The ABC of RSI Jason Boschin Critical Care Paramedic

The ABC of RSIThe ABC of RSI

Jason BoschinJason Boschin

Critical Care ParamedicCritical Care Paramedic

Advanced AirwayAdvanced Airway

Anatomic ConsiderationsAnatomic Considerations

Rapid Sequence inductionRapid Sequence induction

Neuromuscular BlockadeNeuromuscular Blockade

Induction AgentsInduction Agents

Intubation tricks & thoughtsIntubation tricks & thoughts

Indications for Definitive AirwayNeed for Airway ProtectionNeed for Airway Protection Need for VentilationNeed for Ventilation

UnconsciousUnconscious ApneaApnea

Neuromuscular ParalysisNeuromuscular Paralysis

UnconsciousUnconscious

Severe Maxillofacial fx’sSevere Maxillofacial fx’s Inadequate Respiratory Effort’Inadequate Respiratory Effort’

TachypnealTachypneal

HypoxiaHypoxia

HypercarbiaHypercarbia

CyanosisCyanosis

Risk for aspirationRisk for aspiration

BleedingBleeding

VomitingVomiting

Severe closed head injury with need Severe closed head injury with need for hyperventilationfor hyperventilation

Risk for obstructionRisk for obstruction

Neck hematomaNeck hematoma

Laryngeal, tracheal injury/burnLaryngeal, tracheal injury/burn

StridorStridor

Mouth:Mouth:– TongueTongue : :

variable in size (angioedema)variable in size (angioedema)

attached inferior to epiglottisattached inferior to epiglottis– MandibleMandible– UvulaUvula

PharynxPharynx– TonsilsTonsils– Merges with larynx anterior, esophagus Merges with larynx anterior, esophagus

posteriorposterior– Epiglottis high long flaccid and narrow in childEpiglottis high long flaccid and narrow in child

ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATIONFOR INTUBATION

The LarynxThe Larynx– High relative to mandible in childHigh relative to mandible in child– Cricoid smaller in child, narrow part of airwayCricoid smaller in child, narrow part of airway– vocal cord narrow part of adult airwayvocal cord narrow part of adult airway– arytenoid cartilagesarytenoid cartilages

ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)FOR INTUBATION (cont.)

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TracheaTrachea– 12-15 cm. Adult12-15 cm. Adult– 4 cm. Newborn4 cm. Newborn– right mainstem right mainstem

larger,shorter and larger,shorter and less angleless angle

ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)FOR INTUBATION (cont.)

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– Tube Sizes (Kids)Tube Sizes (Kids) Fit through noseFit through nose

Age(years)/4 + 4Age(years)/4 + 4

Oral tube lengthOral tube length– Age(years)/2 + 12 cm.Age(years)/2 + 12 cm.– Nasal add 3 cm.Nasal add 3 cm.

No cuff under 6 to 8 yearsNo cuff under 6 to 8 years

OTHER CONSIDERATIONS FOR OTHER CONSIDERATIONS FOR INTUBATION (cont.)INTUBATION (cont.)

Difficult tubes Difficult tubes – Immobilized trauma patientImmobilized trauma patient– Combative patientCombative patient– Children, esp. InfantsChildren, esp. Infants– Short neckShort neck– Prominent upper incisorsProminent upper incisors– Receding mandibleReceding mandible– Limited jaw opening, limited Limited jaw opening, limited

cervical mobilitycervical mobility– Upper airway conditionsUpper airway conditions– Facial, laryngeal traumaFacial, laryngeal trauma

OTHER CONSIDERATIONS FOR OTHER CONSIDERATIONS FOR INTUBATION (cont.)INTUBATION (cont.)

