AIRWAY 1:

RAPID
SEQUENCE
INTUBATION

Stuart Swadron, MD, FRCPC, FACEP

Program Director
Residency in Emergency Medicine
Keck-USC School of Medicine

LAC+USC Dept. of Emergency Medicine July 19, 2007

 DEFINITIONS

Rapid Sequence Intubation

INDUCTION AGENT UNCONSCIOUSNESS

PARALYTIC MOTOR PARALYSIS

 DEFINITIONS

Pharmacologically Assisted Intubation

INDUCTION AGENT UNCONSCIOUSNESS

 DEFINITIONS

Geneva Convention Violation

PARALYTIC MOTOR PARALYSIS

RATIONALE Principle
Decreased
aspiration

Increased
success
RATIONALE - Secondary

Better
C-spine
control
RATIONALE - Secondary

Blunting
ICP / IOP
RATIONALE - Secondary

Avoid
airway
trauma
RATIONALE - Secondary

Avoid
airway
trauma
 Pain
Discomfort
Recall
HAZARDS

Prolonged
intubation
HAZARDS

Adverse
Drug
Events
HAZARDS

May force
crash
airway
scenario
 INDICATIONS

Failure OR Imminent failure of :

1. oxygenation
2. ventilation
3. airway protection or maintenance
CONTRAINDICATIONS
RSI CAN ALSO BE

UNNECESSARY

- OR

INAPPROPRIATE
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 PREPARATION
t 10 minutes
1. EQUIPMENT PRESENT AND
WORKING

MUST INCLUDE EQUIPMENT

FOR PLAN B
 PREPARATION
t 10 minutes
2. ASK: CAN I

BAG THE PATIENT

TUBE THE PATIENT
CRIC THE PATIENT
CAN I TUBE THIS PATIENT?
L ook at general anatomy
E valuate the 3-3-2 rule
M allampati score
O bstruction
N eck mobility
CAN I BAG THIS PATIENT?

Maybe. Maybe Not.

CAN I CRIC* THIS PATIENT?

* may include alternative airway techniques

 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 PREOXYGENATION
t 5 minutes
1. PRIMUM NO BAGER!
(First, do not bag!)

2. If you do need to bag,

Remember TOM
 NITROGEN WASH-OUT
OXYGEN WASH-IN

pO2 pO2 pO2

LUNGS BLOOD TISSUES
 NITROGEN WASH-OUT
OXYGEN WASH-IN

pO2 pO2 pO2

LUNGS BLOOD TISSUES
 NITROGEN WASH-OUT
OXYGEN WASH-IN

pO2 pO2 pO2

LUNGS BLOOD TISSUES
 NITROGEN WASH-OUT
OXYGEN WASH-IN

pO2 pO2 pO2

LUNGS BLOOD TISSUES
 NITROGEN WASH-OUT
OXYGEN WASH-IN

pO2 pO2 pO2

LUNGS BLOOD TISSUES
 PREOXYGENATION
t 5 minutes

1. Well-fitting mask

2. 8 vital capacity breaths

Nimmagadda et al. Anesthesiology 93 (3): 693-698, 2000

Baraka et al. Anesthesiology 91 (3): 612, 1999
PREOXYGENATION
t 5 minutes

Ill adult
Normal
child Normal
adult
Obese
adult
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 PRETREATMENT
t 3 minutes
L Lidocaine

O Opioids

A Atropine

D Defasciculating Medication
 PRETREATMENT
t 3 minutes
LOAD

may just be a

LOAD
 LIDOCAINE
Traditional Indications

Tight Brains
There is currently no evidence to support the use of
intravenous lidocaine as a pretreatment for RSI in patients with
head injury and its use should only occur in clinical trials
Robinson N, Clancy, M. Emergency Medicine Journal 18(6):453-7, 2001

Tight Lungs
no study has demonstrated a protective effect of [both
intravenous and topical anesthetic agents] in preventing
bronchospasm after intubation..

Maslow et al. Anesthesiology, 93(5): 1198-1204, 2000

 OPIOIDS (Fentanyl)

Traditional Indications

1. Blunt hemodynamic response

2. Decrease pain

Adachi et al. Anesthesia & Analgesia. 95(1):233-7, 2002

 FENTANYL DOSE

Dose = 3g/kg* IV slow push

*Beware of hypotension and apnea

 ATROPINE
Standard practice
Give atropine to:
1. all children less than 8 years old
2. prior to second dose of succinylcholine

Dose = 0.01-0.02 mg/kg IVP

Evidence is mounting that questions routine use of atropine

Fastle et al. Pediatr Emerg Care;20(10):651-5, 2004

McAuliffe et al. Can J Anaesth; 43(7) 754-5,1996
Fleming et al. CJEM. 2005;7(2):114-7
 DEFASCICULATING DOSE
One tenth the RSI dose
Traditional Indications
1. Blunt rise in ICP
2. Decrease risk of aspiration
3. Prevent muscular pain
Questionable value
no definitive evidence that SCh caused a rise in ICP
no studies that investigated the issue of pretreatment
with defasciculating doses and their effect on ICP

