Rapid Sequence Intubation

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Rapid Sequence Intubation

• Anthony G. Hillier, D.O.
• EM Resident
• St. John West Shore

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Rapid Sequence Intubation

• The induction of a state of unconsciousness with
  complete neuromuscular paralysis to achieve
  intubation without interposed mechanical
  ventilation in efforts to facilitate the
  procedure and minimize risks of gastric aspiration

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Rapid Sequence IntubationIndications

• Failure of airway maintenance/protection
• - lost or diminished gag reflex
• Failure of oxygenation/ventilation
• - pulmonary edema, COPD
• Anticipated clinical course
• - multiple trauma, head injured
• - intoxication, air transport

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Rapid Sequence Intubation6 Ps

• Preparation T-10
• Positioning
• Preoxygenation T-5
• Premedication T-3

• ParalysisT-0
• Placement of tube T45
• Post management T2

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Preparation
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Preparation

• Evaluate
• LEMON
• Equipment Check
• Positioning
• Drug Selection
• IVs, monitor, oximetry
• Ancillary Staff
• Anticipate alternative airway maneuver

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Preparation

• LEMON
• L-look
• E-evaluate the 3-3-2 rule
• M-Mallampati
• O-Obstruction
• N-Neck mobility

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PREOXYGENATION
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Preoxygenation

• 100 O2 for 5 minutes of 5 vital capacity
  breaths can theoretically permit 3-5 minutes of
  apnea before desaturation to less than 90 occurs

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Preoxygenation

• nitrogen wash-out
• Avoid bagging the patient if adequately
  preoxygenated

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PREMEDICATION
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Premedication

• Goal is to blunt the patients physiologic
  responses to intubation
• Minimizes bradycardia, hypoxemia, cough/gag
  reflex, increases in intracranial, intraocular,
  and intragastric pressures

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Premedication

• Lidocaine
• Opioid
• Atropine
• Defasciculating doses priming

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Lidocaine

• Thought to blunt the rise in intracranial
  pressure associated with airway manipulation and
  the use of depolarizing neuromuscular blocking
  agents
• 1.5-3.0 mg/kg (average 100mg) three minutes prior
  to intubation

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Atropine

• 0.02 mg/kg, minimum 0.1 mg IV, max 1 mg, three
  minutes prior to intubation
• Can minimize vagal effects, bradycardia and
  secretions
• Infants and children lt 8 years may develop
  profound bradycardia during intubation

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Defasciculating doses

• Decreases muscle fasiculations caused by the
  depolarizing agents (succinylcholine)
• Attenuates rise in intracranial pressure
• Agents used are the non-depolarizing blocking
  agents (vecuronium, pancuronium etc.) usually
  1/10 of standard dose

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Sedation

• Sedative agents administered at doses capable of
  producing unconsciousness with little or no
  cardiovascular effects
• No ideal agent exists
• Sedation should nearly always be used when
  paralyzing the patient

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Sedation

• Barbiturates/hypnotics
• Non-barbiturate
• Neuroleptics
• Opiates
• Benzodiazepines

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Barbiturates/Hypnotics

• Thiopental (Pentothal), Methohexital (Brevital)
• Short onset (10-20) seconds, duration 5-10
  minutes
• May reduce intracranial pressure,
  cerebro-protective
• Histamine release, hypotension, bronchospasm

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Barbiturates/Hypnotics

• Etomidate (Amidate) a nonbarbiturate hypnotic
• Decreases ICP/IOP
• Rapid onset, short duration
• Minimal hemodynamic effects
• No histamine release
• Increases seizure threshold

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Etomidate

• No malignant hyperthermia reported
• Watch for myoclonus, vomiting
• May decrease cortisol synthesis (adrenal
  insufficiency)
• Dose 0.3 mg/kg IV

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Propofol

• Propofol (Diprivan), sedative hypnotic
• Extremely rapid onset (10 sec), duration of 10-15
  minutes
• Decreases ICP
• Can cause profound hypotension
• Dose 1-3 mg/kg IV for induction
• Dose 100-200 mcg/kg/min for maintenance

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Ketamine

• Ketamine-dissociative anesthetic
• Rapid onset, short duration
• Potent bronchodilator, useful in asthmatics
• Increases ICP, IOP, IGP
• Contraindicated in head injuries
• Increases bronchial secretions

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Ketamine

• Emergence phenomenon can occur though rarely in
  children less than 10 years
• Emergence reactions occur in up to 50 of adults
• Dose 1-2 mg/kg

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Opiates
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Fentanyl

• Fentanyl
• Broad dose-response relationship
• Can be reversed with naloxone
• Fentanyl is rapid acting (lt1 min), duration of 30
  min
• Does not release histamine

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Fentanyl

• May decrease tachycardia and hypertension
  associated with intubation
• Seizures and chest wall rigidity have been
  reported
• Dose 2-10 mcg/kg IV

