Rapid Sequence induction

Why Intubate?

• Airway protection – pre-transfer, burns

• Decreased GCS – Caution!

• Patient requires ventilatory assistance

• Need for hyperventilation

• Hyperthermia – paralyse

Pre intubation

• Four P’s: Preparation, preoxygenation, position, plan

• Have your equipment ready

• Optimise oxygenation – individual for each patient

• Position the patient correctly

• Have a plan, have a plan B, have a plan C. Communicate these with the team

Preparation

• Adequate assistance: Airway nurse, drugs nurse, SMO/consultant

• Physiological monitoring – include ETCO2

• Check equipment:– Laryngoscope + VL– IV line– ETT– Bougie/stylet

Pre-oxygenation

• Standard pre-oxygenation should give 8 minutes in well adults, 5 minutes in sick adults, 2.5 minutes in obese adults

• We can do better!

What not to do

??

Better

More Better

+NP at 3-4 litres when awake, 15 litres as soon as asleep

Even Better?

Probably not, but NIV is certainly reasonable

Position

• Normal weight – “sniffing” – flex at lower C spine, extend at C1

• Overweight – “ramp” – Tragus level with sternomanubrial angle

• Children…

Plan

• Have a plan and two backup plans• Communicate them.• E.G.:

– First I will trial intubation with direct laryngoscopy and a bougie

– Then VL with bougie– Then LMA– Then surgical airway

• You can alter your plan – but always change something before you have another attempt

Drugs – general principles

• Think about them –adjust drugs and dose to patients

• My standard is rocuronium 1.2mg/kg and ketamine 1.5mg/kg

• Most of the other consultants use propofol, opiate and sux.

Rocuronium

• Non depolarising muscle relaxant

• No fasciculations – prolongs time to desat

• Lasts 20-30 minutes

• Reversed with sugammadex – never happens

• Fewer contraindications than suxamethonium

When to use sux

• Seizures/status – wears off quicker, you can see them fit

Cricoid pressure

• Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961; 2: 404–406.

• I don’t use it

• Consider bimanual manipulation if needed.

Bougie or stylet?

• Use one or the other

• Stylet may be more traumatic, bougie is slightly more complicated.

• Bougie requires a well trained airway nurse.

• Do not take out the laryngoscope!

Tube’s in. Now what?

• Check position – listen, ETCO2, CXR

• Secure tube

• Sedation – draw up before intubation if possible

• NGT

• IDC

• Head up 30 degrees

Ventilator settings (not COPD)

• SIMV/VC – do not worry about other modes for now

• Vt around 6-8mg/kg

• Rate around 14

• PEEP 5

• FiO2 – start at 100% and titrate down until sats <100%

Vantilator settings (COPD/asthma)

• SIMV/VC

• Vt 8mL/kg

• Rate 10

• PEEP 0

• IE ratio 1:4-5

Ventilator troubles

• If an alarm goes off, a breath is probably not given!

• Take the patient off the vent and bag them

• High pressures• Hypoxia• Hypotension• These are for another lecture