Emergency Airway Management -Rapid Sequence Intubation

DR ANAS ABDUL MAJEED

KING FAHAD MEDICAL CITY,RIYADH

One pound of knowledge takes ten pounds of common sense to apply it.

 RSI is the cornerstone of modern emergency airway management This approach provides optimal intubating conditions, while minimizing the risk of aspiration of gastric contents

Rapid sequence intubation in the emergency department. - Dufour DG - J Emerg Med - 01-SEP1995; 13(5): 705-10
Rapid sequence intubation (RSI) has recently gained wide acceptance among emergency physicians (EP). Two hundred and nineteen intubations were done using an RSI protocol during the study period. All patients were successfully intubated. No mortality was attributed to the use of muscle relaxants. Our results support the safety and effectiveness of RSI in the hands of emergency physicians

Rapid sequence intubation in the emergency department: 5 year trends. - Simpson J Emerg Med J - 01-JAN-2006; 23(1): 54-6 Complication rates for emergency physician RSI is 14% for trauma and 4% for nontrauma (chi2 = 4.44, df = 1, p = 0.035). Mean complication rates for anaesthetists for trauma is 17% and for non-trauma - 22%

RSI Nursing Roles

Identify situations in which emergency intubation is necessary. Discuss the use of sedative and neuromuscular blocking agents during RSI. Define RSI and explain the RSI technique. Discuss trends in the use of various RSI agents

Purpose of this Presentation:

FAMILIARIZE
Medications used for RSI RSI Procedure

RECOGNIZE
RSI: When and When not to perform

ANTICIPATE
Back-up plan Murphys Law

Definition
The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation

IF Endotracheal Intubation fails, you must have a back-up plan...

Is there a need for airway management?

Failure of airway maintenance and protection. a. Unconscious or nearly conscious i. No gag reflex, cannot protect own airway b. Trauma patient i. Injury to mouth, nose, neck ii. Blood or vomit c. Foreign body: choked on an object

Failure to breath or oxygenate a. Respiratory distress: i. Asthma: wheezing ii. Pneumonia iii. Heart failure: pulmonary edema

Expected Clinical Course: what patients can be expected to have trouble? i. Stab wound, neck injury with expanding hematoma ii. Abscess or tumor mass to neck iii. Multiple trauma or burn patient, hypotension, pneumothorax

Approach to the patient

Adequacy of airway Can they speak? Normal voice: no stridor Able to inhale and exhale

Inspect mouth Blood, loose teeth, swollen tongue Long protruding upper teeth Small mouth opening Short jaw Short neck Decreased range of motion of neck Beard Obesity

Listen
Decreased breath sound Fluid, blood, pneumonia Pneumothorax Tension pneumothorax Flail chest

Measure
O2 Arterial blood gas

Preparation is the KEY for an organized, smooth intubation

Remember the 7 Ps!!

RSI Procedure: The Seven Ps

1. Preparation 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

1. Preparation Assess the risks

1. Preparation
A two-part process:
Assess the risks Prepare the equipment

1. Preparation Assess the risks

Assess the Risks

Difficult Airways - Assess the Risks

The difficult airway is something one anticipates; the failed airway is something one experiences.
-Walls 2002

1. Preparation Assess the risks

1. Preparation Assess the risks

Identifying a potentially difficult airway is essential to preparing and developing a strategy for successful ETI and also preparing an alternate plan in the event of a failed ETI.

1. Preparation Assess the risks

Always expect the unexpected!

1. Preparation Assess the risks

1. Preparation Assess the risks

Always have a back-up plan.

Plans A, B, and C Know the answers before you begin

RSI Procedure: The Seven Ps

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

1. Preparation
A two-part process:
Assess the risks Prepare the equipment

1. Preparation Prepare the Equipment

Prepare the Equipment

1. Preparation Prepare the Equipment

Prepare the Equipment

Equipment is present, opened and ready for use Adequate Ambu-mask/oxygen sources/suction 2 laryngoscope handles Assortment of blades Assortment of ET tubes, stylette, syringe RSI Assistant

Prepare the Equipment continued

1-2 secure IV lines All pharmaceutical agents needed for the procedure Back-up plan and rescue airway devices Oxymetry and capnography monitoring Bulb-style tube checker

