Rapid Sequence Intubation

Otto Sabando DO FACOEPProgram DirectorEmergency Medicine ResidencySt. Joseph’s Regional Medical CenterPaterson NJ

Objectives

Overview of Rapid sequence induction (RSI)

RSI Procedure Pretreatment agents Induction agents Paralytic medications Case studies: “Pitfalls” Questions

Overview of RSI

1979, Taryle and colleagues reported complications in 24 of 43 patients needing an emergent airway Improvement of house officer training More liberal use of procedures used in the

OR

Overview of RSI

Objectives: Immediate airway control necessitating

induction of anesthesia and muscle relaxation

Provision of anesthesia and sedation to the awake patient

Minimization of intubation adverse effects, including systemic and intracranial hypertension

Overview of RSI

Prehospital? In non-cardiac arrest patients, overall RSI

success rate 92%-98%. Comparable to ED settings

Without a full compliment of medications, success rate are ~60% as in ED settings

i.e.: Patient combative, intact gag reflex, preexisting muscle tone

Overview of RSI

Impact of prehospital intubations on outcome….Controversial! Gausche and Colleagues

Comparison bag-mask ventilation and endotracheal intubation for critically ill and injured pediatric patients

820 subjects, no paralytics and sedation used 57% intubation success rate Similar outcomes for both study groups

Overview of RSI

Winchell and Hoyt Retrospective review of 1092 blunt trauma

patients with GCS score of less than 9 Prehospital intubation reduced mortality from

36% to 26% (impact on most severely injured) Endotracheal intubation without medications

had success rate of 66%

Overview of RSI

Bochicchio and colleagues Compared brain injured patient outcomes

in patients with and without prehospital RSI Pre-hospital RSI

Higher mortality rate and more ventilator days Equivalence of the patient groups upon

paramedic arrival is unknown Study suggest that prehospital RSI and

intubation may adversely affect outcomes

Overview of RSI

Further prospective evaluations Prehospital physiology Notation of preexisting aspiration Better prospective studies!

RSI Procedure

Preoxygenate with 100% NRB if the patient is spontaneously breathing No positive pressure ventilations

Intravenous line: Preferably 2 lines 20 gauge or larger in adults

Cardiac monitor, pulse oximetry, and Capnography

Prepare equipment: suction, difficult airway cart,

RSI Procedure

Explain the procedure: Document neurologic status

Sedative agent Defasciculating agent, lidocaine, and or

atropine Perform Sellick maneuver Neuromuscular agent Intubate trachea and release Sellick maneuver Confirm placement

RSI Procedure

Sample Rapid Sequence Intubation Using Etomidate and Succinylcholine: Timed Step

Zero minus 10 min Preparation Zero minus 5 min Preoxygenation 100% oxygen for 3 min or eight

vital capacity breaths Zero minus 3 min Pretreatment

  as indicated "LOAD“ Zero Paralysis with induction   Etomidate, 0.3 mg/kg   Succinylcholine,

1.5 mg/kg Zero plus 45 sec Placement   Sellick's maneuver   Laryngoscopy and

intubation   End-tidal carbon dioxide confirmation Zero plus 2 min Post-intubation management   Midazolam 0.1 mg/kg,

plus   Pancuronium, 0.1 mg/kg, or   Vecuronium, 0.1 mg/kg

RSI Procedure

Principal contraindication: Any condition preventing mask ventilation

or intubation

Pretreatment agents

Goal: Attenuate pathophysiologic responses to Laryngoscopy and intubation Reflex sympathetic response

Increase in heart rate and blood pressure Children: vagal response predominates

Bradycardia Laryngeal stimulation

Lanrygospasm, cough, and bronchospasm

Pretreatment agents

To be effective, pretreatment agents should be given 3-5min prior to RSI Not practical at times

Pretreatment agents

Pretreatment Agents for Rapid Sequence Intubation (LOAD) Lidocaine: in a dose of 1.5 mg/kg, used to mitigate bronchospasm in

patients with reactive airways disease and to attenuate ICP response to Laryngoscopy and intubation in patients with elevated ICP

Opioid: Fentanyl, in a dose of 3 μg/kg, attenuates the sympathetic response to Laryngoscopy and intubation and should be used in patients with ischemic coronary disease, intracranial hemorrhage, elevated ICP, or aortic dissection

Atropine: 0.02 mg/kg is given to prevent bradycardia in children ≤ 10 years old who are receiving succinylcholine for intubation

Defasciculation: a Defasciculating dose (1/10 of the paralyzing dose) of a competitive neuromuscular blocker is given to patients with elevated ICP who will be receiving succinylcholine to mitigate succinylcholine-induced elevation of ICP

Induction agents

Ketamine: 1-2mg/kg, onset 1min, duration 5 min Phencyclidine derivative

Potent bronchodilator Status asthmaticus

Hypertension, increased ICP Increase secretions

Atropine to offset Emergence phenomenon

Contraindications Elderly “Cautious” Head injury (ICP increase), increase IOP

Induction agents

Etomidate: 0.3mg/kg.Onset <1min, duration 10-20min. Non-barbiturate, non-receptor hypnotic Water and lipid soluble and reaches the

brain quickly Sedation comparable to barbiturates Acts on CNS to stimulate ∂-aminobutyric acid

receptors and depress the RAS No analgesic activity

Induction agents

Decreases cerebral oxygen consumption, cerebral blood flow and ICP

Best used in patients with head injury and hypovolemia

Side effects Nausea, vomiting, myoclonus Inhibition of adrenal cortical function (not

really seen with one dose induction)