Correct Placement for intubation (b)

Patient in correct position for intubation (sniffing position)

Incorrect airway position (hyperflexed)Incorrect airway position (hyperflexed)

Rapid Sequence InductionRapid Sequence Induction

IndicationsIndications– Ventilatory failure (eg’s)Ventilatory failure (eg’s)– Airway maintenance/protectionAirway maintenance/protection– Treatment and evaluationTreatment and evaluation

neuro resuscitation(hyperventilate)neuro resuscitation(hyperventilate)

shockshock

drug overdosedrug overdose

ContraindicationsContraindications– Cardiac arrestCardiac arrest– Adequate ventilationAdequate ventilation– Deeply comatose patient, absent toneDeeply comatose patient, absent tone– Airway Anatomy use LEMONAirway Anatomy use LEMON


Contraindications Contraindications (cont.)(cont.)– Intubation likely Intubation likely

unsuccessfulunsuccessfulPartially Partially obstructed airwayobstructed airway

Severe facial Severe facial abnormality(trauabnormality(trauma, etc.)ma, etc.)


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Maintain adequate oxygenationMaintain adequate oxygenation

Airway protection Airway protection – Prevent regurgitation, aspirationPrevent regurgitation, aspiration

Obtund adverse cardiovascular and Obtund adverse cardiovascular and ICP response to intubationICP response to intubation

Better early than lateBetter early than late

Hypoxemia and acidosis effectsHypoxemia and acidosis effects


Treatment Algorithm (6 P’s)Treatment Algorithm (6 P’s)– Preparation T-10”Preparation T-10”– Pre-oxygenation( functional reserve capacity) Pre-oxygenation( functional reserve capacity)

T-5”T-5”– Pre-medication T-3”Pre-medication T-3”– Paralysis T-0Paralysis T-0– Placement of Tube T+45Placement of Tube T+45– Post Management T+2”Post Management T+2”


DO NO HARM!DO NO HARM!

TAKE AWAY NOTHING TAKE AWAY NOTHING FROM THE PATIENT YOU FROM THE PATIENT YOU

CANNOT REPLACECANNOT REPLACE

Anticipate the difficultiesAnticipate the difficulties– Identify Identify in advancein advance the patient who may the patient who may

require RSIrequire RSI– Identify the patient with anatomic Identify the patient with anatomic

difficultydifficulty– Have sufficient skill and training : Have sufficient skill and training : – TRAINING NOT DONE ON SCENE..NO TRAINING NOT DONE ON SCENE..NO

EGO’S!!!EGO’S!!!– Have aHave a preformulated preformulated planplan for potential for potential

disasterdisaster


Airway EvaluationAirway Evaluation

Problem Airway

epiglottis Vocal cords

Be prepared:Be prepared:– Competence with all Competence with all

equipmentequipment– Working equipmentWorking equipment– Be prepared for surgical Be prepared for surgical

managementmanagement– Master the art of baggingMaster the art of bagging– Have at least one, if not two, Have at least one, if not two,

working IV linesworking IV lines– STAY ONE STEP AHEAD!!STAY ONE STEP AHEAD!!


Equipment:Equipment:– Suction, OxygenSuction, Oxygen– Laryngoscope, ET Tubes, StyletLaryngoscope, ET Tubes, Stylet– BVMRBVMR– Pharmacologic agents, mixed and Pharmacologic agents, mixed and

readyready– Monitoring equipmentMonitoring equipment

Continuous cardiac monitoringContinuous cardiac monitoring

Pulse oximeter (continuous)Pulse oximeter (continuous)

NIBP (ideal)NIBP (ideal)

CO2 device (ET confirmation device)CO2 device (ET confirmation device)


Pre-oxygenation:Pre-oxygenation:– Functional residual capacityFunctional residual capacity– Oxygen 6-10 l/min via snug maskOxygen 6-10 l/min via snug mask– Three minutes ideal, if spontaneous Three minutes ideal, if spontaneous

breathing assist only.breathing assist only.– BEWARE BVM while spontaneously BEWARE BVM while spontaneously

breathing..Gastric insufflation is real!! breathing..Gastric insufflation is real!! – Avoid BVMR if Spo2 >90% if Avoid BVMR if Spo2 >90% if

breathing….breathing….


