

Rapid Sequence Intubation

Anthony G. Hillier, D.O.

EM Resident

St. John West Shore

rapid sequence intubation2
Rapid Sequence Intubation
  • The induction of a state of unconsciousness with complete neuromuscular paralysis to achieve intubation without interposed mechanical ventilation in efforts to facilitate the procedure and minimize risks of gastric aspiration
rapid sequence intubation indications
Rapid Sequence IntubationIndications
  • Failure of airway maintenance/protection

- lost or diminished gag reflex

  • Failure of oxygenation/ventilation

- pulmonary edema, COPD

  • Anticipated clinical course

- multiple trauma, head injured

- intoxication, air transport

rapid sequence intubation 6 p s
Preparation: T-10”

Positioning

Preoxygenation: T-5”

Premedication: T-3”

Paralysis:T-0

Placement of tube: T+45

Post management: T+2”

Rapid Sequence Intubation“6 P’s”
preparation6
Preparation
  • Evaluate
    • LEMON
  • Equipment Check
  • Positioning
  • Drug Selection
  • IV’s, monitor, oximetry
  • Ancillary Staff
  • Anticipate alternative airway maneuver
preparation7
Preparation
  • LEMON
    • L-look
    • E-evaluate the 3-3-2 rule
    • M-Mallampati
    • O-Obstruction
    • N-Neck mobility
preoxygenation10
Preoxygenation
  • 100% O2 for 5 minutes of 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs
preoxygenation12
Preoxygenation
  • “nitrogen wash-out”
  • Avoid bagging the patient if adequately preoxygenated
premedication14
Premedication
  • Goal is to blunt the patient’s physiologic responses to intubation
  • Minimizes bradycardia, hypoxemia, cough/gag reflex, increases in intracranial, intraocular, and intragastric pressures
premedication15
Premedication
  • Lidocaine
  • Opioid
  • Atropine
  • Defasciculating doses “priming”
lidocaine
Lidocaine
  • Thought to blunt the rise in intracranial pressure associated with airway manipulation and the use of depolarizing neuromuscular blocking agents
  • 1.5-3.0 mg/kg (average 100mg) three minutes prior to intubation
atropine
Atropine
  • 0.02 mg/kg, minimum 0.1 mg IV, max 1 mg, three minutes prior to intubation
  • Can minimize vagal effects, bradycardia and secretions
  • Infants and children < 8 years may develop profound bradycardia during intubation
defasciculating doses
Defasciculating doses
  • Decreases muscle fasiculations caused by the depolarizing agents (succinylcholine)
  • Attenuates rise in intracranial pressure
  • Agents used are the non-depolarizing blocking agents (vecuronium, pancuronium etc.) usually 1/10 of standard dose
sedation
Sedation
  • Sedative agents administered at doses capable of producing unconsciousness with little or no cardiovascular effects
  • No ideal agent exists
  • Sedation should nearly always be used when paralyzing the patient
sedation20
Sedation
  • Barbiturates/hypnotics
  • Non-barbiturate
  • Neuroleptics
  • Opiates
  • Benzodiazepines
barbiturates hypnotics
Barbiturates/Hypnotics
  • Thiopental (Pentothal), Methohexital (Brevital)
  • Short onset (10-20) seconds, duration 5-10 minutes
  • May reduce intracranial pressure, cerebro-protective
  • Histamine release, hypotension, bronchospasm
barbiturates hypnotics22
Barbiturates/Hypnotics
  • Etomidate (Amidate) a nonbarbiturate hypnotic
  • Decreases ICP/IOP
  • Rapid onset, short duration
  • Minimal hemodynamic effects
  • No histamine release
  • Increases seizure threshold
etomidate
Etomidate
  • No malignant hyperthermia reported
  • Watch for myoclonus, vomiting
  • May decrease cortisol synthesis (adrenal insufficiency)
  • Dose 0.3 mg/kg IV
propofol
Propofol
  • Propofol (Diprivan), sedative hypnotic
  • Extremely rapid onset (10 sec), duration of 10-15 minutes
  • Decreases ICP
  • Can cause profound hypotension
  • Dose 1-3 mg/kg IV for induction
  • Dose: 100-200 mcg/kg/min for maintenance
ketamine
Ketamine
  • Ketamine-dissociative anesthetic
  • Rapid onset, short duration
  • Potent bronchodilator, useful in asthmatics
  • Increases ICP, IOP, IGP
  • Contraindicated in head injuries
  • Increases bronchial secretions
ketamine26
Ketamine
  • “Emergence” phenomenon can occur though rarely in children less than 10 years
  • Emergence reactions occur in up to 50% of adults
  • Dose: 1-2 mg/kg
fentanyl
Fentanyl
  • Fentanyl
  • Broad dose-response relationship
  • Can be reversed with naloxone
  • Fentanyl is rapid acting (<1 min), duration of 30 min
    • Does not release histamine
fentanyl29
Fentanyl
  • May decrease tachycardia and hypertension associated with intubation
  • Seizures and chest wall rigidity have been reported
  • Dose: 2-10 mcg/kg IV
