Rapid Sequence Intubation

RSI Definition
The administration of a potent induction agent followed immediately by a rapid acting neuromuscular blocker (NMB) to render unconsciousness and motor paralysis for tracheal intubation

Indications for Tracheal Intubation

failure to maintainairway failure of airway protection Failure of ventilation or oxygenation Anticipated airway obstruction or special situations

RSI Contraindications
Tracheal / laryngeal injury / disruption S/P Laryngectomy Massive facial trauma Anticipated difficult airway

RSI
The 7 Ps

Preparation Preoxygenation Pretreatment Paralysis with induction Protection with positioning Placement with proof Post-intubation management
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RSI Timeline
Time Zero - 10 min Zero - 5 min Zero - 3 min Zero Zero + 20-30 sec Zero + 45-60 sec Zero + 60-90 sec Action Preparation Preoxygenation Pretreatment Paralysis with induction Protection with positioning Placement with proof Post-intubation management

Preparation
Patient
airway assessment, IV access Positioning

Equipment
Airway, monitoring, failed airway Blade type and size, ETT size placement confirmation device Cuff integrity and stylet, laryngoscope functioning

Personnel
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Airway Assessment (LEMON)

Look externally Evaluate 3-3-2 Mallampati or Obstruction Neck

Look Externally
Morbid obesity Abnormalities of the face Facial or neck trauma Protruding tongue Receding mandible Facial hair

Evaluate (3-3-2 Rule)

3 finger breadths between upper lower teeth (mouth opening) 3 finger breadths between tip of the chin and hyoid bone 2 finger breadths between thyroid cartilage and floor of the mouth

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Mallampati Classification
I II III IV Tonsillar pillars and fauces visible Upper portion of pillars and uvula visible Base of uvula / soft palate visible Only tongue and hard palate visible

Patients mouth open, tongue sticking out Correlates with laryngoscopy classification, but not as sensitive in grades 3 and 4
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Mallampati classification for grading airways Class I visualization of the soft palate, fauces, uvula, and anterior and posterior pillars; class II visualization of the soft palate, fauces, and uvula; class III visualization of the soft palate and the base of the uvula; and class IV soft palate is not visible at all. www.chestjournal.org CHEST
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Laryngoscopic Classification
Grade I Grade II Entire glottis visible Arytenoid cartilage and posterior glottis visible Grade III Epiglottis only visible Grade IV Tongue or soft palate visible Grade III and IV are considered difficult intubations (about 5% of OR cases) Visualization predicts intubation success
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Obstruction
Angioedema Epiglottis Foreign bodies tonsil Airway Trauma Tumor

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Neck
Possible cervical spine injury Preexisting disease
Rheumatoid arthritis Ankylosing spondylitis

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ETT Size and Depth

Size
Females 7.5-8; Males 8-8.5 Broslow tape, little finger diameter 4 + age/4

Depth
Females - 21 cm; Males - 23 cm Broslow tape, markings on ETT ETT size x 3 (cm); age + 10
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Preoxygenation
Establish an O2 reservoir in the lungs & body
Essential to no bagging principle of RSI Function residual capacity is primary reservoir Permits several minutes of apnea without desaturation

100% O2 via nonrebreather for 5 minutes OR 8 VC breaths with 100% O2 via bag/mask
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Pretreatment (LOAD)
Mitigate adverse effects of laryngoscopy Lidocaine 1.5 mg/kg
Airway bronchospasm / cough reflex Increased ICP

Opiates (Fentanyl 3-6 mcg/kg)

Increased ICP, aortic dissection, ruptured aortic or IC aneurysm, ischemic heart disease Blunts reflex sympathetic response to laryngoscopy Not recommended under age 1
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Pretreatment (LOAD)
Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg)
Children <= 10 yo Blunts vagal response to laryngoscopy

Defasiculation (with succinylcholine)

