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© 2006 The Airway Course Rapid Sequence Intubation.

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Presentation on theme: "© 2006 The Airway Course Rapid Sequence Intubation."— Presentation transcript:

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2 © 2006 The Airway Course Rapid Sequence Intubation

3 © 2006 The Airway Course Rapid Sequence Intubation Why are you here? ‘Don’t be afraid’ Control the situation; don’t let the situation control you!!

4 © 2006 The Airway Course Rapid Sequence Intubation Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

5 © 2006 The Airway Course Rapid Sequence Intubation Paralytic and NonParalytic RSI Paralytic: use of a NeuroMuscular Blocking (NMB) drug in addition to an Induction agent NonParalytic: induction agent only

6 © 2006 The Airway Course Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

7 © 2006 The Airway Course Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

8 © 2006 The Airway Course Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

9 © 2006 The Airway Course Rapid Sequence Intubation Definition The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

10 © 2006 The Airway Course Rapid Sequence Intubation Definition Assumes: Patient has a full stomach No interposed ventilation Preoxygenation Sellick’s maneuver

11 © 2006 The Airway Course Rapid Sequence Intubation Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

12 © 2006 The Airway Course Rapid Sequence Intubation Universal EMS Airway Algorithm RSI Failed Airway Algorithm Difficult Airway Algorithm Crash Airway Algorithm Needs Intubation Difficult Airway? Agonal/ Unresponsive? Yes No Fails

13 © 2006 The Airway Course Rapid Sequence Intubation Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

14 © 2006 The Airway Course Rapid Sequence Intubation The Seven Ps of RSI P reparation P reoxygenation P retreatment P aralysis with induction P rotection P lacement P ost-Intubation Management

15 © 2006 The Airway Course Rapid Sequence Intubation The Sequence Zero: the time of administration of succinylcholine.

16 © 2006 The Airway Course Rapid Sequence Intubation The Sequence Zero - 10 minutes Preparation Difficult Airway: last chance Plan approach Assemble drugs and equipment Establish access, monitoring Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

17 © 2006 The Airway Course Rapid Sequence Intubation Zero - 5 minutes Preoxygenation 100% oxygen for three minutes 8 vital capacity breaths Provides essential apnea time Apnea time varies The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

18 © 2006 The Airway Course Rapid Sequence Intubation Zero - 3 minutes Pretreatment Lidocaine Opioid Atropine Defasciculation “LOAD the patient before intubation.” The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

19 © 2006 The Airway Course Rapid Sequence Intubation Zero!! Paralysis with induction Induction agent IV push Succinylcholine 1.5 mg/kg IVP The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

20 © 2006 The Airway Course Rapid Sequence Intubation Zero + 30 seconds Protection Sellick’s Maneuver Position patient Do not bag unless S p O 2 < 90% The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

21 © 2006 The Airway Course Rapid Sequence Intubation Zero + 45 seconds Placement The Sequence Check mandible for flaccidity Intubate, remove stylet Confirm tube placement - ETCO 2 Release Sellick’s maneuver Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

22 © 2006 The Airway Course Rapid Sequence Intubation Zero + 90 seconds Post-intubation Management The Sequence Secure tube Chest x-ray Long acting sedation/paralysis Establish ventilator parameters Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

23 © 2006 The Airway Course Rapid Sequence Intubation The Seven Ps of RSI P reparation P reoxygenation P retreatment P aralysis with induction P rotection P lacement P ost-Intubation Management Summary

24 © 2006 The Airway Course Rapid Sequence Intubation What if the intubation attempt is not successful? What is a failed attempt versus a failed airway? Rapid Sequence Intubation Failed Attempt

25 © 2006 The Airway Course Rapid Sequence Intubation Failed Attempt bag/mask ventilation think about the six attributes:  operator  optimum sniff position  BURP  paralysis  length of blade  type of blade

26 © 2006 The Airway Course Rapid Sequence Intubation The first rescue from failed intubation is bagging The first rescue from failed bagging is better bagging Failed Attempt Rescue Maneuvers

27 © 2006 The Airway Course Rapid Sequence Intubation Speeding Up RSI

28 © 2006 The Airway Course Rapid Sequence Intubation Speeding Up RSI Accelerated RSI: preoxygenation for 8 VC breaths shorten pre-treatment interval Immediate RSI: preoxygenation for 8 VC breaths omit pre-treatment

29 © 2006 The Airway Course Rapid Sequence Intubation Outline What is RSI? Where does it fit in? Technique RSI Pharmacology

30 © 2006 The Airway Course Rapid Sequence Intubation RSI Pharmacology Two pharmacologic decision points  Pretreatment  Paralysis and Induction

