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BYMURTAZA RASHID M.D
DEPARTMENT OF EMERGENCY MEDICINEROYAL COMMISSION HOSPITAL, JUBAIL
Rapid Sequence Intubation In Adults
DEFINITION
Rapid sequence intubation (RSI) is the virtually simultaneous administration of a sedative and a neuromuscular blocking (paralytic) agent to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation and to minimize the risk of aspiration.
CPR
SEDATED, BURNT OUT ER PHYSICIAN
WHY RSI
CASE (1) AMITRYPTILLINE TIPPER27 year old overdose benzodiazepines + TCAs 1 hour PTA. Decreasing LOC, HR 140, wide complex regular, BP 90/50, RR
24,O2 sat 99% on O2.
CASE (2) STAB WOUNDS22 yr old multiple abdominal stab wounds 6” knife. Evisceration, agitation and uncooperative. HR 140, BP 90/50, RR 22, O2 sat 99% on O2.
WHAT TO DO AND
HOW TO DO
DILEMMA !
ORAL INTUBATION WITHOUT DRUGS
THE CRASH AIRWAYARREST SITUATIONS ONLYPATIENT IS COMPLETELY UNCONSCIOUS,
PULSELESS, UNRESPONSIVE AND APNIC
PRINCIPLES OF RSI
RSI is the standard of care in emergency airway management for intubations not anticipated to be difficult. Multiple large prospective observational studies confirm that the implementation of RSI has led to improved success and decreased complication rates for emergency intubations
• Emergency intubation is indicated• The patient has a “full” stomach• Intubation is predicted to be successful• If intubation fails, ventilation is predicted to be successful
DO NOT INTUBATEDYSARTHRIC ANTI IPSILATERAL HORNERS SYNDROME DUE TO LATERAL CORTICOMEDULLARY STROKE WITH BLA BLA BLASTEROSIS
CAUTION
CONTRAINDICATIONS
Absolute: Cardiopulmonary arrest present/imminent Operator inexperience
Relative: Anticipated technical difficulties with
laryngoscopy and/or intubation
ADVANTAGES OF RSI
Facilitates and expedites endotracheal intubation increased success rate decreased time to intubation
Minimizes trauma during laryngoscopyMinimizes hypoxia and hypercapniaMinimizes risk of aspirationMinimizes hemodynamic effects of intubation
SEVEN “P” OF RSI
PreparationPre oxygenationPretreatmentParalysis with inductionProtection and positioningPlacement with proofPost intubation management
PREPARATION (10 mins before intubation)
• ETT, stylet, blades, suction, BVM• Cardiac monitor, pulse oximeter, ETCO2• One ( preferably two ) iv lines• Drugs• Difficult airway kit including cricothyrodotomy kit• Patient positioning
PREOXYGENATION (5 mins before intubation)
Facemask with oxygen reservoir (non rebreather)
Manual ventilation prior to intubation should be reserved for patients who are hypoxic (saturation <91 percent). Slow rate 8 b/m to avoid over inflation of lungs and stomach.
It allows 3-5 mins of apnea.
PRETREATMENT (3 mins before intubation)
Laryongoscopy can activate coughing and gagging.
Infants: BradycardiaAdults: High B.P, Bronchospasm, Increase
ICP and Heart Rate
In highly emergent cases it is not worth to wait for pretreatment and can be judiciously omitted.
Drugs vary according to the condition.
PRETREATMENT MNEMONIC “ABC”
ASTHMABRAIN AND BABIESCARDIOVASCULAR
Atropine: Used in infants and sometimes after second dosage of succinylcholine in adults with profound bradycardia.
PRETREATMENT
Lidocaine (1.5 mg/kg i.v): Reduces airway resistance and decreases ICP. Contraindicated in Mobitz II or Third degree heart block.
PRETREATMENT
Fentanyl ( 3 mcg/kg i.v): Decreases ICP, B.P, Heart rate. Given in ACS, Aortic dissection.
Fentanyl can cause respiratory collapse and hypotension. If given only low dosage of 1 mcg/kg.
Fentanyl should be the last pretreatment drug to be used.
Nishat Garden Kashmir
PARALYSIS WITH INDUCTION
Head injury or Stroke: Goal is to maintain adequate cerebral perfusion and maintain arterial pressure.
Etomidate (0.3mg/kg): Excellent sedation and dosent cause hypotension. No change in B.P. Causes adrenal insufficiency.
Ketamine (1-2mg/kg): Use in Septic shock, Bronchospasm and hypotensive patients with head injury. Avoid in cerebral hemorrhage.
Midazolam, barbiturates and propofol can be used in head injury but risk of hypotension must be considered
PARALYSIS WITH INDUCTION
Status Epilepticus:Midazolam (0.2-0.3mg/kg): Can cause hypotension,
use etomidate if patient has hemodynamic compromise.
