AIRWAY 1: RAPID SEQUENCE INTUBATION Stuart Swadron, MD, FRCPC, FACEP Program Director

1. AIRWAY 1: RAPID SEQUENCE INTUBATION Stuart Swadron, MD, FRCPC, FACEP Program Director Residency in Emergency Medicine Keck-USC School of Medicine LAC+USC Dept. of Emergency Medicine July 19, 2007

2. DEFINITIONS Rapid Sequence Intubation INDUCTION AGENT PARALYTIC UNCONSCIOUSNESS MOTOR PARALYSIS

3. DEFINITIONS Pharmacologically Assisted Intubation INDUCTION AGENT UNCONSCIOUSNESS

4. DEFINITIONS Geneva Convention Violation • PARALYTIC • MOTOR PARALYSIS

5. RATIONALE – Principle Decreased aspiration Increased success

6. RATIONALE - Secondary Better C-spine control

7. RATIONALE - Secondary Blunting ↑ICP / IOP

8. RATIONALE - Secondary Avoid airway trauma

9. RATIONALE - Secondary Avoid airway trauma

10. ↓ Pain ↓ Discomfort ↓ Recall

11. HAZARDS Prolonged intubation

12. HAZARDS Adverse Drug Events

13. HAZARDS May force crash airway scenario

14. INDICATIONS Failure OR Imminent failure of : 1. oxygenation 2. ventilation 3. airway protection or maintenance

15. CONTRAINDICATIONS RISK INDICATION

17. RSI CAN ALSO BE… UNNECESSARY - OR – INAPPROPRIATE

18. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds

19. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds

20. PREPARATIONt – 10 minutes 1. EQUIPMENT PRESENT AND WORKING MUST INCLUDE EQUIPMENT FOR PLAN “B”

21. PREPARATIONt – 10 minutes 2. ASK: CAN I… BAG THE PATIENT TUBE THE PATIENT CRIC THE PATIENT

22. CAN I TUBE THIS PATIENT? L ook at general anatomyE valuate the 3-3-2 ruleM allampati scoreO bstructionN eck mobility

23. CAN I BAG THIS PATIENT? Maybe. Maybe Not.

24. CAN I CRIC* THIS PATIENT? * may include alternative airway techniques

27. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds

28. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds

29. PREOXYGENATIONt – 5 minutes 1. “PRIMUM NO BAGER!” (First, do not bag!) 2. If you do need to bag, Remember TOM

30. NITROGEN WASH-OUTOXYGEN WASH-IN pO2 TISSUES pO2 LUNGS pO2 BLOOD

31. NITROGEN WASH-OUTOXYGEN WASH-IN pO2 TISSUES pO2 LUNGS pO2 BLOOD

32. NITROGEN WASH-OUTOXYGEN WASH-IN pO2 TISSUES pO2 LUNGS pO2 BLOOD

33. NITROGEN WASH-OUTOXYGEN WASH-IN pO2 TISSUES pO2 LUNGS pO2 BLOOD

34. NITROGEN WASH-OUTOXYGEN WASH-IN pO2 TISSUES pO2 LUNGS pO2 BLOOD

35. PREOXYGENATIONt – 5 minutes 1. Well-fitting mask • 8 vital capacity breaths Nimmagadda et al. Anesthesiology 93 (3): 693-698, 2000 Baraka et al. Anesthesiology 91 (3): 612, 1999

36. PREOXYGENATIONt – 5 minutes Ill adult Normal child Normal adult Obese adult

37. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds

38. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds

39. PRETREATMENTt – 3 minutes L Lidocaine O Opioids A Atropine D Defasciculating Medication

40. PRETREATMENTt – 3 minutes “LOAD” may just be a LOAD

41. LIDOCAINE Traditional Indications Tight Brains “There is currently no evidence to support the use of intravenous lidocaine as a pretreatment for RSI in patients with head injury and its use should only occur in clinical trials” Robinson N, Clancy, M. Emergency Medicine Journal 18(6):453-7, 2001 Tight Lungs “…no study has demonstrated a protective effect of [both intravenous and topical anesthetic agents] in preventing bronchospasm after intubation..” Maslow et al. Anesthesiology, 93(5): 1198-1204, 2000

42. OPIOIDS (Fentanyl) Traditional Indications 1. Blunt hemodynamic response 2. Decrease pain Adachi et al. Anesthesia & Analgesia. 95(1):233-7, 2002

43. FENTANYL DOSE Dose = 3µg/kg* IV slow push *Beware of hypotension and apnea

44. ATROPINE Standard practice Give atropine to: 1. all children less than 8 years old 2. prior to second dose of succinylcholine Dose = 0.01-0.02 mg/kg IVP Evidence is mounting that questions routine use of atropine Fastle et al. Pediatr Emerg Care;20(10):651-5, 2004 McAuliffe et al. Can J Anaesth; 43(7) 754-5,1996 Fleming et al. CJEM. 2005;7(2):114-7

45. DEFASCICULATING DOSEOne tenth the RSI dose Traditional Indications • Blunt rise in ICP 2. Decrease risk of aspiration • Prevent muscular pain Questionable value “no definitive evidence that SCh caused a rise in ICP” “no studies that investigated the issue of pretreatment with defasciculating doses and their effect on ICP” Clancy et al. Emergency Medicine Journal. 18(5):373-5, 2001

46. And what’s more…DEFASCICULATING DOSEcan be downright dangerous* * it may cause premature apnea

47. PRETREATMENTt – 3 minutes If you’re going to give these drugs: …at least give them some time to circulate (3 minutes)

48. Summary of LOADPRETREATMENT L idocaine  optional O piates  optional A tropine  still mandatory for kids < 8 D efasciculating optional dose

49. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds

50. THE 7 P’s OF RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t + 90 seconds