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© 2005 Elsevier

Pre-medication:Pre-medication:– AtropineAtropine

All children under 12 yearsAll children under 12 years

Adults with heart rate 100 or less ***Adults with heart rate 100 or less ***

Second dose of SuccinylcholineSecond dose of Succinylcholine

Dosage: 0.5 to 1.0 mg adultDosage: 0.5 to 1.0 mg adult

Dosage 0.01 to 0.02 mg child (1 mg max)Dosage 0.01 to 0.02 mg child (1 mg max)

Give ideally 2-3 minutes prior to intubationGive ideally 2-3 minutes prior to intubation


Sedation AgentsSedation AgentsGoal is to blunt the pt’s physiologic responses to intubation Goal is to blunt the pt’s physiologic responses to intubation ie: minimizes bradycardia, hypoxemia, gag/cough & increases ie: minimizes bradycardia, hypoxemia, gag/cough & increases in ICP/IOP/IGPin ICP/IOP/IGP

– Selection of agent(s)Selection of agent(s)perfusion stateperfusion state

presence of head injurypresence of head injury

clinical diagnosisclinical diagnosis


Paralytics Have No Sedative or Analgesic Qualities!!!

Selection of Sedative (cont.)Selection of Sedative (cont.)– BenzodiazepinesBenzodiazepines

Amnestic and at high dose, anestheticAmnestic and at high dose, anesthetic

Little cardiovascular depression if titratedLittle cardiovascular depression if titrated

MidazolamMidazolam– Rapid onsetRapid onset– Potent amnesticPotent amnestic– Moderate decrease in ICPModerate decrease in ICP– 1-5 mg IV (adult) as per CPG1-5 mg IV (adult) as per CPG– 0.1 mg/Kg titrated in kids0.1 mg/Kg titrated in kids


Selection of Sedative (cont.)Selection of Sedative (cont.)– NarcoticsNarcotics

Potent analgesics/sedativesPotent analgesics/sedatives

Rapid onset w/ brief durationRapid onset w/ brief duration

Effect can be reversed!Effect can be reversed!FentanylFentanyl– Rapid acting (<1min), duration of 30minRapid acting (<1min), duration of 30min– No histamine releaseNo histamine release– May decrease tachycardia and hypertension May decrease tachycardia and hypertension

associated with intubationassociated with intubation



ACh binds to post ACh binds to post synaptic receptors synaptic receptors causing depolarization causing depolarization … … Contraction of Contraction of musclemuscle

ACh removed by ACh removed by acetylcholinesterase acetylcholinesterase and by diffusion …. and by diffusion …. Relaxation of Relaxation of musclemuscle

Neuromuscular Junction

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Mechanism of action:Mechanism of action:– NondepolarizersNondepolarizers

CompetitiveCompetitive

Block ACh receptors … paralysisBlock ACh receptors … paralysis

– DepolarizersDepolarizersNoncompetitiveNoncompetitive

Persistent stimulation …fasciculationsPersistent stimulation …fasciculations

Unresponsiveness to ACh….ParalysisUnresponsiveness to ACh….Paralysis


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DepolarizingDepolarizing– SuccinylcholineSuccinylcholine

Vagal effectsVagal effects– Excessive bronchial secretions (blunted by Excessive bronchial secretions (blunted by

Atropine?)Atropine?)

Negative inotropic and chronotropic, esp. Negative inotropic and chronotropic, esp. with repeated dose and in children with repeated dose and in children (Bradycardia..Atropine)(Bradycardia..Atropine)

Fasciculations (amelioration)Fasciculations (amelioration)

Malignant hyperthermia?Malignant hyperthermia?

