1. Emergency RSI Emergency Rapid Sequence Intubation: A “How and When To” Guide Pat Melanson, MD, FRCPC Department of Emergency Medicine Division of Critical Care Medicine Royal Victoria Hospital

2. Emergency RSI Rapid Sequence Intubation : Definition The near simultaneous administration of a sedative-hypnotic agent and a neuromuscular blocker in the presence of continuous cricoid pressure to facilitate endotracheal intubation and minimize risk of aspiration modifications are made depending upon the clinical scenario

3. Emergency RSI A Brief History of Emergency RSI n intubation of the newly/nearly dead (prehistoric) n techniques adapted from anesthetists in Case Room and “crash” full-stomach induction's (exploration) n rapid dissemination of RSI teaching to emergency physicians (proselytism) n evidence-based research supporting safety and advantages of emergency RSI (enlightenment) n increasingly sophisticated techniques and methodology critically evaluated (postmodern)

4. Emergency RSI Intubation Dilemmas: Intubate Awake or Asleep Oral or Nasal Laryngoscopy or Blind Intubation To Paralyze or Not

5. Emergency RSI Oral Intubation Without Drugs Reserved for the completely unconscious, unresponsive, pulseless and apneic Arrest situations only The “ CRASH AIRWAY”

6. Emergency RSI Oral Intubation with Sedation proponents argue use of BZ or opioids –improves airway access –decreases patient resistance –avoids risks of NMB Generally obtunds patient to point of loss of protective reflexes and respiratory drive lower success rate, higher complications compared with RSI

7. Emergency RSI Oral Intubation with Sedation “ In general, the technique of administering a potent sedative agent to obtund the patient’s responses and permit intubation in the absence of NMB is hazardous and to be discouraged… is not an appropriate alternative to properly conducted RSI and affords neither the success rate or the minimal complication rate of RSI.” –RM Walls, page 4, Chapter 1, Rosen

8. Emergency RSI Oral Intubation with Sedation n “ The avoidance of NMB actually creates a more hazardous situation for the patient and this practice should no longer be considered an appropriate method for emergency department ET intubation.” ä RM Walls, page 8, Chapter 1, Rosen

9. Emergency RSI Oral Intubation with Sedation:Use for the Anticipated Difficult Airway if time permits –topical anesthesia –careful titrated sedation –avoid obtundation ‘Awake” intubation technique

10. Emergency RSI Blind Nasal Intubation success rates 65 - 80 % in most series high complication rates –epistaxis –pharyngeal/ esophageal perforations –increased incidence of O2 desats Considered second line approach only reserved for when RSI contraindicated The “ DIFFICULT AIRWAY”

11. Emergency RSI Approach to Airway Management: Algorithms Ê Is intubation indicated ? Ë Is this a Crash Airway situation ? Ì Is this a potentially Difficult Airway? áDifficult laryngoscopy ? áDifficult Bag -Mask Ventilation? ¹ Is RSI appropriate ? º Is this a Failed Airway?

12. Emergency RSI Emergency Airway Concerns “full” stomach minimal respiratory reserve hemodynamic instability acute myocardial ischemia increased intracranial pressure C-spine injury The “Difficult” Airway ä Laryngoscopy ä bag-mask difficulty

13. Emergency RSI Advantages of RSI n facilitates and expedites endotracheal intubation ä increased success rate ä decreased time to intubation n minimizes trauma during laryngoscopy n minimizes hypoxia and hypercapnia n minimizes risk of aspiration n minimizes hemodynamic effects of intubation

14. Emergency RSI Disadvantages of RSI n operator assumes complete responsibility for oxygenation, ventilation and airway patency n irreversible commitment ä (burnt bridges) n adverse effects of medications n ?? increases surgical airway rate ä no evidence

15. Emergency RSI Rapid Sequence Intubation: Principles Emergency intubation is indicated The patient has a “full” stomach Intubation is predicted to be successful If intubation fails, ventilation is predicted to be successful Consists of a series of planned discrete steps

16. Emergency RSI Principles of RSI n Competing demands: ä Minimizing risk of aspiration vs. risk of hypoxia n Preoxygenation: ä ideally avoid BMV-PPV to minimize aspiration ä adequate N2 washout (5 min 100% O2 ) gives oxygen reservoir providing several minutes of O2 supply despite apnea ä 4 assisted PPV breaths prior to paralysis ä pulse oximetry essential ä ANTICIPATE the O2 trend!

17. Emergency RSI Principles of RSI (cont) n Minimizing gastric distention ä avoidance of BMV-PPV ä cricoid pressure –caudal to thyroid cartilage –complete ring esophageal occlusion –release if vomiting occurs –maintain until ETT position confirmed ä minimize peak pressures if BMV-PPV ä immediate ID of esophageal intubation

18. Emergency RSI Typical Emergency RSI: Time Course time 0:00 2:00 2:15 3:00 3:20 5:00 n 100% O2, iv access, monitor, oximetry n assemble equipment, meds and team n thiopental 3mg/kg iv n succinylcholine 1.5mg/kg iv n cricoid pressure with LOC; no bagging n laryngoscopy after fasciculations n tube position confirmed and secured n positive pressure ventilation begins n To CT/lavage/OR/etc. n O2 sat 100% throughout

19. Emergency RSI Drugs used for RSI: Overview n Essential: ä Paralytic ä Sedative/ Induction agent n Optional: ä Defasciculant ä Modulators of hemodynamics/ICP/etc.

