AIRWAY 1:

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AIRWAY 1 RAPID SEQUENCE INTUBATION Stuart
Swadron, MD, FRCPC, FACEP Program
Director Residency in Emergency Medicine Keck-USC
School of Medicine
LACUSC Dept. of Emergency Medicine
July 19, 2007
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DEFINITIONS
Rapid Sequence Intubation
INDUCTION AGENT PARALYTIC
UNCONSCIOUSNESS MOTOR PARALYSIS
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DEFINITIONS
Pharmacologically Assisted Intubation
INDUCTION AGENT
UNCONSCIOUSNESS
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DEFINITIONS
Geneva Convention Violation
PARALYTIC
MOTOR PARALYSIS
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RATIONALE Principle
Decreased aspiration
Increased success
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RATIONALE - Secondary
Better C-spine control
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RATIONALE - Secondary
Blunting ? ICP / IOP
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RATIONALE - Secondary
Avoid airway trauma
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RATIONALE - Secondary
Avoid airway trauma
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? Pain ? Discomfort ? Recall
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HAZARDS
Prolonged intubation
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HAZARDS
Adverse Drug Events
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HAZARDS
May force crash airway scenario
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INDICATIONS

• Failure OR Imminent failure of
• 1. oxygenation
• 2. ventilation
• 3. airway protection or maintenance

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CONTRAINDICATIONS
RISK
INDICATION
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RSI CAN ALSO BE

• UNNECESSARY
• - OR
• INAPPROPRIATE

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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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PREPARATIONt 10 minutes

• 1. EQUIPMENT PRESENT AND WORKING
• MUST INCLUDE EQUIPMENT
• FOR PLAN B

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PREPARATIONt 10 minutes

• 2. ASK CAN I
• BAG THE PATIENT
• TUBE THE PATIENT
• CRIC THE PATIENT

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L ook at general anatomyE valuate the 3-3-2
ruleM allampati scoreO bstructionN eck
mobility
CAN I TUBE THIS PATIENT?
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CAN I BAG THIS PATIENT?
Maybe.
Maybe Not.
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CAN I CRIC THIS PATIENT?
may include alternative airway techniques
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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PREOXYGENATIONt 5 minutes

• 1. PRIMUM NO BAGER!
• (First, do not bag!)
• 2. If you do need to bag,
• Remember TOM

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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2 TISSUES
pO2 LUNGS
pO2 BLOOD
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PREOXYGENATIONt 5 minutes

• 1. Well-fitting mask
• 8 vital capacity breaths

Nimmagadda et al. Anesthesiology 93 (3) 693-698,
2000 Baraka et al. Anesthesiology 91 (3) 612,
1999
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PREOXYGENATIONt 5 minutes
Ill adult
Normal child
Normal adult
Obese adult
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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PRETREATMENTt 3 minutes

• L Lidocaine
• O Opioids
• A Atropine
• D Defasciculating Medication

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PRETREATMENTt 3 minutes

• LOAD
• may just be a
• LOAD

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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

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OPIOIDS (Fentanyl)

• Traditional Indications
• 1. Blunt hemodynamic response
• 2. Decrease pain

Adachi et al. Anesthesia Analgesia.
95(1)233-7, 2002
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FENTANYL DOSE

• Dose 3µg/kg IV slow push

Beware of hypotension and apnea
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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 Care20(10)651-5,
2004 McAuliffe et al. Can J Anaesth 43(7)
754-5,1996 Fleming et al. CJEM. 20057(2)114-7
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DEFASCICULATING DOSEOne tenth the RSI dose

• Traditional Indications
• Blunt rise in ICP
• 2. Decrease risk of aspiration
• 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
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And whats moreDEFASCICULATING DOSEcan be
downright dangerous

• it may cause premature apnea

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PRETREATMENTt 3 minutes

• If youre going to give these drugs
• at least give them some time to circulate (3
  minutes)

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Summary of LOADPRETREATMENT

• L idocaine ? optional
• O piates ? optional
• A tropine ? still mandatory for kids lt 8
• D efasciculating ? optional
• dose

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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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PARALYSIS WITH INDUCTIONTime 0

• PARALYTIC AGENTS
• DEPOLARIZING
• Succinylcholine
• NON-DEPOLARIZING
• Vecuronium
• Rocuronium

• INDUCTION AGENTS
• Etomidate
• Thiopental
• Ketamine
• Propafol
• Midazolam

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SUX IS STILL KING

• but nondepolarizing agents are gaining ground
• Perry et al. Academic Emergency Medicine 9(8)
  813-23, 2002

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SUX versus ROC

• 45 seconds ONSET 1 minute
• 9 minutes DURATION 45 minutes

1-2.5 mg/kg
1 mg/kg
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When Sux Really SucksCONTRAINDICATIONS

• 1. HYPERKALEMIA
• RENAL FAILURE
• RHABDOMYOLYSIS
• 2. RECEPTOR UPREGULATION
• SUBACUTE BURNS (gt1 day)
• SUBACUTE DENERVATING DISORDER
• HISTORY OF MALIGNANT HYPERTHERMIA

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Advent of the Non-Depolarizing Agents

• Pancuronium
• Vecuronium
• Rocuronium
• Rapacuronium oops!

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Making non-depolarizing agents FASTER

• 1. Large Doses
• 2. Priming Doses
• 3. Better Induction Agents

Increase duration
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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

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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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PROTECTION AND POSITIONING t 20 seconds
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C Spine Precautions
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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PLACEMENT AND PROOF t 45 seconds
Over here, Socrates !!!
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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POST-INTUBATION MANAGEMENT t 90 seconds THE
APRÈS INTUBATION

• CONFIRM INTUBATION
• SECURE TUBE
• CHECK CHEST X-RAY, ABGS

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CONFIRMING INTUBATION
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SECURING TUBE
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THE 7 Ps OF RSI

• PREPARATION
• PREOXYGENATION
• PRETREATMENT
• PARALYSIS WITH INDUCTION
• PROTECTION AND POSITIONING
• PLACEMENT AND PROOF
• POST-INTUBATION MANAGEMENT

t 10 minutes
TIME ZERO
t 90 seconds
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PUTTING IT ALL TOGETHER
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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 µg/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

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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

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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

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INTUBATION HURTS!!!

• And it keeps on hurting once the tube is in.

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Thank you!