Transcript RSI: Rapid Sequence Intubation

RSI: Rapid Sequence Intubation
What, When, Where, Why & How
Michael T. Czarnecki, MD
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Objective
What is RSI?
Discuss the “7 P’s” of RSI
Review RSI pharmacologic agents
Highlight current controversies with RSI
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RSI Defined
“Virtually simultaneous administration
of a potent sedative agent and a
neuromuscular blocking agent to
induce unconsciousness and motor
paralysis for tracheal intubation”
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Why Bother with RSI?
Rapid airway control
Less risk of aspiration
Highest success rates/lowest complications
– More controlled
Optimal intubating conditions
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What are The Problems Inherent to
Intubation?
Laryngoscopy and Intubation
– Increased bronchospasm
– Increased ICP
– Increased catecholamine release
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Beneficial Effects of RSI
“Tight Heads”
– Intracranial pathology
“Tight Hearts” or “Tight Vessels”
– Cardiovascular disease
“Tight Lungs”
– Reactive airway disease
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Assumptions in Airway
Management
Pt. has a full stomach
Pt. is preoxygenated
Pts. do not receive BVM ventilation unless
necessary to keep O2 sat. over 90%
Sellick’s maneuver always used
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RSI: “7 P’s”
1.
2.
3.
4.
5.
6.
7.
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P = Preparation
P = Preoxygenation
P = Pretreatment
P = Paralysis with induction
P = Protection
P = Placement of the tube
P = Post-Intubation management
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RSI: Timeline
T – 10 minutes
T – 5 minutes
T – 3 minutes
T=0
T + 30 seconds
T + 45 seconds
T + 90 seconds
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Prepare
Preoxygenate
Pretreat
Paralysis with
induction
Protection
Placement
Post-Intubation
management
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Preparation: T – 10 minutes
Prepare the patient
– Monitoring/access
– Positioning
– Assess for difficult airway
• “4 D’s”,“LEMON”, “BONES”, “SHORT”
• Mallampati
Prepare your equipment
Prepare yourself (mental checklist)
Prepare your personnel
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Difficult Airway Assessment
4 D’s
– Distortion, Disproportion, Dysmobility, Dentition
BONES
– Beard, Obese, No teeth, Elderly, Snores (sleep apnea)
SHORT
– Surgery (head/neck/jaw), Hematoma, Obese, Radiation,
Tumor
LEMON
MALLAMPATI
Always have a “Rescue Airway” technique ready
JUMP AHEAD
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MALLAMPATI SCORE
Class I
Class II
Class III
Class IV
JUMP BACK
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60-SECOND EXAM “LEMON”
Look for external difficulty
Evaluate using 3=3=2 rule
3 fingers
fit in
Mallampati(Class
I&
II)mouth
 3 fingers fit from mentum
Obstruction to hyoid cartilage
 2 fingers fit from mandible
Neck Mobility
to top of thyroid cartilage
JUMP BACK
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Rescue Airways
Gum Elastic Bougie (GEB)
Laryngeal Mask Airway (LMA/ILMA)
Combitube
Surgical Cricothyrotomy
JUMP BACK
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Preoxygenate: T – 5 minutes
Provides reservoir of oxygen during apnea
If pt. spont. breathing – then NRB for 5’
– Provides maximum of 70% FiO2
Avoid bagging the spont. breathing patient
– If needed, use sellick & airway adjunct
– 8 effective Vital Capacity breaths provides best
preoxygenation
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Pretreat: T – 3 minutes
L - Lidocaine
O - Opiates
A - Atropine
D – Defasiculating Agent
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Lidocaine (1.5 mg/kg)
Consider in “Tight Head” or “Tight Lungs”
– Blunts ICP rise (??)
– Suppress cough response
• may blunt bronchospasm
• may blunt sympathetic response
Does Lido help in head trauma?
– No clinical trials have answered question
– Not proven to change outcome
– Little downside in using
Robinson, Emeg Med J 2001; 18:453
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Opioids
Fentanyl (3 mcg/kg slow IV over 3’)
– Consider in “Tight Heads”, “Tight Heart”, &
“Tight Vessels”
– Beware: cautious use in pt’s dependent on
sympathetic drive (aka, trauma)
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Atropine
Only needed in:
– Children under 10 y.o.
– Adults receiving 2nd dose of succinylcholine
0.01 mg/kg IV push
– Minumum dose: 0.1 mg
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Defasiculating Agent
Use any paralytic at 10% paralyzing dose
Consider in “Tight Heads”
Beware: may cause hypoventilation and
frank paralysis – be prepared
Who needs defasiculation?
