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AIRWAY 1:RAPID
SEQUENCEINTUBATION
Stuart Swadron, MD, FRCPC, FACEPProgram Director
Residency in Emergency MedicineKeck-USC School of Medicine
LAC+USC Dept. of Emergency Medicine July 19, 2007
DEFINITIONS
INDUCTION AGENT
PARALYTIC
UNCONSCIOUSNESS
MOTOR PARALYSIS
Rapid Sequence Intubation
DEFINITIONS
INDUCTION AGENT
Pharmacologically Assisted Intubation
UNCONSCIOUSNESS
DEFINITIONS
Geneva Convention Violation
PARALYTIC
MOTOR PARALYSIS
RATIONALE – Principle
Increasedsuccess
Decreasedaspiration
BetterC-spinecontrol
RATIONALE - Secondary
Blunting↑ ICP / IOP
RATIONALE - Secondary
Avoid airway trauma
RATIONALE - Secondary
Avoid airway trauma
RATIONALE - Secondary
↓ Pain↓ Discomfort ↓ Recall
Prolongedintubation
HAZARDS
Adverse Drug Events
HAZARDS
May force crash airway scenario
HAZARDS
INDICATIONS
Failure OR Imminent failure of :
1. oxygenation
2. ventilation
3. airway protection or maintenance
CONTRAINDICATIONS
INDICATIONRISK
RSI CAN ALSO BE…
UNNECESSARY
- OR –
INAPPROPRIATE
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
PREPARATIONt – 10 minutes
1. EQUIPMENT PRESENT AND WORKING
MUST INCLUDE EQUIPMENT
FOR PLAN “B”
PREPARATIONt – 10 minutes
2. ASK: CAN I…
BAG THE PATIENT
TUBE THE PATIENT
CRIC THE PATIENT
L ook at general anatomyE valuate the 3-3-2 ruleM allampati scoreO bstructionN eck mobility
CAN I TUBE THIS PATIENT?
CAN I BAG THIS PATIENT?
Maybe. Maybe Not.
CAN I CRIC* THIS PATIENT?
* may include alternative airway techniques
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
PREOXYGENATIONt – 5 minutes
1. “PRIMUM NO BAGER!”
(First, do not bag!)
2. If you do need to bag,
Remember TOM
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
PREOXYGENATIONt – 5 minutes
1. Well-fitting mask
2. 8 vital capacity breaths
Nimmagadda et al. Anesthesiology 93 (3): 693-698, 2000Baraka et al. Anesthesiology 91 (3): 612, 1999
PREOXYGENATIONt – 5 minutes
Normal adult
Obese adult
Normal child
Ill adult
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
PRETREATMENTt – 3 minutes
L Lidocaine
O Opioids
A Atropine
D Defasciculating Medication
PRETREATMENTt – 3 minutes
“LOAD”
may just be a
LOAD
LIDOCAINETraditional 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
OPIOIDS (Fentanyl)
Traditional Indications
1. Blunt hemodynamic response
2. Decrease pain
Adachi et al. Anesthesia & Analgesia. 95(1):233-7, 2002
FENTANYL DOSE
Dose = 3µg/kg* IV slow push
*Beware of hypotension and apnea
ATROPINEStandard practiceGive atropine to:
1. all children less than 8 years old2. 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, 2004McAuliffe et al. Can J Anaesth; 43(7) 754-5,1996Fleming et al. CJEM. 2005;7(2):114-7
DEFASCICULATING DOSEOne tenth the RSI dose
Traditional Indications
1. Blunt rise in ICP
2. Decrease risk of aspiration
3. Prevent muscular pain
Clancy et al. Emergency Medicine Journal. 18(5):373-5, 2001
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”
And what’s more…
DEFASCICULATING DOSEcan be downright dangerous*
* it may cause premature apnea
PRETREATMENTt – 3 minutes
If you’re going to give these drugs:
…at least give them some time to circulate (3 minutes)
Summary of LOADPRETREATMENT
L idocaine optional
O piates optional
A tropine still mandatory for kids < 8
D efasciculating optional dose
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
PARALYSIS WITH INDUCTION
Time “0”INDUCTION AGENTS
Etomidate
Thiopental
Ketamine
Propafol
Midazolam
PARALYTIC AGENTS
DEPOLARIZING
Succinylcholine
NON-DEPOLARIZING
Vecuronium Rocuronium
+
SUX IS STILL KING
…but nondepolarizing agents are gaining ground
Perry et al. Academic Emergency Medicine 9(8): 813-23, 2002
SUX versus ROC
45 seconds ONSET 1 minute
9 minutes DURATION 45 minutes
1 mg/kg1-2.5 mg/kg
When Sux Really “Sucks”CONTRAINDICATIONS
1. HYPERKALEMIARENAL FAILURERHABDOMYOLYSIS
2. RECEPTOR UPREGULATIONSUBACUTE BURNS (>1 day)SUBACUTE DENERVATING DISORDERHISTORY OF MALIGNANT HYPERTHERMIA
Advent of the Non-Depolarizing Agents
Pancuronium
Vecuronium
Rocuronium
Rapacuronium –oops!