morphine sulfate
Morphine Sulfate
  • Longer onset (3-5) minutes and duration (4-6) hours
  • May not blunt the rise in ICP, hypertension and tachycardia as well as fentanyl
  • Dose 0.1-0.2 mg/kg IV
  • Histamine release
benzodiazepines32
Benzodiazepines
  • Midazolam, Diazepam, Lorazepam
  • Provide excellent amnesia and sedation
  • Broad dose-response relationship
  • Reversed with Flumazenil (Romazicon)
  • Doses required are higher for RSI than for general sedation
midazolam
Midazolam
  • Slower onset (3-5) min than the barbiturate/hypnotic agents
  • Considered short-acting (30-60 min)
  • Does not increase ICP
  • Causes respiratory and cardiovascular depression
  • Dose: 0.1-0.4mg/kg IV
diazepam and lorazepam
Diazepam and Lorazepam
  • Moderate/long acting agents
  • Longer onset time than midazolam
  • May be more beneficial post-intubation for sedation
neuromuscular blocking agents
Neuromuscular Blocking Agents
  • Chemical paralysis facilitates intubation by allowing visualization of the vocal cords and optimizing intubating condition
  • Only CONTRAINDICATION is anticipated difficult airway
    • Mallampati Class
    • Thyromental Distance
depolarizing agents
Depolarizing Agents
  • Exert their affect by binding with acetylcholine receptors at the neuromuscular junction, causing sustained depolarization of the muscle cell
nondepolarizing
Nondepolarizing
  • Bind to acetylcholine receptors in a competitive, non-stimulatory manner, no receptor depolarization
  • Histamine release
  • Agents can be reversed with edrophonium or neostigmine
  • Caution with myasthenia gravis
slide41
Depolarizing agents
    • Succinylcholine (Anectine)
  • Nondepolarizing Agents
    • Pancuronium (Pavulon)
    • Vecuronium (Norcuron)
    • Atracurium (Tracrium)
    • Rocuronium (Zemuron)
    • Mivacurium (Mivacron)
succinylcholine
Succinylcholine
  • Stimulates nicotinic/muscarinic cholinergic receptors
  • Gold standard for 50 years
  • Onset 45 seconds, duration 8-10 minutes
  • Dose: (adults 1.5 mg/kg IV)
  • Children 2.0 mg/kg IV
  • Inactivated by pseudocholinesterase
succinylcholine cont
Succinylcholine cont
  • Prolonged paralysis seen with:
    • Pregnancy
    • Liver disease
    • Malignancies
    • Cytotoxic drugs
    • Certain antibiotics
    • Cholinesterase inhibitors
    • Organophosphate poisoning
succinylcholine44
Succinylcholine
  • Adverse reactions
    • Muscle fasiculations
    • Hyperkalemia
    • Bradycardia
    • Prolonged neuromuscular blockade
    • Trismus
    • Malignant hyperthermia
depolarizing agents45
Depolarizing Agents
  • Muscle fasiculations
    • Thought to increase ICP/IOP/IGP
    • Causes muscle pain
    • Minimized by “priming” dose of NMB
  • Hyperkalemia
    • Average increase in potassium of 0.5-1 mEq/L
    • Burns, crush injuries, spinal cord injuries, neuromuscular disorders, chronic renal failure
depolarizing agents46
Depolarizing agents
  • Bradycardia
    • Most common in children <10 years due to higher vagal tone
    • Also with repeated doses of succinylcholine
    • Premedicate with atropine
depolarizing agents47
Depolarizing Agents
  • Malignant hyperthermia
    • From excessive calcium influx through open channels
    • Genetic predisposition
    • Rapid temperature, rhabdomyolysis, muscle rigidity, DIC
    • 60% mortality
    • Treatment: IV Dantrolene
depolarizing agents48
Depolarizing Agents
  • Trismus (Masseter spasm)
    • Usually in children
    • Unknown cause
    • Treat with a nondepolarizing NMB
pancuronium
Pancuronium
  • Long-acting agent (45-90 min)
  • Slow onset (1-5 min)
  • Renal excretion
  • Vagolytic tachyarrythmias common
  • Dose: 0.10-0.15 mg/kg IV
vecuronium
Vecuronium
  • Duration of 30-60 min
  • Onset of 1-4 min
  • Hypotension may occur from loss of venous return and sympathetic blockade
  • Mostly biliary excretion
  • Dose 0.1 mg/kg
  • “priming dose” 0.01 mg/kg
rocuronium
Rocuronium
  • Has the shortest onset of the nondepolarizing agents (1-3 min)
  • Duration 30-45 min
  • Tachycardia can occur
  • Dose: 0.6-1.2 mg/kg
placement of tube
Placement of Tube
  • Allow medications to work and assure complete neuromuscular blockade of the patient
  • Maintain Sellick maneuver until cuff inflated
  • Ventilate with bag-valve mask if unsuccessful
  • Additional doses of sedatives/NMB may be necessary
  • Confirm tube placement
post intubation management
Post Intubation Management
  • Secure tube
  • Continuous pulse oximetry
  • Reassess vital signs frequently
  • Obtain chest x-ray, ABG
  • Restrain patient
  • Consider long term sedation
questions

Questions??

Thank You!