Rapid Sequence and delayed sequence intubation

1. Rapid Sequence and delayed sequence intubation Prepared by Shane Barclay MD

2. Overview • A review of intubation medications. • Discuss ‘Timing Principle’ for intubations. • Go through the steps of Rapid Sequence Intubation and Delayed Sequence Intubation.

3. Historical Perspective Historically rural doctors have done a variety of things for patients that needed respiratory support – ie intubation. • Bag and wait for the medivac. • Intubate using drugs and techniques that may now be out of date. • Use the same drugs and techniques that are used by full time urban emergency physicians today.

4. Two types of drugs • Induction drugs – Midazolam, Propofol, Ketamine. • Paralytics (Neuromuscular Blockage Agents – NBA) – Succinylcholine, Rocuronium.

5. Paralytics - NBA Succinylcholine. - Onset 5 – 10 seconds. - Duration of action 8 -15 minutes. Rocuronium. - Onset 30 seconds. (using 0.5 mg/kg), ~ 10 seconds (using 1.2 mg/kg) - Duration of action 45 – 60 minutes.

6. A great 8 minute talk by Dr. Reuben Strayer on Succinylcholine versus Rocuronium

8. Timing and Sequence of RSI medications

9. Timing of medications Historically the order and timing of RSI meds has been: - pre RSI meds (Fentanyl, lidocaine, atropine etc.) - Induction medication (Midazolam, Propofol, Ketamine etc) Wait for the patient to ‘go to sleep’. - Paralytic (Succinylcholine, Rocuronium) The timing between induction and paralytic has been debated.

10. Timing of medications “Timing Principle” This is an anesthetic term that involves giving a bolus of nondepolarizing muscle relaxant, followed by an induction drug at the ‘onset of weakness’ (ie ptosis)

11. Timing of medications “Timing Principle” The rationale behind it is that induction agents cause apnea. If you cause apnea and then give a paralytic and have to wait for its onset of action, the patient will be in a longer state of apnea with its concomitant potential risks.

12. Timing of medications “Timing Principle” The other argument has been that if you are using Rocuronium it has a longer onset of action.Therefore by giving Roc and waiting for ‘weakness’ you can then give a quick acting induction agent thereby shortening the apneic period.

13. Timing of medications “Timing Principle” The timing principle has only recently entered the emergency medicine literature relative to the anesthetic literature. Although timing principle has not been widely adopted, the more general consensus has been to give induction agent with paralytic at the same time or one after the other, followed by a saline flush.

14. Timing of medications However, Midazolam and Propofol cause apnea, but Ketamine does not. Second, if Rocuronium is given at the 0.6 mg/kg dose it does have a long time of onset. However if given at 1.2 mg/kg its onset is the same as Sux. So one option is to give Ketamine and Rocuronium (at 1.2 mg/kg) at the same time or one right after the other, followed by a saline flush. This seems to minimize the time of any apnea in the patient.

15. Timing of medications The ONE issue with giving both induction and paralytic close together or the same time, ensure you give an adequate induction dose! Nothing worse that paralyzing someone and trying to intubate them when they are still awake!

16. RSI versus DSI

17. Definitions Rapid sequence intubation (RSI) is an airway management technique that produces immediate unresponsiveness using induction agents and muscular relaxation (neuromuscular blocking agent) Delayed sequence intubation is a technique for patients requiringemergent airway management, but who are resistant to pre-intubation preparations because of altered mental status.

18. Rapid sequence intubation

19. Steps in RSI (30 of them!) 1. Oxygen. Pre-oxygenate with NRB/+/- OPA or OPA/BVM or LMA/BVM at 15 lpm x 4 minutes or HFNC 50-60 lpm 2. Positioning – sniffing position, ideally head up 30 degrees

20. A note on Pre-oxygenation Pre-oxygenation is not a theoretical construct. The 2 things that increase mortality and morbidity in intubations are hypotension and hypoxia. No intubation should be attempted until Oxygen saturations are at least up over 95% (ideally 100%) for several minutes. This requires all the skills under ‘supraglottic airway management’, including head position, OPAs, NRB mask, addition of nasal prongs, proper 2 handed BVM …

21. Pre-oxygenation The idea behind pre-oxygenation is to get the patient as close to 100% oxygen saturation as possible BEFORE intubation attempt. This will usually take a minimum of 3 - 4 minutes. If you are providing BVM, it must be done correctly.