Making non-depolarizing agents FASTER
1. Large Doses
2. Priming Doses
3. Better Induction Agents
}Increase duration
The Choice of Induction Agent
ETOMIDATE – the agent of choice
THIOPENTAL – hypotension
– not the greatest intubating conditions
PROPAFOL – hypotension
– storage, allergy concerns
KETAMINE – not the greatest intubating conditions
– some like it for asthma
– good for penetrating neck trauma
MIDAZOLAM – effective induction doses cause hypotension
– usually underdosed (requires 0.3mg/kg)
– better for conscious sedation
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
PROTECTION AND POSITIONING t + 20 seconds
C Spine Precautions
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
PLACEMENT AND PROOF t + 45 seconds
Over here,
Socrates !!!
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
POST-INTUBATION MANAGEMENT t + 90 seconds
THE “APRÈS INTUBATION”
CONFIRM INTUBATION
SECURE TUBE
CHECK CHEST X-RAY, ABG’S
CONFIRMING INTUBATION
SECURING TUBE
THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
PUTTING IT ALL TOGETHER
TRAUMA WITH HEAD INJURY
PREPARATIONPREOXYGENATION WITH 100% O2 (t -5min)PRETREATMENT (t -3min)
Lidocaine 1.5 mg/kg IVP (Optional - if time allows)Vecuronium 0.01 mg/kg IVP (Optional - if time / resp status allows)Fentanyl 3 μg/kg IVP (Optional - if time / BP allows)
PARALYSIS WITH INDUCTION (t = 0)Etomidate 0.3 mg/kgSuccinylcholine 1.5 mg/kg
PROTECTION AND POSITIONING
PLACEMENT AND PROOF (t +45 sec)
with in-line C-spine stabilization POST-INTUBATION MANAGEMENT
STATUS ASTHMATICUS
PREPARATIONPREOXYGENATION WITH 100% O2 (t -5min)PRETREATMENT (t -3min)
Lidocaine 1.5 mg/kg IVP (Optional - if time allows)
PARALYSIS WITH INDUCTION (t = 0)Ketamine 1.5 mg/kg IVP Succinylcholine 1.5 mg/kg
PROTECTION AND POSITIONING
PLACEMENT AND PROOF (t +45 sec)
POST-INTUBATION MANAGEMENT
ONE SIZE FITS ALL!
PREPARATION
PREOXYGENATION WITH 100% O2 (t -5min)
PARALYSIS WITH INDUCTION (t = 0)Etomidate 0.3 mg/kgSuccinylcholine 1.5 mg/kg OR Rocuronium 1mg/kg
PROTECTION AND POSITIONING
PLACEMENT AND PROOF (t +45 sec)
POST-INTUBATION MANAGEMENT
INTUBATION HURTS!!!
And it keeps on hurting once the tube is in.
Thank you!
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