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RSI: Rapid Sequence Intubation What, When, Where, Why & How. Michael T. Czarnecki, MD. 265. Objective. What is RSI? Discuss the “7 P’s” of RSI Review RSI pharmacologic agents Highlight current controversies with RSI. RSI Defined.

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Presentation Transcript
objective
Objective
  • What is RSI?
  • Discuss the “7 P’s” of RSI
  • Review RSI pharmacologic agents
  • Highlight current controversies with RSI
rsi defined
RSI Defined

“Virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation”

why bother with rsi
Why Bother with RSI?
  • Rapid airway control
  • Less risk of aspiration
  • Highest success rates/lowest complications
    • More controlled
  • Optimal intubating conditions
what are the problems inherent to intubation
What are The Problems Inherent to Intubation?
  • Laryngoscopy and Intubation
    • Increased bronchospasm
    • Increased ICP
    • Increased catecholamine release
beneficial effects of rsi
Beneficial Effects of RSI
  • “Tight Heads”
    • Intracranial pathology
  • “Tight Hearts” or “Tight Vessels”
    • Cardiovascular disease
  • “Tight Lungs”
    • Reactive airway disease
assumptions in airway management
Assumptions in Airway Management
  • Pt. has a full stomach
  • Pt. is preoxygenated
  • Pts. do not receive BVM ventilation unless necessary to keep O2 sat. over 90%
  • Sellick’s maneuver always used
rsi 7 p s
RSI: “7 P’s”
  • P = Preparation
  • P = Preoxygenation
  • P = Pretreatment
  • P = Paralysis with induction
  • P = Protection
  • P = Placement of the tube
  • P = Post-Intubation management
rsi timeline
RSI: Timeline

T – 10 minutes Prepare

T – 5 minutes Preoxygenate

T – 3 minutes Pretreat

T = 0 Paralysis with induction

T + 30 seconds Protection

T + 45 seconds Placement

T + 90 seconds Post-Intubation management

preparation t 10 minutes
Preparation: T – 10 minutes
  • Prepare the patient
    • Monitoring/access
    • Positioning
    • Assess for difficult airway
      • “4 D’s”,“LEMON”, “BONES”, “SHORT”
      • Mallampati
  • Prepare your equipment
  • Prepare yourself (mental checklist)
  • Prepare your personnel
difficult airway assessment
Difficult Airway Assessment
  • 4 D’s
    • Distortion, Disproportion, Dysmobility, Dentition
  • BONES
    • Beard, Obese, No teeth, Elderly, Snores (sleep apnea)
  • SHORT
    • Surgery (head/neck/jaw), Hematoma, Obese, Radiation, Tumor
  • LEMON
  • MALLAMPATI
  • Always have a “Rescue Airway” technique ready

JUMP AHEAD

mallampati score
MALLAMPATI SCORE

Class I Class II Class III Class IV

JUMP BACK

60 second exam lemon
60-SECOND EXAM “LEMON”
  • Look for external difficulty
  • Evaluate using 3=3=2 rule
  • Mallampati (Class I & II)
  • Obstruction
  • Neck Mobility
  • 3 fingers fit in mouth
  • 3 fingers fit from mentum

to hyoid cartilage

  • 2 fingers fit from mandible

to top of thyroid cartilage

JUMP BACK

rescue airways
Rescue Airways
  • Gum Elastic Bougie (GEB)
  • Laryngeal Mask Airway (LMA/ILMA)
  • Combitube
  • Surgical Cricothyrotomy

JUMP BACK

preoxygenate t 5 minutes
Preoxygenate: T – 5 minutes
  • Provides reservoir of oxygen during apnea
  • If pt. spont. breathing – then NRB for 5’
    • Provides maximum of 70% FiO2
  • Avoid bagging the spont. breathing patient
    • If needed, use sellick & airway adjunct
    • 8 effective Vital Capacity breaths provides best preoxygenation
pretreat t 3 minutes
Pretreat: T – 3 minutes
  • L - Lidocaine
  • O - Opiates
  • A - Atropine
  • D – Defasiculating Agent
lidocaine 1 5 mg kg
Lidocaine (1.5 mg/kg)
  • Consider in “Tight Head” or “Tight Lungs”
    • Blunts ICP rise (??)
    • Suppress cough response
      • may blunt bronchospasm
      • may blunt sympathetic response
  • Does Lido help in head trauma?
    • No clinical trials have answered question
    • Not proven to change outcome
    • Little downside in using

Robinson, Emeg Med J 2001; 18:453

opioids
Opioids
  • Fentanyl (3 mcg/kg slow IV over 3’)
    • Consider in “Tight Heads”, “Tight Heart”, & “Tight Vessels”
    • Beware: cautious use in pt’s dependent on sympathetic drive (aka, trauma)
atropine
Atropine
  • Only needed in:
    • Children under 10 y.o.
    • Adults receiving 2nd dose of succinylcholine
  • 0.01 mg/kg IV push
    • Minumum dose: 0.1 mg
defasiculating agent
Defasiculating Agent
  • Use any paralytic at 10% paralyzing dose
  • Consider in “Tight Heads”
  • Beware: may cause hypoventilation and frank paralysis – be prepared
  • Who needs defasiculation?
    • Helps mitigate ICP rise with succinylcholine
    • Not really useful in any other ICU situation
paralysis with induction t 0
Paralysis with Induction: T = 0
  • Tailor inducing agent to specific needs
    • Barbituates
    • Etomidate
    • Midazolam
    • Ketamine
    • Propofol