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Morphine Sulfate

• Longer onset (3-5) minutes and duration (4-6)
  hours
• May not blunt the rise in ICP, hypertension and
  tachycardia as well as fentanyl
• Dose 0.1-0.2 mg/kg IV
• Histamine release

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Benzodiazepines
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Benzodiazepines

• Midazolam, Diazepam, Lorazepam
• Provide excellent amnesia and sedation
• Broad dose-response relationship
• Reversed with Flumazenil (Romazicon)
• Doses required are higher for RSI than for
  general sedation

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Midazolam

• Slower onset (3-5) min than the
  barbiturate/hypnotic agents
• Considered short-acting (30-60 min)
• Does not increase ICP
• Causes respiratory and cardiovascular depression
• Dose 0.1-0.4mg/kg IV

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Diazepam and Lorazepam

• Moderate/long acting agents
• Longer onset time than midazolam
• May be more beneficial post-intubation for
  sedation

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Paralysis
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Neuromuscular Blocking Agents

• Chemical paralysis facilitates intubation by
  allowing visualization of the vocal cords and
  optimizing intubating condition
• Only CONTRAINDICATION is anticipated difficult
  airway
• Mallampati Class
• Thyromental Distance

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Depolarizing Agents

• Exert their affect by binding with acetylcholine
  receptors at the neuromuscular junction, causing
  sustained depolarization of the muscle cell

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Nondepolarizing

• Bind to acetylcholine receptors in a competitive,
  non-stimulatory manner, no receptor
  depolarization
• Histamine release
• Agents can be reversed with edrophonium or
  neostigmine
• Caution with myasthenia gravis

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• Depolarizing agents
• Succinylcholine (Anectine)
• Nondepolarizing Agents
• Pancuronium (Pavulon)
• Vecuronium (Norcuron)
• Atracurium (Tracrium)
• Rocuronium (Zemuron)
• Mivacurium (Mivacron)

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Succinylcholine

• Stimulates nicotinic/muscarinic cholinergic
  receptors
• Gold standard for 50 years
• Onset 45 seconds, duration 8-10 minutes
• Dose (adults 1.5 mg/kg IV)
• Children 2.0 mg/kg IV
• Inactivated by pseudocholinesterase

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Succinylcholine cont

• Prolonged paralysis seen with
• Pregnancy
• Liver disease
• Malignancies
• Cytotoxic drugs
• Certain antibiotics
• Cholinesterase inhibitors
• Organophosphate poisoning

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Succinylcholine

• Adverse reactions
• Muscle fasiculations
• Hyperkalemia
• Bradycardia
• Prolonged neuromuscular blockade
• Trismus
• Malignant hyperthermia

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Depolarizing Agents

• Muscle fasiculations
• Thought to increase ICP/IOP/IGP
• Causes muscle pain
• Minimized by priming dose of NMB
• Hyperkalemia
• Average increase in potassium of 0.5-1 mEq/L
• Burns, crush injuries, spinal cord injuries,
  neuromuscular disorders, chronic renal failure

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Depolarizing agents

• Bradycardia
• Most common in children lt10 years due to higher
  vagal tone
• Also with repeated doses of succinylcholine
• Premedicate with atropine

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Depolarizing Agents

• Malignant hyperthermia
• From excessive calcium influx through open
  channels
• Genetic predisposition
• Rapid temperature, rhabdomyolysis, muscle
  rigidity, DIC
• 60 mortality
• Treatment IV Dantrolene

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Depolarizing Agents

• Trismus (Masseter spasm)
• Usually in children
• Unknown cause
• Treat with a nondepolarizing NMB

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Pancuronium

• Long-acting agent (45-90 min)
• Slow onset (1-5 min)
• Renal excretion
• Vagolytic tachyarrythmias common
• Dose 0.10-0.15 mg/kg IV

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Vecuronium

• Duration of 30-60 min
• Onset of 1-4 min
• Hypotension may occur from loss of venous return
  and sympathetic blockade
• Mostly biliary excretion
• Dose 0.1 mg/kg
• priming dose 0.01 mg/kg

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Rocuronium

• Has the shortest onset of the nondepolarizing
  agents (1-3 min)
• Duration 30-45 min
• Tachycardia can occur
• Dose 0.6-1.2 mg/kg

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Placement of Endotracheal Tube
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Placement of Tube

• Allow medications to work and assure complete
  neuromuscular blockade of the patient
• Maintain Sellick maneuver until cuff inflated
• Ventilate with bag-valve mask if unsuccessful
• Additional doses of sedatives/NMB may be
  necessary
• Confirm tube placement

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Post Intubation
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Post Intubation Management

• Secure tube
• Continuous pulse oximetry
• Reassess vital signs frequently
• Obtain chest x-ray, ABG
• Restrain patient
• Consider long term sedation

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Questions??

• Thank You!