1. Preparation Prepare the Equipment

1. Preparation Prepare the Equipment

Monitor the Patient

Cardiac monitor
Monitor for dysrythmias
bradycardia, tachycardia, ectopy

Blood Pressure monitoring (manual or NIBP)

Monitor for hypo- or hypertension

Pulse oxymeter
Monitor for hypoxia

Waveform Capnography
Monitor for hypo- or hypercarbia

RSI Procedure: The Seven Ps

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

2. Preoxygenation

2. Preoxygenation
Pre-oxygenate with 100% O2 via non-rebreather mask for at least 3-5 minutes
Replaces the patients functional residual capacity (FRC) of the lung with oxygen
Nitrogen Washout

If done properly, this will permit as much as 3-4 minutes of apnea before hypoxia develops

In emergent cases, three mask breaths with 100% oxygen may have to suffice.

Nurse: You will most likely be responsible for the preoxygenation of your patient.

RSI Procedure: The Seven Ps

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

Rapid Sequence Intubation Medications

3. Premedication
These medications are given 2 minutes prior to intubation to reduce/blunt the patients physiologic responses to the subsequent intubation Possible physiologic responses include:
Bradycardia Tachycardia Hypertension Hypoxia Increased intracranial and intraocular pressures Cough and gag reflexes

Pretreatment
Pretreatment drugs for RSI Lidocaine: 1.5 mg/kg iv over 4 minutes to decrease bronchospasm and decrease intracranial pressure Opioids- fentanyl:in a dose of 3 g/kg- pain, heart disease Atropine: Esp for children less than the age of ten-Dose: 0.02 mg/kg, min 0.1 mg, max 0.5 mg

3. Premedication

Lidocaine
Why: May prevent a rise in intracranial pressure in traumatic brain injured patients. When: At least minutes prior to intubation
Nurse: Will not see any major change in patient.

3. Premedication

Lidocaine
Lidocaine for head injuries, non-traumatic head bleeds (strokes) and asthma patients (Tight head, tight chest) Takes 3 minutes to work, so may not be worthwhile if time is critical..

3. Premedication

Atropine
Why: Given to prevent worsening bradycardia
From Succs, vagal stimulation during direct visualization, and hypoxia

When: Prior to intubation for bradycardic adults

Nurse: Will not see any major change in patient.

RSI Procedure: The Seven Ps

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

The 7 Ps of RSI continued

Paralysis with induction Sedation charges: 1. Thiopental (pentothal 3-5 mg/kg/hr) 2. Benzodiazepines Midazolam 0.1mg/kg/hr (Versed) Lorazepam 0.1 mg/kg/hr (Ativan) Diazepam 0.3 o.5 mg/hr (Valium) 3. Etomidate: very popular now: .15 -.3 mg/Kg/hr, rapid onset, less hypotension 4. Ketamine: good with severe asthma: 1-2 mg/kg

4. Paralyze

4. Paralyze
A three step process:
Induction Cricoid Pressure
Constant vigilance for necessary intervention (i.e suctioning, hypoxia)

Paralytic

4. Paralyze

Paralysis
Sedatives (or hypnotic) agents MUST be administered PRIOR to neuromuscular blockage.

4. Paralyze

Induction with Etomidate

Hypnotic induction agent
No analgesic properties

Should always be given prior to paralytic Etomidate, 0.3 mg/kg

Nurse: Will see the patient become less responsive.

4. Paralyze

Cricoid Pressure
Also known as Sellicks Maneuver
Should be automatic
Begin just as Etomidate is administered Maintained until ETT placement is confirmed and tube is secure (cuff inflated) Used to occlude the esophagus and prevent passive regurgitation common with Succs

If patient starts to actively vomit RELEASE! and suction oropharnyx.

Otherwise, can lead to esophageal rupture

Nurse: This an important role for you!

Identification of the Cricoid cartilage to apply pressure so as to occlude the oesophagus against the spine

The correct way to apply the cricoid pressure

Bimanual way of applying cricoid pressure also known as Sellicks Maneuver

Sellicks Maneuver (Cricoid Pressure)

Airway before applying Sellicks

The Tongue as an Airway Obstruction

Airway with Sellicks applied (note compression on the esophagus)

4. Paralyze

Succinylcholine
Why: Relaxes the patients muscles enabling the Emerg Physician to intubate the patient. When: Immediately after Etomidate. Will cause fasciculations Nurse: You will likely see the patient go through a brief period of fasciculation followed by complete flaccidity, as the patient become paralyzed.