22. Pre-oxygenation

23. Pre-oxygenation You want to be as high up and to the right on that dissociation curve as you can possibly be!

24. Pre-oxygenation So if the patient is fighting you and you can’t adequately oxygenate them, you want to do a ‘Delayed Sequence Intubation’. You don’t start intubation just when you have all your equipment and check lists done – you also need the patient to be oxygenated! This can involve partially sedating the patient so you can adequately oxygenate them.

25. Steps in RSI 1. Oxygen. Pre-oxygenate with NRB/+/- OPA or OPA/BVM or LMA/BVM at 15 lpm x 4 minutes or HFNC 50-60 lpm 2. Positioning – sniffing position, ideally head up 30 degrees 3. Decide on RSI meds below (16, 17, 18) – ask RN to draw up. 4. Have RN draw up post intubation vent sedation (Fentanyl or Morphine, etc) 5. Have someone get the ventilator, plug in and attach to wall Oxygen.

26. Steps in RSI 6. Designate someone to watch monitor. Announce if Sats < 93% or MAP < 65 mmHg. 7. Have someone (or yourself) draw up Push dose pressor of choice (Epi or Phenylephrine) 8. Check for dentures – in for bag mask, out for intubation. 9. Attach in line EtCO2 monitor to BVM 10. Check neck for potential cricothyrotomy, have kit available. 11. Have OPA, NPA and LMA available in proper size if not already in use.

27. Steps in RSI 12. Pick ET tube. Check balloon with 10 - 20 cc air, leave syringe attached. Place stylet or have bougie handy. 13. +/-‘Lube the tube’ – put small amount of sterile lube jelly on ETT tip 14. Choice of laryngoscope. Blade size. Check bulb working. Have spare laryngoscope handy. 15. Suction – turn on, place handle under right shoulder of patient or under pillow.

28. Steps in RSI Normotensive, neurologically stable patient: 16. Pretreatment agent? – Fentanyl 3 mcg/kg 17. Induction agents – Ketamine2mg/kg or Propofol1.5 – 3 mg/kg (or Midazolam 0.3 mg/kg TBW) 18. Neuromuscular blocking agents – Succinylcholine2 mg/kg or Rocuronium 1.2 mg/kg

29. Steps in RSI Hypotensive/Shock patient16. Consider Atropine ? 0.4 mg IV 17. Induction agents – Ketamine 0.25 mg/kg or Propofol 0.1 – 0.15 mg/kg 18. Neuromuscular blocking agents – Succinylcholine 2 – 2.5 mg/kg

30. Steps in RSI Elevated ICP/Traumatic head injury patient16. Have Labetalol 20-25 mg IV or Hydralazine 10 mgIV on hand for elevated systolic pressure. 17. Induction agents – Ketamine2 mg/kg 18. Neuromuscular blocking agents – Succinylcholine2 mg/kg or Rocuronium 1.2 mg/kg

31. Steps in RSI Asthmatic patient 16. If time permits can give Lidocaine1.5 mg/kg 3 minutes prior 17. Induction agents – Ketamine2 mg/kg 18. Neuromuscular blocking agents – Rocuronium 1.2 mg/kg or Succinylcholine 2 mg/kg

32. Steps in RSI 19. Ask the team “anything we have missed, any concerns…?” 20. Give Drugs - announce to team "PARALYTICS IN" 21. Cricoid Pressure if needed – BURP 22. Intubate – place ETT 23 cm to lips for males, 21 cm to lips for females. Inflate balloon. Secure tube.

