Rapid Sequence

1
Rapid Sequence Intubation
Erik D. Barton, MD, MS, MBA
University of Utah Affiliated Emergency
Medicine Residency Program
2
The Decision to Intubate
Four Reasons for Intubation

• Establish, maintain or protect airway
• Failure to ventilate
• Failure to oxygenate
• Anticipated clinical course

3
First Provider Intubations
Sagarin, Barton, et al, Ann Emer Med, 2005
4
Rescue Intubations
Sagarin, Barton, et al, Ann Emer Med, 2005
5
Rapid Sequence Intubation
Definition
The virtually simultaneous administration of a
potent sedative agent and a neuromuscular
blocking agent to induce unconsciousness and
motor paralysis for tracheal intubation.
6
Rapid Sequence Intubation

• Just like Skydiving.
• Skydiving is lethal unless one deploys a
  parachute
• RSI is lethal unless you rescue the
  airway!

7
Rapid Sequence Intubation

• Just like Skydiving.
• Redundancy of safety (primary backup)
• Planned, stepwise approach to primary system
• Simple, fast backup system
• Attention to monitoring
• Equipment vigilance
• Levitan, RM. Ann Emerg Med. 20034281-87.

8
Rapid Sequence Intubation
Definition Incorporates

• Every patient has a full stomach
• Preoxygenation
• No interposed ventilations
• Sellicks maneuver

9
Rapid Sequence Intubation
Advantages of RSI

• Rapid control of the airway
• Minimizes risk of aspiration
• Highest success rates
• Lowest complication rates
• Optimal intubating conditions
• Adaptable to patient condition
• Can mitigate adverse effects

10
Rapid Sequence Intubation
The Six Ps of RSI
Preparation Preoxygenation Pretreatment Paralysis
with Sedation Protection Placement
11
Rapid Sequence Intubation
The Sequence
Zero the time of administration of
succinylcholine.
12
Rapid Sequence Intubation
The Sequence
Zero - 10 minutes
Preparation

• Assess airway difficulty (LEMON)
• Plan approach
• Assemble drugs and equipment
• Establish access
• Establish monitoring

13
Rapid Sequence Intubation
The Difficult Airway Rule
L ook externally E valuate 3-3-2 M allampati O
bstruction? N eck mobility
14
Rapid Sequence Intubation
The Sequence
Zero - 5 minutes
Preoxygenation

• 100 oxygen for five minutes
• 8 vital capacity breaths
• Provides essential apnea time
• Apnea time varies

15
Rapid Sequence Intubation
Time to Desaturation
16
Rapid Sequence Intubation
The Sequence
Zero - 3 minutes
Pretreatment

• Lidocaine
• Opioid
• Atropine
• Defasciculation

LOAD the patient before intubation.
17

PRETREATMENT AGENTS
National Emergency Airway Management Course
18
PRETREATMENT AGENTS

• L idocaine
• O pioid
• A tropine
• D efasciculation

Give 3 minutes before SCh
National Emergency Airway Management Course
19
PRETREATMENT AGENTS
LIDOCAINE
1.5 mg/kg

• Increased intracranial pressure
• Bronchospasm

National Emergency Airway Management Course
20
PRETREATMENT AGENTS
OPIOID
Fentanyl 3 mg/kg

• Cardiovascular disease
• Intracranial hypertension

Caution sympathetic drive
National Emergency Airway Management Course
21
PRETREATMENT AGENTS
ATROPINE
0.01 mg/kg

• Children lt 10 years who receive Sch

National Emergency Airway Management Course
22
PRETREATMENT AGENTS
DEFASCICULATION
10 of the paralyzing dose

• Vecuronium (0.01 mg/kg)
• Pancuronium (0.01 mg/kg)
• Rocuronium (0.06 mg/kg)

• Intracranial hypertension

National Emergency Airway Management Course
23
INDUCTION AGENTS
National Emergency Airway Management Course
24
INDUCTION AGENTS
HEALTHY, STABLE PATIENTS