Paralysis
Paralytic agent a. Succinylcholine profound paralysis in 45 seconds and duration of less than few minutes Adverse affects: Fasciculations Hyperkalemia Increased intracranial pressure Increased Intraocular pressure Not good for patients with old burns, old crush injuries, or muscular dystrophy Do not use for head or eye injuries or in renal failure. Dose: 1.5 mg/kg IV

Rocuronium: nondepolarizing agent Disadvantage: longer time to onset and longer duration of action So if intubate failed, it will require longer rescue breathing 0.8-1.2 mg/kg

RSI Procedure: The Seven Ps

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

Placement and proof:

Placement: 45 seconds after administration of succinylcholine, intubate patient. Place laryngoscope in open mouth, sweep tongue to the side, visualize vocal cords, pass the endotracheal tube through the cords, remove the stylet, inflate the balloon, connect the bag, and ventilate the patient.

i.

Correct Placement for intubation (b)

Patient in correct position for intubation (sniffing position)

Incorrect airway position (hyperflexed)

6. Proof of Placement

6. Proof of Placement
OBJECTIVE Direct visualization
BEST

CXR Pulse oximetry Capnography CO2 detectors

SUBJECTIVE Absence of abdominal sounds while ambu- bagged Mist in the tube Bilateral breath sounds Rise/fall in chest

Easy Cap - colormetric

Self-inflating bulb Confirm placement using at least 3 methods, including capnography waveform.

Nurse: Be familiar with the set-up and/or assembly of the various confirmation devices as you will likely be called upon to connect them.

Colorimetric End-Tidal CO2 Detector

RSI Procedure: The Seven Ps

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

7. Post Intubation Management

i. secure endotracheal tube with commercially available device or tape ii. Chest X-RAY to confirm placement iii. Continued sedation and paralysis:

Sequence of RSI
Preparation: Zero minus 10 minutes Preoxygenate: Zero minus 5 minutes Premedicate: Zero minus 3 minutes Paralysis with induction: Zero Protection: Zero plus 20-30 seconds

Placement: Zero plus 45 seconds

Post Intubation Management: zero plus 1 minute

Medication Sequence
Oxygen Lidocaine and/or Atropine if indicated Etomidate Cricoid Pressure Succinylcholine INTUBATION Lorazepam / Fentanyl prn Rocuronium or Vecuronium-0.1 mg/kg prn

Engaging laryngoscope blade and handle

Activating laryngoscope light source

Laryngoscope Blades

ETT

ETT, Stylet, and Syringe, assembled for intubation

VAL

GLIDOSCOPE

Hyperventilate patient.

Prepare equipment.

Apply Sellicks Maneuver and insert laryngoscope.

Visualize larynx and insert the ETT.

Airway Management

Airway Management

Airway Management

Glottis visualized through laryngoscopy

Inflate cuff, ventilate, and auscultate.

Confirm placement with an ETCO2 detector.

Secure tube.

Reconfirm ETT placement.

Case Studies

Case 1
You are planning for RSI for a morbidly obese patient, height 70 inches, weight 200 kg. How do you dose SCh?

Ideal vs. lean vs. total

Ideal body weight: patients ideal weight if proportioned correctly Lean body weight: correction to IBW to allow for the lean parts of obesity (typically 30% of TBW-IBW) Total body weight: well, duh

Dosing Succinylcholine

Use standard dose of 1.5 mg/kg Base dosing on TBW! Multiple studies confirm this Our patient gets 300 mg!
Lemmens HJ and Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006; 102:438-42. Rose JB et al. The potency of succinylcholine in obese adolescents. Anesth Analg 2000;90: 576-578.

Case 2
67 y/o female code blue in asystole. PLAN?

Case 3
41 y/o female with c/o asthma attacks x20 minutes. Severe respiratory distress. RR 32, HR 127, BP 160/92. Bilateral I/E wheezes. Within 10 minutes, she becomes lethargic and her RR slows. PLAN?

Case 4
25 y/o male with GSW to abdomen. Pt is intoxicated, decreased LOC, minimal gag reflex. RR 8-10, HR 120, BP 100/80. PLAN?

THANK YOU