JUMP AHEAD

barbituates
Barbituates
  • Decreases GABA dissociation at receptor
  • Rapid onset sedation
  • Decreases ICP
  • Hypotension (especially in hypovolemia)
  • Choices:
    • Thiopental, pentobarbital, methohexital

Overall – Etomidate is better that Barbs

JUMP BACK

thiopental
Thiopental
  • Onset 15 seconds, duration 3-5 minutes
  • Cardiac depressant, venodilator
    • Hypotension
  • Dose depedent on pt. profile
    • Euvolemic adult (3-5 mg/kg IV)
    • Hypovolemic adult (1-3 mg/kg IV)

JUMP BACK

etomidate
Etomidate
  • Nonnarcotic, nonbarbituate, nonanalgesic
  • Minimal cardio effects, lowers ICP
  • Is it the ideal agent for RSI?
    • May cause critical adrenal suppression
      • Inhibits adrenal mitochondrial hydroxylase activity
      • Occurs after both single bolus and infusions
      • Infusions incr. ICU death rate & incr. infections
    • Clinical significance is unclear
      • Randomized, controlled trials on outcomes needed

Malerba, et al: Intensive Care Med 2005

etomidate con t
Etomidate (con’t)
  • Induction dose: 0.2 – 0.3 mg/kg IV
  • Onset: 20 – 30 seconds
  • Duration: 7 – 15 minutes
  • May cause myoclonic jerking, hiccups, injection pain, N/V (also on emergence)
  • Risk for adrenal insufficiency incr. 12-fold

Jackson, Chest 2005 MarMurray, Chest 2005 Mar; 127:707-709

JUMP BACK

midazolam
Midazolam
  • Nonanalgesic sedative, anxiolytic, amnestic
  • Respiratory depressant and hypotension
    • Give slow IV
    • Give ½ the dose in elderly or COPD
  • Rapid onset (< 1 minute)
  • Induction dose (0.1 - 0.3 mg/kg) DIFFERENTthan sedation dose (0.01 – 0.03 mg/kg)
    • In RSI, 92% of adults are underdosed

Sagarin, et al: Acad Emerg Med 2003 Apr; 10:329-38

JUMP BACK

ketamine 1 2 mg kg
Ketamine (1 – 2 mg/kg)
  • Dissociative, analgesic, amnestic
  • Causes catecholamine release
    • Incr. BP, HR, ICP, Laryngospasm risk
  • Bronchodilator →induction agent in asthma
  • Onset: 15 – 30 seconds
  • Duration: 10 – 15 minutes

JUMP BACK

propofol 0 5 1 2 mg kg white magic milk of amnesia
Propofol(0.5 – 1.2 mg/kg)(white magic, milk of amnesia)
  • Sedative-hypnotic
  • Cardiac depressant, venodilator
    • Hypotension
    • Decr. ICP at expense of CPP

JUMP BACK

nmbs neuromuscular blocking agents
NMBs: Neuromuscular Blocking Agents
  • Depolarizing
    • Succinylcholine
  • Non-Depolarizing
    • Pan/Vec/Atra/Rocuronium
  • Potential Problems
    • Inadequate pre-intubation neuro exam
    • Failure to sedate
    • Inadequate pre-treatment or inadequate dosing
    • Aspiration and Dysrhythmias
    • Failed intubation → surgical airway needed
succinylcholine 1 5 2 0 mg kg
Succinylcholine(1.5 – 2.0 mg/kg)
  • Onset: 15 – 30 sec; Duration: 5 – 12 min
  • Contraindications:
    • FHx malignant hyperthermia, burns, crush injuries, progressing neuromuscular disease
  • Side Effects:
    • Brady, hyper-K+, fasciculations, MH
      • ↓HR: pretreat all kids; adults 2nd dose with atropine
      • ↑K+: peaks in 5’, resolves in 15’
        • Treat like any hyperkalemia case
  • Use actual-body weight for dose

Rose, et al: Anesth Analg 2000

non depolarizing nmbs
Non-depolarizing NMBs
  • Longer duration than SUX, onset about equal
  • Aminosteroid compounds
    • Pan/Vec/Rocuronium
  • Benzylisoquinolinum compounds
    • Atracuronium
rocuronium
Rocuronium
  • Is it equivalent to SUX?
    • Meta-analysis 1600 pts → equivalent in:
      • Acceptable conditions for intubation
      • Rates of intubation success
        • But SUX is BEST at creating EXCELLENT conditions

Perry, AEM 2002

rsi timeline1
RSI: Timeline

T – 10 minutes Prepare

T – 5 minutes Preoxygenate

T – 3 minutes Pretreat

T = 0 Paralysis with induction

T + 30 seconds Protection

T + 45 seconds Placement

T + 90 seconds Post-Intubation management

slide35
Confirm placement/review CXR
  • Secure tube
  • Vent Settings
  • Administer sedation
  • Maintain paralysis if indicated

And…..

don t ever forget the 7 ps
Don’t Ever Forget the “7 Ps”
  • P = Preparation
  • P = Preoxygenation
  • P = Pretreatment
  • P = Paralysis with induction
  • P = Protection
  • P = Placement of the tube
  • P = Post-Intubation management