– Helps mitigate ICP rise with succinylcholine
– Not really useful in any other ICU situation
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Paralysis with Induction: T = 0
Tailor inducing agent to specific needs
–
–
–
–
–
Barbituates
Etomidate
Midazolam
Ketamine
Propofol
JUMP AHEAD
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Barbituates
Decreases GABA dissociation at receptor
Rapid onset sedation
Decreases ICP
Hypotension (especially in hypovolemia)
Choices:
– Thiopental, pentobarbital, methohexital
Overall – Etomidate is better that Barbs
JUMP BACK
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Thiopental
Onset 15 seconds, duration 3-5 minutes
Cardiac depressant, venodilator
– Hypotension
Dose depedent on pt. profile
– Euvolemic adult (3-5 mg/kg IV)
– Hypovolemic adult (1-3 mg/kg IV)
JUMP BACK
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Etomidate
Nonnarcotic, nonbarbituate, nonanalgesic
Minimal cardio effects, lowers ICP
Is it the ideal agent for RSI?
– May cause critical adrenal suppression
• Inhibits adrenal mitochondrial hydroxylase activity
• Occurs after both single bolus and infusions
• Infusions incr. ICU death rate & incr. infections
– Clinical significance is unclear
• Randomized, controlled trials on outcomes needed
Malerba, et al: Intensive Care Med 2005
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Etomidate (con’t)
Induction dose: 0.2 – 0.3 mg/kg IV
Onset: 20 – 30 seconds
Duration: 7 – 15 minutes
May cause myoclonic jerking, hiccups,
injection pain, N/V (also on emergence)
Risk for adrenal insufficiency incr. 12-fold
Jackson, Chest 2005 Mar
Murray, Chest 2005 Mar; 127:707-709
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Midazolam
Nonanalgesic sedative, anxiolytic, amnestic
Respiratory depressant and hypotension
– Give slow IV
– Give ½ the dose in elderly or COPD
Rapid onset (< 1 minute)
Induction dose (0.1 - 0.3 mg/kg) DIFFERENT
than sedation dose (0.01 – 0.03 mg/kg)
– In RSI, 92% of adults are underdosed
Sagarin, et al: Acad Emerg Med 2003 Apr; 10:329-38
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JUMP BACK
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Ketamine (1 – 2 mg/kg)
Dissociative, analgesic, amnestic
Causes catecholamine release
– Incr. BP, HR, ICP, Laryngospasm risk
Bronchodilator → induction agent in asthma
Onset: 15 – 30 seconds
Duration: 10 – 15 minutes
JUMP BACK
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Propofol (0.5 – 1.2 mg/kg)
(white magic, milk of amnesia)
Sedative-hypnotic
Cardiac depressant, venodilator
– Hypotension
– Decr. ICP at expense of CPP
JUMP BACK
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NMBs: Neuromuscular Blocking Agents
Depolarizing
– Succinylcholine
Non-Depolarizing
– Pan/Vec/Atra/Rocuronium
Potential Problems
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–
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Inadequate pre-intubation neuro exam
Failure to sedate
Inadequate pre-treatment or inadequate dosing
Aspiration and Dysrhythmias
Failed intubation → surgical airway needed
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Succinylcholine (1.5 – 2.0 mg/kg)
Onset: 15 – 30 sec; Duration: 5 – 12 min
Contraindications:
– FHx malignant hyperthermia, burns, crush
injuries, progressing neuromuscular disease
Side Effects:
– Brady, hyper-K+, fasciculations, MH
• ↓HR: pretreat all kids; adults 2nd dose with atropine
• ↑K+: peaks in 5’, resolves in 15’
– Treat like any hyperkalemia case
Use actual-body weight for dose
Rose, et al: Anesth Analg 2000
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Non-depolarizing NMBs
Longer duration than SUX, onset about equal
Aminosteroid compounds
– Pan/Vec/Rocuronium
Benzylisoquinolinum compounds
– Atracuronium
Vecuronium
0.1 – 0.2 mg/kg
1.5 – 2.5 minutes
25 – 45 minutes (90)
Less vagolytic
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Rocuronium
1 mg/kg
60 seconds
30 minutes (45)
Least cardio effects
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Rocuronium
Is it equivalent to SUX?
– Meta-analysis 1600 pts → equivalent in:
• Acceptable conditions for intubation
• Rates of intubation success
– But SUX is BEST at creating EXCELLENT conditions
Perry, AEM 2002
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RSI: Timeline
T – 10 minutes
T – 5 minutes
T – 3 minutes
T=0
T + 30 seconds
T + 45 seconds
T + 90 seconds
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Prepare
Preoxygenate
Pretreat
Paralysis with
induction
Protection
Placement
Post-Intubation
management
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Align the 3 axes – critical for success
Sellick’s maneuver
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Confirm placement/review CXR
Secure tube
Vent Settings
Administer sedation
Maintain paralysis if indicated
And…..
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Don’t Ever Forget the “7 Ps”
P = Preparation
P = Preoxygenation
P = Pretreatment
P = Paralysis with induction
P = Protection
P = Placement of the tube
P = Post-Intubation management
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WHEN IN DOUBT, PULL IT OUT!
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