Clancy et al. Emergency Medicine Journal. 18(5):373-5, 2001

 And whats more

DEFASCICULATING DOSE
can be downright dangerous*

* it may cause premature apnea

 PRETREATMENT
t 3 minutes

If youre going to give these drugs:

at least give them some time to

circulate (3 minutes)
 Summary of LOAD
PRETREATMENT

L idocaine optional

O piates optional

A tropine still mandatory for kids < 8

D efasciculating optional
dose
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 PARALYSIS WITH
INDUCTION
Time 0
INDUCTION AGENTS PARALYTIC AGENTS

Etomidate DEPOLARIZING

Thiopental Succinylcholine
Ketamine
Propafol
+ NON-DEPOLARIZING
Vecuronium
Midazolam Rocuronium
SUX IS STILL KING

but nondepolarizing
agents are gaining
ground

Perry et al. Academic Emergency

Medicine 9(8): 813-23, 2002
 SUX versus ROC

45 seconds ONSET 1 minute

9 minutes DURATION 45 minutes

1-2.5 mg/kg 1 mg/kg

 When Sux Really Sucks
CONTRAINDICATIONS

1. HYPERKALEMIA
RENAL FAILURE
RHABDOMYOLYSIS

2. RECEPTOR UPREGULATION
SUBACUTE BURNS (>1 day)
SUBACUTE DENERVATING DISORDER
HISTORY OF MALIGNANT HYPERTHERMIA
 Advent of the Non-Depolarizing
Agents
Pancuronium

Vecuronium

Rocuronium

Rapacuronium oops!
Making non-depolarizing agents
FASTER

1. Large Doses

2. Priming Doses
} Increase duration

3. Better Induction Agents

The Choice of Induction Agent
ETOMIDATE the agent of choice

THIOPENTAL hypotension
not the greatest intubating conditions

PROPAFOL hypotension
storage, allergy concerns

KETAMINE not the greatest intubating conditions

some like it for asthma
good for penetrating neck trauma

MIDAZOLAM effective induction doses cause hypotension

usually underdosed (requires 0.3mg/kg)
better for conscious sedation
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
PROTECTION AND POSITIONING
t + 20 seconds
C Spine Precautions
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
PLACEMENT AND PROOF
t + 45 seconds
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
POST-INTUBATION MANAGEMENT
t + 90 seconds
THE APRS INTUBATION

CONFIRM INTUBATION

SECURE TUBE

CHECK CHEST X-RAY, ABGS

CONFIRMING INTUBATION
SECURING TUBE
 THE 7 Ps OF RSI
t 10 minutes PREPARATION
PREOXYGENATION
PRETREATMENT
TIME ZERO PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
t + 90 seconds POST-INTUBATION MANAGEMENT
PUTTING IT ALL TOGETHER
 TRAUMA WITH HEAD INJURY
PREPARATION
PREOXYGENATION WITH 100% O2 (t -5min)
PRETREATMENT (t -3min)
Lidocaine 1.5 mg/kg IVP (Optional - if time allows)
Vecuronium 0.01 mg/kg IVP (Optional - if time / resp status allows)
Fentanyl 3 g/kg IVP (Optional - if time / BP allows)

PARALYSIS WITH INDUCTION (t = 0)

Etomidate 0.3 mg/kg
Succinylcholine 1.5 mg/kg

PROTECTION AND POSITIONING

PLACEMENT AND PROOF (t +45 sec)
with in-line C-spine stabilization
POST-INTUBATION MANAGEMENT
 STATUS ASTHMATICUS
PREPARATION
PREOXYGENATION WITH 100% O2 (t -5min)
PRETREATMENT (t -3min)
Lidocaine 1.5 mg/kg IVP (Optional - if time allows)

PARALYSIS WITH INDUCTION (t = 0)

Ketamine 1.5 mg/kg IVP
Succinylcholine 1.5 mg/kg

PROTECTION AND POSITIONING

PLACEMENT AND PROOF (t +45 sec)

POST-INTUBATION MANAGEMENT
 ONE SIZE FITS ALL!
PREPARATION

PREOXYGENATION WITH 100% O2 (t -5min)

PARALYSIS WITH INDUCTION (t = 0)

Etomidate 0.3 mg/kg
Succinylcholine 1.5 mg/kg OR Rocuronium 1mg/kg

PROTECTION AND POSITIONING

PLACEMENT AND PROOF (t +45 sec)

POST-INTUBATION MANAGEMENT
 INTUBATION
HURTS!!!

And it keeps on hurting once the tube is in.

Thank you!