Rapid Sequence Induction

What is it?

It is a virtually simultaneous administration of a potent sedative and a neuromuscular blocking agent for the purpose of intubation

Purpose

Routine: To introduce anesthesia and neuromuscular blockade in preparation for intubation Emergency: To produce neuromuscular blockade to facilitate placement of an endotracheal tube in those patients in which the airway could not otherwise be managed.

Candidates for RSI

Adults and children Full or partially conscious Seizures resulting in status epilepticus unresponsive to benzodiazepines. Hypoxic and Combative, unable to intubate by regular means Trauma with seizures or trismus

Advantages

Easier intubation Reduces ICP associated with intubation Short-acting

Indications

Inadequate oxygenation Inadequate ventilation Inability to maintain a patent airway Protection of the lower airway Treatment of elevated ICP Impending airway collapse Control of the patient Head injuries Drug overdose Status epilepticus

General Order of Rapid Sequence Induction

Brief History Equipment Preparation Preoxygenation Premedication Sedation Cricoid Pressure Muscle Relaxation Intubation Verification of Tube Placement Tube Security

Brief History

ABCs have been checked if a decision to intubate has been made History of present illness or injury Inspection of head and airway

Difficult airway???

Assessment of neck for possible trauma

Difficult Airways-MEDICTUBES

Mouth, mandible Excessive weight Deformity Incisors C-spine Thyromental distance Uvula Burns Emesis Stridor

Mouth, Mandible
Measure the width of the mouth opening. Anything less than three (3) fingers width can complicate laryngoscopy. Mandible should be without deformity or dislocation.

Excessive Weight
Overweight, pregnant or no-neck patients can also be very complicated. Complete repositioning of the patient may be required in order to visualize the airway

Deformity

Incisors

C-Spine, Trauma
Patients with cervical immobilization in place have mis-aligned airway structures, landmarks and pathways. These patients must remain immobile with cervical spine secured without manipulation when attempting intubation.

Thyromental Distance

Distance from chin to thyroid cartilage. Anything less than three (3) fingers width suggests difficult intubation.

Uvula
Mallampati Signs. Ideally, you should be able to see the entire oropharynx, including the uvula. Any airways with a partial or complete concealment of this structure may prove difficult to intubate.

Burns

Emesis

Stridor

Equipment and Medication

SOAPME

Suction Oxygen Airway (laryngoscope, ET tubes, stylet, BVM, tube holder) Pharmacology (mix, draw-up and label) Monitoring Equipment (ECG, SaO2, etCO2)

Preoxygenation

2- 5 minutes of 100% Oxygen before initiation of sedation and neuromuscular blockade BVM only if necessary

Premedication

Atropine *

in children only

Due to vagal stimulation causing bradycardia Prevention of increased ICP

Lidocaine

Defasciculating Agent

Atropine

Bradycardia may be caused by hypoxia, succinylcholine or vagal stimulation during laryngoscopy or vagal stimulation Atropine reduces vagal tone Atropine decreases secretions *Atropine may be indicated before a second dose of succinylcholine in adolescents and adults Adult: 0.6 0.8 mg IV, Pediatric: 0.02 mg/kg

Lidocaine

Is believed to blunt the increased ICP response to intubation It is required in all cases of suspected head trauma Dosage: 1.5 mg/kg IVP

Sedation

Administered to eliminate the sensation of paralysis and decrease sympathetic tone Remember that paralytics do NOT alter consciousness. They do not work on the central nervous system. Your patient is aware of everything that is going on!

Sedation Options

Sedative selection must be made on an individual patient basis with consideration of hypovolemia, hypotension, increased ICP, age and underlying medical conditions Sedatives should never be withheld from the patient about to undergo paralysis! There are ethical considerations as well.

Sedatives
While benzodiazepines are mostly given in the field, you may also need to be familiar with these other sedatives: Thiopental (Pentothal) Midazolam (Versed) Lorazepam (Ativan) Fentanyl (Sublimaze) Ketamine (Ketalar) Etomidate (Amidate) Propofol (Diprivan)

Thiopental (Pentothal)

Short-acting barbiturate Produces rapid, deep sedation but not analgesia Excellent choice for sedation of patients with head injury because:
attenuates the ICP response to intubation reduces the cerebral metabolic rate and oxygen consumption acts as a free radical scavenger to decrease brain damage by toxic metabolites in the injured brain

Thiopental (Pentothal) contd

Adverse Effects:
respiratory depression and apnea decreased cardiac output hypotension anaphylaxis bronchospasm

Midazolam (Versed)

Benzodiazepine Provides sedation, amnesia and anticonvulsant properties No analgesia Advantages over other benzodiazepines
faster onset than Ativan or Valium shorter duration than Ativan or Valium

Midazolam (Versed) contd

Adverse effects:
cardiovascular depression respiratory depression broad dosing range and need for titration

Fentanyl (Sublimaze)

Short-acting narcotic Often used in combination with a benzodiazepine The dose for induction is variable and much higher than for premedication

Fentanyl (Sublimaze) contd

Adverse Effects:
cardiovascular depression at high doses skeletal and thoracic muscle rigidity

Ketamine (Ketalar)

A dissociative anesthetic agent Also a phencyclidine derivative Causes analgesia, amnesia, dissociation from the environment, maintenance of reflexes, cardiorespiratory stability