Do not use Ketamine due to stimulant effect.
• Severe Bronchospasm:Hemodynamically stable: Ketamine, Propofol,
Etomidate, Midazolam.Hemodynamically unstable: Ketamine or Etomidate
PARALYSIS WITH INDUCTION
Cardiovascular : Etomidate preferred in CAD and Aortic dissection. Use fentanyl as pretreatment.
Shock: Etomidate or Ketamine. If refractory septic shock, with etomidate give Hydrocortisone
In patient in which we need “awake” look, use ketamine. Provides analgesia, amnesia and sedation without respiratory concern.
NEUROMUSCULAR BLOCKING AGENTS
PRODUCE PARALYSIS. NOT PROVIDE SEDATION OR ANALGESIA. USED IMMEDIATELY AFTER INDUCTION AGENTS.
DEPOLARIZING: Succinylcholine (Sch), binds to Ach receptors produces fasciculation's and paralysis.
NON DEPOLARIZING: Rocuronium, Vecuronium, and Pancuronium. Competitively inhibit the post-synaptic Ach receptor and produce paralysis.
DEPOLARIZING PARALYTICS
SUCCINYLCHOLINE (1.5 mg/kg): Mostly preferred agent due to rapid onset (45-60 sec) and offset (6-10 mins). Better to overdose than under dose.
Absolute Contraindications: SIGNIFICANT HYPERKALEMIA DEMONSTRATED BY EKG
FINDING. MALIGNANT HYPERTHERMIA (FAMILY OR PERSONAL Hx.) RHABDOMYOLYSIS STROKE OR BURN 72 HOUR OLD, DUE TO UPREGULATION
OF Ach RECEPTORS SIGNIFICANT NEUROMUSCULAR Dx OR MUSCULAR
DYSTROPHY
DEPOLARIZING PARALYTICS
SIDE EFFECTS TRISMUS FASCICULATIONS BRADYCARDIA ESP. IN CHILDREN
NONDEPOLARIZING NEUROMUSCULAR BLOCKING AGENTS (NMBAS)
USED WHEN DEPOLARIZING AGENTS ARE CONTRAINDICATED OR PROLONGED BLOCKADE IS WARRANTED.
ROCURONIUM (1 mg/kg): Short onset (45-60 sec), duration upto 45 mins. Effect comparable to Succinylcholine.
VECURONIUM (0.15 mg/kg): onset about 90 sec.
A predicted difficult airway is the most common relative contraindication to the use of nondepolarizing NMBAs for RSI
REVERSAL OF NONDEPOLARIZING AGENTS
COMPETITIVELY BIND Ach RECEPTORS NEOSTIGMINE: Acetyl cholinesterase inhibitor which allows
ACh to continue to stimulate the neuromuscular junction and cause muscular stimulation.
SUGAMMADEX: is a novel agent that encapsulates and binds with molecules of rocuronium or vecuronium, thereby rapidly reversing their neuromuscular blocking effects. Still pending for FDA.
In Myasthenia Gravis dose of Depolarizing agent should be increased while dose of non-depolarizing should be decreased.
PROTECTION (CRICOID PRESSURE) AND POSITIONING
This phase of RSI refers to protecting the airway against aspiration prior to placement of the endotracheal tube by avoiding bag-mask ventilation and applying cricoid pressure (Sellick's maneuver). Bag-mask ventilation is unnecessary if the patient has been successfully preoxygenated.
Provided oxygen saturation remains above 90 percent, bag-mask ventilation is unnecessary, even between laryngoscopy attempts
A common error is to apply pressure to the thyroid cartilage (Adam's apple).
ANATOMY PROCEDURE
SELLICK'S MANEUVER
PLACEMENT WITH PROOF
After paralysis has been achieved finally the tube is placed through glottis and cuff is inflated.
The most accurate means of confirming ETT placement is End-tidal CO2 (EtCO2) determination.
A single-view chest radiograph is only useful to determine depth of placement (eg, tracheal versus right mainstem).
DO NOT BELIEVE WHAT THEY ARE TELLING YOU !
POSTINTUBATION MANAGEMENT
RSI remains incomplete until the properly placed endotracheal tube is secured. Several techniques are commonly used to secure the tube, including taping, tying etc.
Hypotension can occur due to decreased venous return from increased intrathoracic pressure due to mechanical ventilation or due to sedatives.
GENERAL TECHNIQUE
VARIATIONS OF TECHNIQUE — The general approach described above is a commonly accepted way of performing rapid sequence intubation (RSI). There are, however, a number of variations, depending on clinical circumstance.
DEFAULT STRATEGY AND BACKUP
Autumn in Kashmir
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NICE DAY
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