STAR Course Foundation Lecture

RSI and Intubation Approach and Decision Making

Emergency Anesthesia

Initial Approach and Decision Making

Decision to IntubateBased on clinical assessment of need, not on predetermined

list of indications.

• Failure to maintain the airway

• Failure to protect the airway

• Failure to oxygenate

• Failure to ventilate

• Expected or anticipated clinical course 1

• (Humanitarian)

!

Secrets to RSI Success• Simulate this in your OWN environment.

• Positioning! You and the Patient! Levitan’s Line -Ear to Sternal Notch positioning2,3

• Doing a primary survey and starting Resus before RSI

• Maximise oxygenation - BVM on >20L + Hi-flo Nasal Cannula4!

• Minimize Hypotension - resus + dose adjust

• Having a back-up plan A to D4 before giving any drugs1.

• Using enough paralysis - discussing drug doses .

• Waiting for the paralysis to work.

• Allocate Roles - airway operator, airway assistant, MILS, +/- Cric, Drugs + Monitoring .

• Adequate briefing and Communicating.

• Using EtCO25

Who Shouldn't I Paralyze and who I should Paralyze with Caution….

Impossible and Difficult Laryngoscopy 1

L Laryngeal trauma, distortion, radiation or operation.

E Evaluate 3 3 2

M Mallampati Score

O Obstruction

N Neck Mobility, Neck Anatomy

Difficult, Impossible or Standard?

• 14 year old male

• Snow mobile

• Fence wire vs Throat

• Horse voice

• Stridor

Who Shouldn't I Paralyze and who I should Paralyze with Caution….

Impossible and Difficult Laryngoscopy 1

L Laryngeal trauma, distortion, radiation or operation.

E Evaluate 3 3 2

M Mallampati Score

O Obstruction

N Neck Mobility, Neck Anatomy

Potentially Impossible Laryngoscopy

Difficult, Impossible or Standard?

Evaluate 3 3 2

Difficult, Impossible or Standard?

Decision to intubate

Near death Agonal respiration

Apnoea Cardiac arrest

Anticipated to be unresponsive to

laryngoscopy

‘Crash’ Intubation No Drugs.

Awake Fibre Optic +/- ENT Surgeon?

YES

NO

NO

YES

RSI (with drugs)

L Laryngeal trauma, distortion, radiation or operation.

E Evaluate 3 3 2

M Mallampati Score

O Obstruction

N Neck Mobility, Neck Anatomy

‘Failed’ Intubation

• Four failed attempts at laryngoscopy - no more

• Single failed attempt at laryngoscopy with inability to maintain SpO2 ≥ 92% with correct bag-valve-mask apparatus

Near death Agonal respiration

Apnoea Cardiac arrest

Anticipated to be unresponsive to

laryngoscopy

‘Crash’ Intubation

YES

NO

NO

Standard ‘RSI’

L Laryngeal trauma, distortion, radiation or operation.

E Evaluate 3 3 2

M Mallampati Score

O Obstruction

N Neck Mobility, Neck Anatomy

4 Failed Attempts or SaO2 <92%

Plan A 1. Direct + Bougie 2. Video + Stylet

Plan B (i)LMA

Plan COPA + 2 NPA + 2 Person Technique + Waveform EtCO2

Plan D Surgical Airway

If you have to bag someone Maximally Aggressive Basic Airway

Alignment + Adjuncts + HiFlo Nasal + 2 person and 2 thumbs down + EtCO2

• Checklist

• Oxygenate

• Drugs

• Position

• Intubate

• EtCO2 x 3

• Clinical Assessment (primary survey)

• Extend Anaesthesia X 3

RSI with your CODPIECE!

Once asleep - Balanced Anesthesia

• ANALGESIA!!!! 6

• Sedation.

• Paralysis.

Secrets to RSI Success• Simulate this in your OWN environment.

• Positioning! You and the Patient! Levitan’s Line -Ear to Sternal Notch positioning2,3

• Doing a primary survey and starting Resus before RSI

• Maximise oxygenation - BVM on >20L + Hi-flo Nasal Cannula4!

• Minimize Hypotension - resus + dose adjust

• Having a back-up plan A to D4 before giving any drugs1.

• Using enough paralysis - discussing drug doses .

• Waiting for the paralysis to work.

• Allocate Roles - airway operator, airway assistant, MILS, +/- Cric, Drugs + Monitoring .

• Adequate briefing and Communicating.

• Using EtCO25

Credit and thanks to……

References and Resources1. Ron M Walls, Micheal F Murphy. Manual of Emergency Airway Management, 4th edition, 2012.

Lippincott Williams. An excellent book on airway management

2. http://www.airwaycam.com/index.html a fantastic website by Richard Levitan with links to all things airway.

3. Obes Surg. 2004 Oct;14(9):1171-5.Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions.. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM.

4. Annals of Emergency Medicine 2012 Mar 59(3): 165-175 Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Scott Weingart and Richard Levitan. http://emcrit.org/wp-content/uploads/2011/10/Preox-annals-article.pdf

5. 4th National Airway Project (NAP4). Major Complications of Airway Management. March 2011. Executive Summary http://www.rcoa.ac.uk/node/1415

6. Strom et al. evaluated this: RCT of 140 patients-analgesia vs. analgesia+sedation. Analgesia only showed shorter vent time and ICU LOS.(Strøm, Martinussen, and Toft 2010)* and look at this website Emcrit http://emcrit.org/podcasts/post-intubation-sedation-2014/