Ketamine (Ketalar) contd

Adverse Effects:
increases ICP increases blood pressure increases airway secretions increases intraocular pressure increases intragastric pressure causes hallucinations known as emergence reactions

Etomidate (Amidate)

Rapid-onset Short-acting Sedative-hypnotic agent Not approved for children under 10 years Reduces cardiorespiratory depression Minimizes increased ICP during intubation

Etomidate (Amidate) contd

Adverse Effects:
transient reduction in plasma cortisol levels transient reduction in aldosterone levels

Propofol (Diprivan)

Relatively new anesthetic induction and sedative agent Rapid onset Short duration of action Cerebroprotective effects similar to thiopental Recommended for ages 3 and over

Propofol (Diprivan) contd

Adverse Effects:
can decrease mean arterial pressure

Prehospital Choice

There is literature that demonstrates that approximately 30% of prehospital RSI could be avoided by using Highdose Versed Dose 0.1 mg/kg (max dose is 10 mg) Often, the patient will sedate enough to be intubated without requiring RSI. If unsuccessful, proceed to paralytics.

Cricoid Pressure

Sellecks Maneuver prevents passive regurgitation during intubation Place digital pressure over the cricoid cartilage to occlude the esophagus Cricoid pressure is released after the patient has been successfully intubated

Muscle Relaxation

Neuromuscular Blockade allows for easier intubation and ventilation A muscle relaxant is given in rapid sequence with a sedative before intubation is attempted

Categories of Neuromuscular Blocking Agents

Depolarizing

(noncompetitive and nonreversible) produces a brief period of excitation resulting in fasciculations followed by a brief period of neuromuscular blockade

Nondepolarizing
(competitive and reversible) slower onset than depolarizing agent no fasciculations

Neuromuscular Blockade

Using neuromuscular blockade How neuromuscular blocking agents work

Before Paralysis

Clinical endpoint should be established at the start Know exactly why the patient is being paralyzed How will we know when we have met goals of care?

Indications for Paralysis

To facilitate intubation Agitation so severe that patient is at risk of injury despite appropriate sedation Severe hypoxemia, to reduce oxygen consumption by muscle movement Increased ICP Seizures, trismus

Indications for Paralysis

To facilitate procedures and diagnostic tests such as CT scans and MRIs, when patients must remain still

Indications for Paralysis

When patients with seizures are paralyzed, it is critical to remember that just because you cant see motor activity, it doesnt mean the seizures are stopped in the brain!

How Muscles Contract

Muscle receives impulse from nerve or nerve group Muscle and nerve do not touch Synapse at the neuromuscular or myoneural junction

How Muscles Contract

Axon contains neurotransmitter Muscle has special receptors Between nerve and muscle, neurotransmitter is acetylcholine

How Muscles Contract

Acetylcholine triggers cholinergic receptors on muscle cells Muscle contracts Acetylcholinesteras e removes neurotransmitter

Classifying NMBs

Depolarizing mimic acetylcholine sustained depolarization at synapse prevents repolarization muscle fiber refractory

Nondepolarizing block cholinergic transmission at synapse binds to acetylcholine receptors on muscle

Classifying NMBs

Depolarizing succinylcholine

Nondepolarizing atracurium doxacurium mivacurium pancuronium rocuronium Vecuronium rapacuronium

Classifying NMBs

Short & Intermediate rapacuronium atracurium mivacurium rocuronium vecuronium

Long Acting doxacurium pancuronium

Patient Care Responsibilities

All patients receiving paralytic drugs must also receive sedation

Succinylcholine (Anectine)

Depolarizing agent Rapid onset Short duration

Succinylcholine (Anectine) contd

Adverse Effects:
increased ICP increased intraocular pressure increased intragastric pressure hyperthermia muscarinic stimulation of the SA node causing bradycardia especially in children release of potassium

Succinylcholine (Anectine) contd

Contraindications:
patients with burns more that 24 hours old massive muscle injury patients with upper motor neuron diseases such as Muscular Dystrophy penetrating globe injury history of malignant hyperthermia other agents are preferable in children

Rocuronium (Zemuron)

Nondepolarizing agent Relatively new agent Rapid onset Vagolytic properties Studies with Succinylcholine have shown no difference in time to action No fasiculations at onset of paralysis

Rocuronium (Zemuron) contd

Longer duration than Succinylcholine

Vecuronium (Norcuron)

Nondepolarizing agent Slower onset Longer duration Minimal cardiovascular effects Produces no histamine release

Vecuronium (Norcuron) contd

Longer duration than Succinylcholine 90 - 120 minutes

Reversing Nondepolarizing Agents

Neostigmine Pyridostigmine Edrophonium Administer Atropine before reversing a nondepolarizing agent to abort the muscarinic effects

Intubation

Visualization with direct laryngoscopy Introduction of the appropriate sized ET tube

Verification of Placement

Auscultation of bilateral breath sounds Equal chest rise, misting in tube Absence of epigastric air movement Use one other method besides auscultation
End-Tidal CO2 monitoring Esophageal Detector Device

Security of ET Tube

Chart the depth of the ET tube at the patients lip Use tape or an approved ET tube holder to secure the ET tube at the correct depth Re-evaluate tube placement by checking the depth of the ET tube and auscultating breath sounds at regular intervals

Summary

Be prepared Re-assess frequently Be vigilant