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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 LAC+USC.

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Presentation on theme: "AIRWAY 1: RAPID SEQUENCE INTUBATION Stuart Swadron, MD, FRCPC, FACEP Program Director Residency in Emergency Medicine Keck-USC School of Medicine LAC+USC."— Presentation transcript:

1 AIRWAY 1: RAPID SEQUENCE INTUBATION Stuart Swadron, MD, FRCPC, FACEP Program Director Residency in Emergency Medicine Keck-USC School of Medicine LAC+USC Dept. of Emergency Medicine July 19, 2007

2 DEFINITIONS INDUCTION AGENT PARALYTIC UNCONSCIOUSNESS MOTOR PARALYSIS Rapid Sequence Intubation

3 DEFINITIONS INDUCTION AGENT Pharmacologically Assisted Intubation UNCONSCIOUSNESS

4 DEFINITIONS Geneva Convention Violation PARALYTIC MOTOR PARALYSIS

5 RATIONALE – Principle Increased success Decreased aspiration

6 Better C-spine control RATIONALE - Secondary

7 Blunting ↑ ICP / IOP RATIONALE - Secondary

8 Avoid airway trauma RATIONALE - Secondary

9 Avoid airway trauma RATIONALE - Secondary

10 ↓ Pain ↓ Discomfort ↓ Recall

11 Prolonged intubation HAZARDS

12 Adverse Drug Events HAZARDS

13 May force crash airway scenario HAZARDS

14 INDICATIONS Failure OR Imminent failure of : 1. oxygenation 2. ventilation 3. airway protection or maintenance

15 CONTRAINDICATIONS INDICATION RISK

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17 RSI CAN ALSO BE… UNNECESSARY - OR – INAPPROPRIATE

18 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

19 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

20 PREPARATION t – 10 minutes 1.EQUIPMENT PRESENT AND WORKING MUST INCLUDE EQUIPMENT FOR PLAN “B”

21 PREPARATION t – 10 minutes 2.ASK:CAN I… BAG THE PATIENT TUBE THE PATIENT CRIC THE PATIENT

22 L ook at general anatomy E valuate the rule M allampati score O bstruction N eck mobility CAN I TUBE THIS PATIENT?

23 CAN I BAG THIS PATIENT? Maybe. Maybe Not.

24 CAN I CRIC* THIS PATIENT? * may include alternative airway techniques

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27 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

28 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

29 PREOXYGENATION t – 5 minutes 1. “PRIMUM NO BAGER!” (First, do not bag!) 2. If you do need to bag, Remember TOM

30 NITROGEN WASH-OUT OXYGEN WASH-IN pO2 LUNGS pO2 TISSUES pO2 BLOOD

31 NITROGEN WASH-OUT OXYGEN WASH-IN pO2 LUNGS pO2 TISSUES pO2 BLOOD

32 NITROGEN WASH-OUT OXYGEN WASH-IN pO2 LUNGS pO2 TISSUES pO2 BLOOD

33 NITROGEN WASH-OUT OXYGEN WASH-IN pO2 LUNGS pO2 TISSUES pO2 BLOOD

34 NITROGEN WASH-OUT OXYGEN WASH-IN pO2 LUNGS pO2 TISSUES pO2 BLOOD

35 PREOXYGENATION t – 5 minutes 1. Well-fitting mask 2. 8 vital capacity breaths Nimmagadda et al. Anesthesiology 93 (3): , 2000 Baraka et al. Anesthesiology 91 (3): 612, 1999

36 PREOXYGENATION t – 5 minutes Normal adult Obese adult Normal child Ill adult

37 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

38 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

39 PRETREATMENT t – 3 minutes LLidocaine OOpioids AAtropine DDefasciculating Medication

40 PRETREATMENT t – 3 minutes “LOAD” may just be a LOAD

41 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): , 2000

42 OPIOIDS (Fentanyl) Traditional Indications 1. Blunt hemodynamic response 2. Decrease pain Adachi et al. Anesthesia & Analgesia. 95(1):233-7, 2002

43 FENTANYL DOSE Dose = 3µg/kg* IV slow push *Beware of hypotension and apnea

44 ATROPINE Standard practice Give atropine to: 1. all children less than 8 years old 2. prior to second dose of succinylcholine Dose = mg/kg IVP Evidence is mounting that questions routine use of atropine Fastle et al. Pediatr Emerg Care;20(10):651-5, 2004 McAuliffe et al. Can J Anaesth; 43(7) 754-5,1996 Fleming et al. CJEM. 2005;7(2):114-7

45 DEFASCICULATING DOSE One tenth the RSI dose Traditional Indications 1.Blunt rise in ICP 2.Decrease risk of aspiration 3.Prevent muscular pain Clancy et al. Emergency Medicine Journal. 18(5):373-5, 2001 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”

46 And what’s more… DEFASCICULATING DOSE can be downright dangerous* * it may cause premature apnea

47 PRETREATMENT t – 3 minutes If you’re going to give these drugs: …at least give them some time to circulate (3 minutes)

48 Summary of LOAD PRETREATMENT L idocaine  optional O piates  optional A tropine  still mandatory for kids < 8 D efasciculating  optional dose

49 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

50 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

51 PARALYSIS WITH INDUCTION Time “0” INDUCTION AGENTS Etomidate Thiopental Ketamine Propafol Midazolam PARALYTIC AGENTS DEPOLARIZING Succinylcholine NON-DEPOLARIZING Vecuronium Rocuronium +

52 SUX IS STILL KING …but nondepolarizing agents are gaining ground Perry et al. Academic Emergency Medicine 9(8): , 2002

53 SUX versus ROC 45 seconds ONSET 1 minute 9 minutes DURATION 45 minutes 1 mg/kg mg/kg

54 When Sux Really “Sucks” CONTRAINDICATIONS 1. HYPERKALEMIA RENAL FAILURE RHABDOMYOLYSIS 2. RECEPTOR UPREGULATION SUBACUTE BURNS (>1 day) SUBACUTE DENERVATING DISORDER HISTORY OF MALIGNANT HYPERTHERMIA

55 Advent of the Non-Depolarizing Agents Pancuronium Vecuronium Rocuronium Rapacuronium –oops!

56 Making non-depolarizing agents FASTER 1.Large Doses 2.Priming Doses 3.Better Induction Agents } Increase duration

57 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

58 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

59 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

60 PROTECTION AND POSITIONING t + 20 seconds

61 C Spine Precautions

62 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

63 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

64 PLACEMENT AND PROOF t + 45 seconds Over here, Socrates !!!

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67 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

68 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

69 POST-INTUBATION MANAGEMENT t + 90 seconds THE “APRÈS INTUBATION” CONFIRM INTUBATION SECURE TUBE CHECK CHEST X-RAY, ABG’S

70 CONFIRMING INTUBATION

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73 SECURING TUBE

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77 THE 7 P’s OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF POST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

78 PUTTING IT ALL TOGETHER

79 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

80 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

81 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

82 INTUBATION HURTS!!! And it keeps on hurting once the tube is in.

83 Thank you!


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