20. Emergency RSI Emergency RSI: Selecting the Patient Is RSI contraindicated? n Absolute: ä Cardiopulmonary arrest present/imminent ä Operator inexperience n Relative: ä Anticipated technical difficulties with laryngoscopy and/or intubation ä Anticipated difficulty with BVM

21. Emergency RSI Emergency RSI: Selecting the Paralytic Neuromuscular blocking agents n Depolarizing: ä Succinylcholine n Non-depolarizing: ä Vecuronium ä Rocuronium

22. Emergency RSI Emergency RSI: Selecting the Paralytic n Is succinylcholine contraindicated? NO:choose succinylcholine YES:choose rocuronium (or vecuronium) n If using SUX, is atropine needed? atropine 0.02mg/kg (.15mg-.5mg) 2min before n If using SUX, is a defasciculant desired ? 10% dose of non-depolarizing agent 2 min prior

23. Emergency RSI Succinylcholine ( Anectine) n dose: 1.5 mg/kg n onset : 45 - 60 seconds n duration : 6 to 10 min (3 to 15) n disadvantages : ä ACh analog - bradycardia ä fasciculations ä hyperkalemia ( K+ release) ä malignant hyperthermia

24. Emergency RSI Succinylcholine : Contraindications Hyperkalemia - renal failure Active neuromuscular disease with functional denervation ( 6 days to 6 months) Extensive burns, crush injuries Malignant hyperthermia Pseudocholinesterase deficiency Organophosphate poisoning

25. Emergency RSI Succinylcholine : Complications Inability to secure airway Increased vagal tone ( second dose ) Histamine release ( rare ) Increased ICP/ IOP/ gastric pressure Myalgias Hyperkalemia with burns, NM disease Malignant hyperthermia

26. Emergency RSI Vecuronium ( Norcuron ) dose : 0.1 - 0.2 mg/kg action : 120 secs to 60 minutes “prime” with 1/10 dose 2 min prior onset in 90 secs advantages : non-depolarizing neutral hemodynamics hepatic clearance

27. Emergency RSI Rocuronium ( Zemuron ) dose : 0.6 - 1.2 mg/kg onset : 60 -90 secs advantages : almost as rapid as SUX disadvantages less rapid in elderly long duration

28. Emergency RSI Emergency RSI: Selecting the Sedative Thiopental Ketamine Midazolam Propofol Etomidate (nothing) ? ? ? ?

29. Emergency RSI Thiopental ( Pentothal ) n dose : 1- 5 mg/kg n action : 20 sec to 5 minutes n advantages ä ultrafast, short duration ä neuroprotective, anticonvulsant ä familiar n disadvantages ä hypotension ( myocardial depression, vd) ä ultrashort duration ( 3 - 5 minutes ) ä demyelination in porphyria ä chemical endarteritis, thrombosis

30. Emergency RSI Midazolam ( Versed ) n dose : 0.1 - 0.4 mg/kg n action : 2 min to 120 minutes n advantages: ä wide therapeutic index ä amnesia n disadvantages ä variable dose response ä slower onset ä suboptimal effect at lower doses ä negative inotrope, vasodilation

31. Emergency RSI Ketamine ( Ketalar ) n dose : 1 - 2 mg/kg n action : 30 secs to 15 minutes n advantages : ä bronchodilation ä supports BP n disadvantages : ä increases ICP and IOP ä salivation ä emergence reactions

32. Emergency RSI Propofol ( Diprivan ) n dose : 0.5 - 2.5 mg/kg (20-40mg q10 s) n action : 20 sec to 5 minutes n advantages : ä ultrarapid ä neuroprotective n disadvantages ä hypotension, bradycardia ä ultrashort duration

33. Emergency RSI Etomidate ( Amidate ) n dose ; 0.3 mg/kg n action : 1 minute to 10 minutes n advantages : ä hemodynamically neutral ä neuroprotective n disadvantages : ä unfamiliar ä vomiting ä cortisol suppression

34. Emergency RSI Emergency RSI: Selecting the Sedative Identify Primary Concern: n Hemodynamics: fentanyl, ketamine, etomidate n Neuroprotection: thiopental, propofol (midazolam) n Bronchodilation: ketamine n Speed: thiopental, propofol (ketamine)

35. Emergency RSI Emergency RSI: Selecting the Sedative Identify any Secondary Concerns: n Hemodynamics: beware thiopental, propofol (midazolam) n Neuroprotection: avoid ketamine (??) n Speed: beware midazolam n Patient given naloxone: avoid fentanyl n Specific contraindications (e.g. porphyria): avoid drug