Complete paralysis w/in 30-45 sec. Complete paralysis w/in 30-45 sec. Lasting 4-6 minLasting 4-6 min

– 1.5-2 mg/kg IV1.5-2 mg/kg IV


– Succinylcholine (cont.)Succinylcholine (cont.)Metabolized via CholinesteraseMetabolized via Cholinesterase

– 0.3% defective enzyme0.3% defective enzyme

ContraindicationsContraindications– Absolute - noneAbsolute - none– HyperkalemiaHyperkalemia

Renal failureRenal failure

Crush injury Crush injury

Burns Burns

MyotoniaMyotonia

ParaplegiaParaplegia


•Non-depolarizing

–Rocuronium•Minimal cardiovascular effect•Long duration of action (may exceed 45 mins)•Shorter onset than Pancuronium/Vecuronium: 1-3 min•0.6-1.2 mg/kg


Airway ManagementAirway Management



Digital Digital Tactile Tactile IntubationIntubationRetrogradeRetrograde

Airtraq Airtraq

FiberscopeFiberscope

BURPBURP

Intubation TricksIntubation Tricks

SURGICAL AIRWAYSSURGICAL AIRWAYS•Cricothyrotomy

–Indications (Identified need for intubation)•Maxillofacial trauma•Oropharyngeal obstruction

–Edema–FBAO–Mass Lesion–Cancer

•Unsuccessful oral/nasal tracheal•Difficult anatomy•Massive hemorrhage/regurgitation

SURGICAL AIRWAYSSURGICAL AIRWAYS•Cricothyrotomy (cont..)

–Contraindications:–Age <10-12–Laryngeal crush injury–Laryngeal tumor/stricture–Tracheal transsection–subglottic stenosis–Expanding hematoma–Coagulopathy–Unfamiliar w/ procedure

SURGICAL AIRWAYSSURGICAL AIRWAYS

Anatomy:Anatomy:– Thyroid cartilageThyroid cartilage– Cricoid ringCricoid ring– Cricoid cartilageCricoid cartilage– Thyroid glandThyroid gland– TracheaTrachea– Major vesselsMajor vessels


Netter; Atlas of Human Anatomy


Procedure:Procedure:– Identify thyroid cartilageIdentify thyroid cartilage

Cricothyroid membraneCricothyroid membrane

– Vertical incision through skinVertical incision through skinPrep priorPrep prior

Incise membraneIncise membrane

– Open incisionOpen incisionDilator/tracheal hookDilator/tracheal hook

– Insert ETT/Trach tubeInsert ETT/Trach tubeVentilate patientVentilate patient


Complications:Complications:– Incorrect placementIncorrect placement– Long execution timeLong execution time– HemorrhageHemorrhage– Passage sub QPassage sub Q– Plugging Plugging – PneumomediastinumPneumomediastinum– AspirationAspiration– etc.etc.

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Retrograde Tracheal Intubation Retrograde Tracheal Intubation (RTI):(RTI):– IndicationsIndications

Abnormal anatomyAbnormal anatomy– Pt. W/ epiglottitisPt. W/ epiglottitis– Severe kyphosisSevere kyphosis– Cervical spondylosisCervical spondylosis

TraumaTrauma

Reasonable alternative to Surg and Reasonable alternative to Surg and Needle CrikeNeedle Crike


RTI (cont...):RTI (cont...):– ContraindicationsContraindications

Trismus (w/o paralytic)Trismus (w/o paralytic)

CoagulopathyCoagulopathy

Enlarged thyroidEnlarged thyroid

– Procedure:Procedure:Supplemental OSupplemental O22

Catheter over needle into CTMCatheter over needle into CTM

Insert guidewire through catheterInsert guidewire through catheter

Visualize guidewire and pass tubeVisualize guidewire and pass tube

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QUESTIONS ??QUESTIONS ??

Defasiculating Doses (priming Defasiculating Doses (priming with 10% NDNMB)with 10% NDNMB)

KetamineKetamine

Braeslow system for KidsBraeslow system for Kids

Documents

The ABC of RSI Jason Boschin Critical Care Paramedic