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#5 Intro to EM Airway Management - RSI Pharmacology

#5 Intro to EM Airway Management - RSI Pharmacology. Andrew Brainard. # 5 RSI Medications on a Dialysis Pt. Learning Objectives: Prep team / plan/room/equipment Mask Seal, BVM, adjuncts, suction, Pre & apnoeic oxygenation Positioning Airway assessment and plan MOANS/LE M ON

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#5 Intro to EM Airway Management - RSI Pharmacology

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  1. #5Intro to EM Airway Management-RSI Pharmacology Andrew Brainard

  2. #5 RSI Medications on a Dialysis Pt • Learning Objectives: • Prep team/plan/room/equipment • Mask Seal, BVM, adjuncts, suction, • Pre & apnoeic oxygenation • Positioning • Airway assessment and plan • MOANS/LEMON • Briefing for Plans A, B, C, & D • Completes airway checklist • Call and response • <1 min • Dose, timing, advantages/disadvantages of RSI sedatives • Etomidate • Propofol • Ketamine • Thiopental • Dose, timing, and of RSI paralytics • Rocuronium • Suxamethonium • R40: 50y/o M unresponsive • Unresponsive for >24 hours • Has missed last several dialysis appointments • GCS 7, RR 6, SaO2 95%, pulse 50, BP 80/60. • ECG shows wide complex bradycardia • On arrival: • Same vitals • Pt being bagged well by Ambos • 2-hands, 2 people w/ OPA + NPA • Obvious dialysis shunt • LEMON shows: • Beard , 2-1-1 (small mouth, no neck, small jaw), no obstruction, no neck • Very difficult airway: • harder than you feel comfortable with • MOANS • Easy to ventilate/oxygenate with BVM • Consultant suggests RSI • Pt will gradually desaturateunless: • Bagged, positioned, and preoxygenated • Prepare for sedation w/ minimal thio or etomidate or ketamine • Prepare for paralytic w/ rocuronium • Run through checklist • Be prepared for intubation but… • Wait for help

  3. Sedatives for RSI

  4. Sedatives • Etomidate (0.3mg/kg TBW) • Minimal hemodynamic effects • Minimal respiratory depression • Controversial in sepsis • Myoclonus • Fentanyl (5-10mcg/kg) • Familiar agent for paeds • Minimal Sedation • Ketamine (0.5-2mg/kg IBW) • Minimal hemodynamic effects • Minimal respiratory depression • Bronchodilator • Increased secretions • Laryngeal spasm (very rare) • Propofol (0.5-3mg/kg TBW) • Familiar agent • Respiratory depression • Hypotension • Thiopental (0.25-3mg/kg TBW) • Antiepileptic • Respiratory depression • Hypotension • Histamine release

  5. Paralytics for RSI

  6. Paralytics • Rocuronium (1.2mg/kg IBW) • Identical intubationing conditions • Few contraindications • Longer duration • Avoid in status • Difficulty canceling cases • Suxamethonium (1.5-2mg/kg TBW) • Familiar and fast • 10 minute duration • Bradycardia • Short duration • Poor relaxation • Can lead to redosing • Contraindications • Hyperkalemia • Renal failure, rhabdo, crush injuries • UpregulatedaCh receptors • Old burns, old strokes, old paralysis • Malignant Hyperthermia

  7. Drug Controversies • Access • IV/IO • Equal • IM • Double dose ketamine/sux • When are drugs needed? • Type • Dose • Pushing RSI Drugs • Sedative • Flush (for thio) • Paralytic • Fluid/presser • RSI • Rapid push of Sedative and Paralytic • Non-RSI regimens • Awake Intubation • Cooperative patient • Topical airway anesthesia • DL/VL or FiberOptic intubation • Delayed Sequence Intubation (DSI) • Sedation for agitation and pre-oxygenation then RSI for ETT • Rapid Sequence Airway (RSA) • Sedation/Paralysis to SGA • ETT after pt optimized via SGA • Premeditations? • Oxygen, sedation, analgesia, neuroprotection? • Sedation only intubation • Give sedative (+/- topical anesthesia) • DL/VL/FOI • Non-rapid RSI • Small doses of analgesia and sedation then paralysis • No Drug Intubation • Almost all pts require sedation and paralysis for optimal conditions

  8. ACEP Practice Management- Focus on Rapid Sequent Intubation: http://www.acep.org/Clinical---Practice-Management/Focus-On--Rapid-Sequence-Intubation-Pharmacology/(Accessed 21/03/2013) • Walls RM. Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF. (Eds), Lippincott Williams and Wilkins, Philadelphia 2012 • Morris et al Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009 May;64(5):532-9.

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