Increased ICP 1/10th dose of a non-depolarizing NMB Not indicated under age 5

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Paralysis with Induction

Rapid IV administration of sedation followed immediately by rapid administration of a neuromuscular blocking agent Iv induction agent (etomidate, propofol, thiopentone or ketamine) Iv suxamethonium (immediately after induction agent) Fluid bolus
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Protection and Positioning

Sellicks maneuver
Cricoid pressure Maintain until placement confirmation and cuff inflation

Positioning
Patient in supine position

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Placement with Proof

Test for jaw flaccidity Extend head on neck Gentle controlled technique Blade entry on right, sweep tongue to left Lift handle up and away Suction prn Insert into esophagus, then slowly withdraw Visualize vocal cords Watch ETT pass through vocal cords Check ETT depth Never let go of the tube! Inflate cuff Auscultation
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Placement with Proof

Confirm tracheal placement
Direct visualization plus either EtCO2 detector or Esophageal detector
Preferred in cardiopulmonary arrest

Confirm depth (cords > bronchus)

Auscultation CXR
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Post-Intubation Management
Secure ETT Reassess VS PCXR for depth of placement Bradycardia / Hypoxia -> Nontracheal tube placement until proven otherwise Hypertension->inadequate sedation/analgesia Hypotension
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Post-intubation Management
(Hypotension)

Tension PTX
High PIP, hard to bag, decreased BS, hypoxia Immediate thoracostomy

Decreased venous return

High PIPs 2ndary to high intrathoracic pressure Fluids, bronchodilators, Increase expiratory time, decrease TV

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Post-intubation Management
(Hypotension)

Induction agent
Other causes excluded Fluid bolus, consider reversal agent, expectant

Cardiogenic
Usually a compromised pt Check EKG, exclude other causes Fluid bolus (caution), pressors

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Medications
Pretreatment drugs (LOAD)
Lidocaine Opiates Atropine Defasiculation

Sedation Paralysis

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Sedation
Midazolam Etomidate Methohexital / Thiopental Ketamine Propofol

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Neuromuscular Blocking Agents

Noncompetitive depolarizer
Succinylcholine (Anectine)

Competitive nondepolarizer Benzylisoquinolinium group

Atracurium (Tracrium), cisatracurium (Nimbex), mivacurium (Mivacron)

Aminosteroid group
Pancuronium (Pavulon), vecuronium (Norcuron), rocuronium (Zemuron)
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Succinylcholine (SCh) (Anectine)

Rapid onset (45 seconds) and short duration of action (<= 10 minutes) Mechanism of action Metabolism Sequence of action Dosing

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SCh Adverse Effects

Malignant hyperthermia Masseter spasm Hyperkalemia Increased ICP / Increased IOP
Fasciculations
Bradycardia (peds) Prolonged NMB Hypotension (histamine release, (-) inotrope)

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SCh Contraindications
Personal or FH of malignant hyperthermia
Known or suspected hyperkalemia > 24 hours post-burn (>10% BSA, 1-2 yrs) > 1 week post crush injury (60-90 days) > 1 week post SCI or CVA (6 months) Neuromuscular disease (indefinite)
MS, ALS, muscular dystrophy

Anticipated difficult airway

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Competitive, Nondepolarizing NMB

Most commonly utilized post-intubation No CIs other than the difficult airway Disadvantage is longer onset and duration Metabolism variable Higher dose reduces time to paralysis but prolongs time to recovery

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Competitive, Nondepolarizing NMB

Aminosteroid group dose not cause histamine release Reversible with AChesterase inhibitor
Requires 40% spontaneous recovery

Consider administering sedation shortly after administering vecuronium or pancuronium for RSI

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Competitive, Nondepolarizing NMB

Rapacurium off the market Rocuronium (0.6-1.2 mg/kg) Mivacurium (0.15 mg/kg) Vecuronium (0.3 mg/kg) Pancuronium (0.1 mg/kg)

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