Induction agents

Propofol : 0.5-1.5mg/kg IV onset 20-40 seconds, duration 8-15 minutes Highly lipophylic Alkylphenol sedative-hypnotic

Has amnestic effect but no analgesic effects Dose dependant depression of

consciousness ranging from light sedation to coma

Lowers intracranial pressure Anti seizure effects

Induction agents

Side effects Direct myocardial depression leading to

hypotension especially in the elderly

Induction agents

Opioids Not first line selections Fentanyl: 3-10µg/kg IV. Onset 1-2min,

duration 20-30min Highly lipophylic, rapid serum clearance, high

potency, and minimal histamine release 50-100 times more patent than morphine Best used for hypotensive patients in pain

Induction agents

Side effects: Chest wall rigidity (>15µg/kg IV) ICP variable Respiratory depression (seen with other

sedatives)

Induction agents

Barbiturates: Thiopental: 3-5mg/kg IV. Onset 30-60sec.

Duration 10-30 minutes Methohexital (brevital): 1mg/kg IV. Onset

<1min. Duration 5-7 min. CNS depressant that leads to deep sedation

and coma Best indication is for status epilepticus, ICP

related to trauma or HTN emergency

Induction agents

Side effects Myocardial depression leading to

hypotension (MAP decrease by 40mm/hg) Decreased respiratory drive Lanrygospasm

Paralytic Medications

Depolarizing agents Succinylcholine: 1-1.5mg/kg. Onset 45-

60sec, duration 5-9 min. Most commonly used agent for paralysis Chemical structure similar to acetylcholine

Depolarize postjuctional neuromuscular membrane

Rapidly hydrolyzed by pseudocholiesterase

Paralytic Medications

Complications: Bradyarrythmias Masseter spasm ICP?, IOP, increase intragastric pressure Malignant hyperthermia

Tx: Dantrolene Hyperkalemia

Increase 0.5mEq/ml Histamine release Fasciculation induced musculoskeletal trauma

Prevent by using defisciulating dose of nondepolorizing agent (10% of normal dose)

Prolonged apnea with pseudocholinesterase deficiency

Paralytic Medications

Contraindications: Major burns Muscle trauma Crush injuries Myopathies Rhabdomyolysis Narrow angle

glaucoma

Renal failure Neurologic disorder Spinal cord injury Guillian-Barre

Syndrome Children with

undiagnosed myopathies?

Paralytic Medications

Nondepolorizing agents: Vecuronium 0.08 mg/kg-0.15mg/kg, 0.15-

0.28mg/kg. Onset 2-4min, duration 25-120min

Rocuronium 0.6mg/kg. Onset 1-3min. Duration 30-45 min

Atracurium 0.4-0.5mg/kg. Onset 2-3min. Duration 25-45 min.

Pancuronium 0.1mg/kg. Onset 2-5min. Duration 40-60 min.

Paralytic Medications

Competitive agents that block the effects of acetylcholine at the neuromuscular junction Rocuronium is the alternative medication

when succinylcholine is contraindicated

Paralytic Medications

Reversal agents: Mostly in OR anesthetized patients, rarely used in

the ED setting Neostigmine 0.02mg-0.04mg slow IVP

Additional doses of 0.01 to 0.02 mg/kg slow IVP can be given if reversal is incomplete

Total dose not to exceed 5mg in an adult Give atropine 0.01mg/kg to block cholinergic

effects of Neostigmine Max adult dose 1mg Minimum pediatric dose 0.1mg

Paralytic Medications

Complications Vecuronium

Prolonged recovery time in elderly and obese patients or hepatorenal dysfunction

Rocuronium Tachycardia

Atracurium Hypotension, histamine release,

bronchospasm Pancuronium

Hypertension, tachycardia, histamine release

Cases

Case 1

A 24 y.o. male with a medical history of asthma is short of breath secondary to his asthma. You note that the patient is hypoxic and getting tired.

Which RSI Medications for sedation would be best for this case?

Answer

Case 2

A patient is hit in the head by a bat. His GCS is 8. You decide to RSI this patient as he is combative and altered. Which medications would be best in this situation?

Sedative Paralytic adjunct

Case 3

A 45 y.o. male in respiratory distress with crush injuries to his legs needs to be intubated. Which of the following paralytics are indicated in this case?

Succinylcholine Rocuronium Vecuronium Pancuronium

Questions

References

Yano M, et al: Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 64:651, 1986

Kirkegaard-Nielsen H, et al: Rapid tracheal intubation with rocuronium. Anesthesiology 91:131, 1999

Schneider RE, Caro D: Pretreatment agents. In Walls RM, et al (eds): Manual of Emergency Airway Management. Philadelphia, Lippincott Williams & Wilkins, 2004

Gausche M. Lewis RJ, Stratton SJ et al. Effect of out of Hospital Pediatric Endotracheal Intubation on Survival and Neurologic Outcome: A controlled Clinical Trial. JAMA 283:783,2000

Bochicchio GV, Ilahi O,Joshi M et al. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutly lethal traumatic brain injury. J Trauma 54:307, 2003

Winchell RJ, Hoyt DB: Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 132:592, 1997

References

Roberts and Hedges. Clinical Procedures in Emergency Medicine. Edition 4. Saunders, 2004

Tintnalli J et al. Emergency Medicien: A comprehensive study guide. Edition 6. McGraw Hill, 2004

Rosen’s Emergency Medicine: Concept in Clinical Practice. Edition 6. Elsevier, 2006

Etomidate Propofol barbiturate

Lidocaine

1.5 mg/kg

Suppresses cough

Suppress ICP?

Decrease pressor response secondary to intubation?

Use with paralytics?