1. Rapid Sequence Intubation

2. Control the situation; don’t let the situation control you!!
Why are you here?
‘Don’t be afraid’
Control the situation; don’t let the situation control you!!

3. Outline
What is RSI?
Where does it fit in?
Technique
RSI Pharmacology

4. Paralytic and NonParalytic RSI
Paralytic: use of a NeuroMuscular Blocking (NMB) drug in addition to an Induction agent
NonParalytic: induction agent only

5. 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.

6. 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. 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. 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. Rapid Sequence Intubation
Definition Assumes:
Patient has a full stomach
No interposed ventilation
Preoxygenation
Sellick’s maneuver

10. Outline
What is RSI?
Where does it fit in?
Technique
RSI Pharmacology

11. Universal EMS Airway Algorithm
Agonal/
Unresponsive?
Crash
Airway
Algorithm
Yes
Fails
Needs Intubation No
Difficult Airway?
Difficult
Airway
Algorithm
Failed
Airway
Algorithm
Yes
Fails No
RSI
Fails

12. Outline
What is RSI?
Where does it fit in?
Technique
RSI Pharmacology

13. Rapid Sequence Intubation
The Seven Ps of RSI
Preparation
Preoxygenation
Pretreatment
Paralysis with induction
Protection
Placement
Post-Intubation Management

14. Rapid Sequence Intubation
The Sequence
Zero:
the time of administration of succinylcholine.

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

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

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

18. Rapid Sequence Intubation
The Sequence
Preparation
Preoxygenation
Pretreatment
Paralysis
Protection
Placement
Post-Intubation
Zero!!
Paralysis with induction
Induction agent IV push
Succinylcholine 1.5 mg/kg IVP

19. Rapid Sequence Intubation
The Sequence
Preparation
Preoxygenation
Pretreatment
Paralysis
Protection
Placement
Post-Intubation
Zero + 30 seconds
Protection
Sellick’s Maneuver
Position patient
Do not bag unless SpO2 < 90%

20. Rapid Sequence Intubation
The Sequence
Preparation
Preoxygenation
Pretreatment
Paralysis
Protection
Placement
Post-Intubation
Zero + 45 seconds
Placement
Check mandible for flaccidity
Intubate, remove stylet
Confirm tube placement - ETCO2
Release Sellick’s maneuver

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

22. Rapid Sequence Intubation
Summary
The Seven Ps of RSI
Preparation
Preoxygenation
Pretreatment
Paralysis with induction
Protection
Placement
Post-Intubation Management

23. Rapid Sequence Intubation
Failed Attempt
What if the intubation attempt is not successful?
What is a failed attempt versus a failed airway?

24. 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

25. Rapid Sequence Intubation
Failed Attempt
Rescue Maneuvers
The first rescue from failed intubation is bagging
The first rescue from failed bagging is better bagging

26. Rapid Sequence Intubation
Speeding Up RSI

27. 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

28. Outline
What is RSI?
Where does it fit in?
Technique
RSI Pharmacology

29. RSI Pharmacology Two pharmacologic decision points Pretreatment
Paralysis and Induction

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

31. PATIENTS AT RISK Larynx, trachea, carina are richly innervated
Intubation is intensely stimulating
Sympathetic Discharge (RSRL)
ICP response (not 2o catecholamines)
ICP response to SCh
Bronchospastic response
Bradycardia (in children)

32. PATIENTS AT RISK Intracranial pathology “tight brain”
Cardiovascular disease
“tight heart”
“shear pressure”
Reactive airways disease
“tight lungs”
Children

33. LIDOCAINE 1.5 mg/kg Increased intracranial pressure
Blunts ICP response to stimulation
Bronchospasm/reactive airways

34. LIDOCAINE
1.5 mg/kg
Tight Brain
Tight Lungs

35. OPIOID Fentanyl 3 mg/kg Blunts catecholamine release
Cardiovascular disease
Intracranial hypertension
May give slowly over 1-3 minutes
!! Caution if dependent on sympathetic drive

36. OPIOID
Fentanyl 3 mg/kg
Tight Heart/Shear Pressure
Tight Brain

37. ATROPINE 0.02 mg/kg (minimum dose 0.1 mg)
Children < 10 years who will receive SCh
Standby for second dose of SCh

38. DEFASCICULATION Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg
Rocuronium mg/kg
Intracranial hypertension

39. DEFASCICULATION Vecuronium 0.01 mg/kg Pancuronium 0.01 mg/kg
Rocuronium mg/kg
Tight Brain

40. INDUCTION AGENTS

41. 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”

42. 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

43. For specific conditions
INDUCTION AGENTS
For specific conditions
Reactive airways ketamine
ICP etomidate, pentothal
Hypotensive ketamine
Operator preference

44. NEUROMUSCULAR BLOCKING AGENTS

45. NEUROMUSCULAR BLOCKING AGENTS
Depolarizing - succinylcholine
Competitive (nondepolarizing)
Aminosteroids (“…onium”)
Benzylisoquinolines (“…curi”)

46. Succinylcholine has one very, very lethal side effect…
Succinylcholine is a universally safe drug.
No-one is too sick to get succinylcholine.
Fatal Hyperkalemia

47. 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.

48. USE OF NONDEPOLARIZERS
Pretreatment (Defasciculation)
Rapid sequence intubation
rocuronium 1 mg/kg
vecuronium 0.01 mg/kg+0.15 mg/kg

49. Rapid Sequence Intubation
Fin

50. Positive Pressure (Ventilation)

51. Negative Pressure (Inspiration)

53. Valve Effect: Inspiration