33. Steps in RSI – TUBE DEPTH The ‘23 cm for males and 21 cm for females’ tube depth has been the standard for a long time and in most cases will get you fairly close to where you want to be. However more accurate charts are available for ETT depth

34. Steps in RSI – TUBE DEPTH

35. Steps in RSI 23. Confirm – listen to chest, check EtCO2 (or colorimetric after 8 breaths) 24. Order CXR to confirm ETT depth 25. Post intubation medications – Fentanyl or morphine infusion. +/- sedation 26. Place OroGastric tube, in line suction 27. Head of bed up 30-45 degrees. 28. Foley catheter.

36. Steps in RSI 29. Ventilator settings. Mode: AC FiO2: 100% RR 10-14 bpm for Normotensive or Hypotensive. 14 - 18 bpm for ICP 6 - 10 bpm for Asthmatic (or match RR to Pt’s pre intub RR) • Tidal Volume 8 cc/kg IBW for all patients (except pneumonia, may be less: 6-8) PEEP 5 or as needed for all except asthmatics. 0 for asthmatics initially. Give bronchodilators continuously for asthmatics. 30. ABG within 30 minutes post intubation.

37. Steps in RSI So only 30 steps to remember for RSI! Easy! ALWAYS use an RSI checklist

38. Delayed sequence intubation

39. Delayed Sequence Intubation DSI is basically procedural sedation, followed by a paralytic and intubation! The ‘procedure’ in this case is ‘oxygenation’.

40. Delayed Sequence Intubation Pt. requires intubation but resistant to pre-intubation preparation due to altered mental status. • Dissociation. Give Ketamine 0.5 – 1 mg/kg slow IV push. Repeat q 10 – 15 seconds until patient is ‘dissociated’. • Preoxygenate with Non-rebreather plus nasal cannula. If sats < 95% switch to NIV CPAP. Denitrogenate for 3 minutes. • Once dissociated, you can also position Pt, add IVs, etc. • May add some more ketamine, then paralyze as usual. • Intubate (with nasal cannula still on at 15 lpm)

41. Delayed Sequence Intubation Why Ketamine? As mentioned previously, Midazolam and Propofol cause apnea. Unless you rapidly bolus a large dose, patients will not become apneic with Ketamine.

42. Delayed Sequence Intubation So once you have the patient calm and oxygenated, the rest of the sequence or steps is the same as for RSI previously.

43. Face to face Intubation In a previous slide it is mentioned that ideally the patient should have their head elevated 30 degrees for intubation, as this can reduce aspiration. One should also be aware and comfortable doing “face to face” intubation.

44. Face to face Intubation Indications: • Patient trapped in upright position (ie MVA) and needs intubation. • Penetrating chest trauma where patient is spitting/coughing up copious amounts of blood. • Excessive vomiting and risk of aspiration. • Acute congestive heart failure, where laying the patient down can be too uncomfortable. • ‘Bull neck’ or difficult neck anatomy where being upright can assist with visualization with intubation.

45. Face to face Intubation Technique: • Wear full face mask. • Hold laryngoscope in right hand (opposite to usual intubation) • Hold bougie or ETT in left hand. Have suction ready. • Position on patients right side. • Kneel on bed (or straddle patient on the stretcher). • Ideally have someone stabilize the patient’s head.

46. Face to face Intubation 7. After induction meds, place blade on tongue, slide and insert with pressure down. 8. Visualize cords and introduce bougie or ETT and intubate as usual. 9. Proceed with inflation, auscultation etc as for regular intubation.

48. Summary • Rocuronium is probably a safer and better paralytic in mostintubation scenarios. • For RSI, don’t give an induction agent then wait for the patient to become apneic before giving the paralytic. • You can give the paralytic and induction agent at the same time followed by a saline flush. • Pre-oxygenation is crucial for best patient outcomes. • If the patient is uncooperative/combative, use delayed sequence intubation with ketamine to allow you to properly oxygenate the patient.

49. The END