• Etomidate 0.3 mg/kg
• Midazolam 0.2 mg/kg
• Ketamine 1.5 mg/kg
• Propofol 1 mg/kg
• Pentothal 3 mg/kg

National Emergency Airway Management Course
25
INDUCTION AGENTS
COMPROMISED/UNSTABLE PATIENTS

• Etomidate 0.1 mg/kg
• Midazolam 0.1 mg/kg
• Ketamine 1 mg/kg
• Propofol 0.5 mg/kg
• Pentothal 1.5 mg/kg

National Emergency Airway Management Course
26
INDUCTION AGENTS
FOR SPECIFIC CONDITIONS

• Reactive airways ketamine
• ICP etomidate, pentothal
• Hypotensive ketamine
• Operator preference

National Emergency Airway Management Course
27
Rapid Sequence Intubation
The Sequence
Zero!!
Paralysis with sedation

• Induction agent IV push
• Succinylcholine 1.5 mg/kg IVP

Entering the red zone...
28
NEUROMUSCULAR BLOCKADE

• Depolarizing
• succinylcholine
• Competitive (nondepolarizing)
• Aminosteroids
• Benzylisoquinolines

National Emergency Airway Management Course
29
Rapid Sequence Intubation
Succinylcholine

• Still the ED NMB of choice
• Rapid effect
• Short duration
• Generally well tolerated
• A few important side effects

30
NEUROMUSCULAR BLOCKADE
SUCCINYLCHOLINE

• Rapid onset / brief duration
• May ICP
• Fatal hyperkalemia
• burns beyond day one
• active neuromuscular disease
• crush injuries
• intra-abdominal sepsis (7D)

National Emergency Airway Management Course
31
NEUROMUSCULAR BLOCKADE
Aminosteroids
Benzylisoquinolines

• atracurium
• cisatracurium
• mivacurium
• metocurine
• DTC

• rocuronium
• pancuronium
• vecuronium
• rapacuronium

National Emergency Airway Management Course
32
NEUROMUSCULAR BLOCKADE
Summary

• SCh for RSI
• Competitive for pre-treatment
• Rocuronium for competitive RSI

National Emergency Airway Management Course
33
Rapid Sequence Intubation
The Sequence
Zero 30 seconds
Protection

• Sellicks Maneuver
• Position patient
• Do not bag unless S O lt 90

p
2
34
Rapid Sequence Intubation
The Sequence
Zero 45 seconds
Placement

• Check mandible for flaccidity
• Intubate, remove stylet
• Confirm tube placement - E CO
• Release Sellicks maneuver
• Long acting agents/ventilator

t
2
35
Rapid Sequence Intubation
Failed Attempt
Rescue Maneuvers

• Plan in advance
• Systematic approach essential
• Equipment
• Training
• remember Skydiving!!

36
Rapid Sequence Intubation
Failed Attempt
Rescue Maneuvers

• The first rescue from failed intubation is
  bagging.
• The first rescue from failed bagging is better
  bagging.
• Rescue devices

37
Rapid Sequence Intubation
How do we know that RSI really works?
38
The Science of Airway Management

• The problems
• Self-reporting
• Emergency conditions
• Multiple factors influence each course
• highly variable
• operator dependent
• Jargon not standardized

Wang, HE. Acad Emerg Med. 200310644-5.
39
NEAR
6294 ED Intubations from the second report of
the ongoing National Emergency Airway Registry
Study (NEAR II)
40