31 © 2006 The Airway Course Rapid Sequence Intubation Zero - 3 minutes Pretreatment Lidocaine Opioid Atropine Defasciculation “LOAD the patient before intubation.” The Sequence Preparation Preoxygenation Pretreatment Paralysis Protection Placement Post-Intubation

32 © 2006 The Airway Course Rapid Sequence Intubation PATIENTS AT RISK Larynx, trachea, carina are richly innervated Intubation is intensely stimulating  Sympathetic Discharge (RSRL)  ICP response (not 2 o catecholamines)  ICP response to SCh  Bronchospastic response  Bradycardia (in children)

33 © 2006 The Airway Course Rapid Sequence Intubation PATIENTS AT RISK Intracranial pathology “tight brain” Cardiovascular disease “tight heart” “shear pressure” Reactive airways disease “tight lungs” Children

34 © 2006 The Airway Course Rapid Sequence Intubation L IDOCAINE Increased intracranial pressure  Blunts ICP response to stimulation Bronchospasm/reactive airways 1.5 mg/kg

35 © 2006 The Airway Course Rapid Sequence Intubation L IDOCAINE 1.5 mg/kg Tight Brain Tight Lungs

36 © 2006 The Airway Course Rapid Sequence Intubation O PIOID Fentanyl 3  g/kg  Blunts catecholamine release Cardiovascular disease Intracranial hypertension May give slowly over 1-3 minutes !! Caution if dependent on sympathetic drive

37 © 2006 The Airway Course Rapid Sequence Intubation O PIOID Fentanyl 3  g/kg Tight Heart/Shear Pressure Tight Brain

38 © 2006 The Airway Course Rapid Sequence Intubation A TROPINE 0.02 mg/kg (minimum dose 0.1 mg) Children < 10 years who will receive SCh Standby for second dose of SCh

39 © 2006 The Airway Course Rapid Sequence Intubation D EFASCICULATION Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg Intracranial hypertension

40 © 2006 The Airway Course Rapid Sequence Intubation D EFASCICULATION Tight Brain Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg Rocuronium 0.06 mg/kg

41 © 2006 The Airway Course Rapid Sequence Intubation INDUCTION AGENTS

42 © 2006 The Airway Course Rapid Sequence Intubation INDUCTION AGENTS HEALTHY, STABLE PATIENTS Etomidate 0.3 mg/kg Midazolam 0.3 mg/kg Ketamine 1.5 mg/kg Propofol 1.5 mg/kg Pentothal 3 mg/kg “IV Push”

43 © 2006 The Airway Course Rapid Sequence Intubation INDUCTION AGENTS COMPROMISED PATIENTS Etomidate mg/kg Midazolam 0.1 mg/kg Ketamine 1 mg/kg Propofol 0.5 mg/kg Pentothal 1.5 mg/kg

44 © 2006 The Airway Course Rapid Sequence Intubation INDUCTION AGENTS For specific conditions  Reactive airways ketamine  ICP etomidate, pentothal  Hypotensive ketamine  Operator preference

45 © 2006 The Airway Course Rapid Sequence Intubation NEUROMUSCULAR BLOCKING AGENTS

46 © 2006 The Airway Course Rapid Sequence Intubation NEUROMUSCULAR BLOCKING AGENTS Depolarizing - succinylcholine Competitive (nondepolarizing) Aminosteroids (“…onium”) Benzylisoquinolines (“…curi”)

47 © 2006 The Airway Course Rapid Sequence Intubation Succinylcholine has one very, very lethal side effect… Fatal Hyperkalemia Succinylcholine is a universally safe drug. No-one is too sick to get succinylcholine.

48 © 2006 The Airway Course Rapid Sequence Intubation Succinylcholine Hyperkalemia Receptor Upregulation  Burns, crush, prolonged ICU care  UMN lesions, including stroke  spinal cord injury  MS, ALS, other denervations Myopathic Processes  Muscular dystrophy  Rare idiopathic Mortality 11% Mortality 30% Gronert: Anesthesiology 94: , 2001.

49 © 2006 The Airway Course Rapid Sequence Intubation USE OF NONDEPOLARIZERS Pretreatment (Defasciculation) Rapid sequence intubation rocuronium 1 mg/kg vecuronium 0.01 mg/kg+0.15 mg/kg

50 © 2006 The Airway Course Rapid Sequence Intubation Fin

51 © 2006 The Airway Course Rapid Sequence Intubation Positive Pressure (Ventilation)

52 © 2006 The Airway Course Rapid Sequence Intubation Negative Pressure (Inspiration)

53 © 2006 The Airway Course Rapid Sequence Intubation

54 © 2006 The Airway Course Rapid Sequence Intubation Valve Effect: Inspiration

55 © 2006 The Airway Course Rapid Sequence Intubation

56 © 2006 The Airway Course Rapid Sequence Intubation


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