6294 Intubations from the National Emergency
Airway Registry
Methods Prospective, observational study from
8/97 to 4/00 of 26 teaching hospitals in the U.S.
during the second phase of the ongoing National
Emergency Airway Registry (NEAR II) study.
41
6294 Intubations from the National Emergency
Airway Registry
Personnel Performing ED Intubations
42
6294 Intubations from the National Emergency
Airway Registry
Demographics of Cases Indication Cases Female
Male Unknown Trauma 1605 (22) 349 (22) 1059
(65) 97 (3) Medical 4286 (72) 1740 (40) 2194
(51) 352 (9) Not Provided 277 (6) 84 (2) 166
(3) 27 (1) TOTAL 6294 (100) 1642 (36) 2545
(55) 415 (9)
43
6294 Intubations from the National Emergency
Airway Registry
Oral RSI 4377 (69) Oral no meds 1088
(17) Oral induction without paralysis 427 (7
) Nasal awake with topical 206 (3) Nasal
no meds 69 (1) Nasal induction without
paralysis 45 Surgical cric/tracheotomy
39 (0.6) Other 16 Oral awake with
topical 21 Unknown
5 TOTAL 6294
44
6294 Intubations from the National Emergency
Airway Registry
1st Course Success Rates Medical
Trauma Oral RSI 99.8 97.7 Oral no
meds 94.7 96.3 Oral induction without
paralysis 95.0 93.7 Nasal awake with
topical 97.2 98.1 Nasal no
meds 91.3 45.4 Nasal induction without
paralysis 97.0 100 Oral awake with
topical 93.7 N/A Other 50.0 100 Surg
ical cricothyrotomy 60.0 68.7 Unknown 50.
0 N/A TOTAL 94.7 96.2
45
6294 Intubations from the National Emergency
Airway Registry
Success Rates by Intubator First pass
Overall EM 84.7 98.5 Anesthesia
93.5 93.5 Other 64.9 97.4 Attending
EM 90.2 97.9 PGY 3 or 4 87.2
98.4 PGY 1 or 2 77.5 98.7 Other 81
.1 98.5
46
NEAR

• Other Studies
• Analysis of failed intubations and rescue
  techniques
• - Bair, AE, et al. J Emerg Med.
  200223131-40.
• Sedative agents facilitate intubations with NMB
• - Sivilotti, MLA, et al. Acad Emerg Med.
  200310612-20.
• Underdosing of midazolam in 92 of adults, 56
  of kids - Sagarin, MJ, et al. Acad Emerg
  Med. 200310329-38.
• Benchmarking intubation data for North American
  EM residents - Sagarin, MJ, et al. Ann Emerg
  Med. 2004.

47
Air Medical Research Collaborative (AMTC)

• Golden Hour Data Systems project
• Prospectively collect data on all intubations in
  the field by air medical personnel
• 13 Helicopter and air ambulance companies in the
  U.S.
• RSI defined as the use of Suxx an induction
  agent

48
Air Medical Research Collaborative (AMTC)

• Results
• Over 30,000 patient transports from 1998-2004
• 2853 patients had intubations (9)
• RSI 68 (1944 patients)
• Non-RSI 32 (909 patients)

49
Air Medical Research Collaborative (AMTC)

• Success Failure Total
  Success Rate
• Trauma/Burn RSI (58) 1542 115
  1657 93.1
• Trauma/Burn non-RSI (22) 532 92
  624 85.3
• Medical RSI (10) 265
  22 287 92.3
• Medical non-RSI (9) 238
  30 268 88.8
• Total RSI (68) 1807
  137 1944 93.0
• Total non-RSI (32) 777
  132 909 85.5
  
• (plt0.05)
• Surgical Cric/tracheotomy 45 (1.6)

50
The Science of Airway Management
The Future

• Standardize the jargon
• What is an intubation attempt?
• Immediate vs. long-term complications
• Difficult airway assessments
• Rapid and predictive
• Universally applied

51
The Science of Airway Management
The Future

• Unbiased reporting systems
• Large-scale data collection (web)
• Standardized reporting tools
• NEAR III and IV
• Data analysis
• Trends and outcomes
• New devices/technologies

52
Emergency medicine
53
the specialty that
54
ALWAYS
55
has customers!!
The End