36. Emergency RSI The “Intubation Reflex “ Catecholamine release in response to laryngeal manipulation Tachycardia, hypertension, raised ICP Attenuated by beta-blockers, fentanyl ICP rise possibly attenuated by lidocaine Midazolam and thiopental have no effect

37. Emergency RSI Emergency RSI: Selecting optional medications n Increased ICP: Lidocaine n Bronchospasm : Lidocaine n Tachycardia harmful: fentanyl (esmolol) 3 min before n atropine if child receiving Sux n defasciculant n “priming” dose of neuromuscular blocking agent n topical/regional anesthetics

38. Emergency RSI Emergency RSI Checklist: Flight planning n Move patient to resuscitation suite n Assemble personnel n 100% O2 n Patient too unstable for RSI => intubate ASAP n Inadequate ventilation/sat BMV n Select drugs and doses, delegate “Drug Nurse” n Cardiac monitor, BP cuff, O2 sat continuously n IV running in limb contralateral to BP cuff n Cleared to taxi

39. Emergency RSI Emergency RSI Checklist: Taxiing n C-Spine?OK: pillow/folded sheet under head ?: designate assistant in-line stabilization n Check ETT and lubricate (+/- stylet) n Check laryngoscope (and other airway device prn) n Yankauer suction on and under mattress (to right) n Final neuro assessment (AVPU, posturing, pupils) n Baseline HR, BP, O2 sat n Review drugs, doses and sequence with Drug Nurse n Cleared for take-off

40. Emergency RSI Emergency RSI Checklist: Take-off 0:00 3:00 3:15 4:00 4:30 5:00- 15:00 n administer optional drugs n administer sedative n administer paralytic n cricoid pressure with loss of ciliary reflex n BMV if hypercapnia deleterious/sat <90% n laryngoscopy once fully relaxed n BURP to visualize larynx n Confirm ETT placement and secure n Ventilator settings n Treat fluctuations in VS as indicated n CXR time (mm:ss)

41. Emergency RSI Rapid Sequence Intubation : Procedure Pre-intubation assessment Pre-oxygenate Prepare Premedicate Paralyze with Induction Pressure on cricoid Place the tube Post intubation assessment

42. Emergency RSI Pre-oxygenate ( Time - 5 Minutes ) 100 % oxygen for 5 minutes 4 conscious deep breaths of 100 % O2 Fill FRC with reservoir of 100 % O2 Allows 3 to 5 minutes of apnea Essential to allow avoidance of bagging If necessary bag with cricoid pressure

43. Emergency RSI Preparation ( Time - 5 Minutes ) ETT, stylet, blades, suction, BVM Cardiac monitor, pulse oximeter, ETCO2 One ( preferably two ) iv lines Drugs Difficult airway kit including cric kit Patient positioning

44. Emergency RSI Pre-treatment/ Prime ( Time - 2 Minutes ) Lidocaine 1.5 mg/kg iv Defasciculating dose of non- depolarizing NMB Fentanyl 3- 5 mcg/kg Atropine 0.02 mg/kg ( The above agents are optional and given if there is a specific indication and time permits)

45. Emergency RSI Induction agent –Thiopental 3 - 5 mg/kg –Midazolam 0.1 - 0.4mg/kg –Ketamine 1.5 - 2.0 mg/kg –Propafol 0.5 - 2.0 mg/kg –Etomidate 0.2 - 0.3 mg/kg

46. Emergency RSI Paralyze ( Time Zero ) Succinylcholine 1.5 mg/kg iv Allow 45 - 60 seconds for complete muscle relaxation Alternatives –Vecuromium 0.1 - 0.2 mg/kg –Rocuronium 0.6 - 1.2 mg/kg

47. Emergency RSI Pressure Sellick maneuver initiate upon loss of consciousness continue until ETT balloon inflation release if active vomiting

48. Emergency RSI Place the Tube ( Time Zero + 45 Secs ) Wait for optimal paralysis Confirm tube placement with ETCO2

49. Emergency RSI Post-intubation Hypotension Loss of sympathetic drive Myocardial infarction Tension pneumothorax Auto-peep

50. Emergency RSI Difficult Airway Kit Multiple blades and ETTs ETT guides ( stylets, bougé, light wand) Emergency nonsurgical ventilation ( LMA, Combitube, TTJV ) Emergency surgical airway access ( cricothyroidotomy kit, cricotomes ) ETT placement verification Fiberoptic and retrograde intubation

51. Emergency RSI Amitriptyline tripper 27 year old overdose benzos + TCAs 1 hour PTA. Decreasing LOC (?ciliary reflex). HR 140 wide-complex regular, BP 90/50, RR 24, O2 sat 99% on O2.

52. Emergency RSI Walking at the scene 22 yr old multiple abdominal stab wounds 6” knife. Evisceration, agitation and uncooperative. HR 140, BP 90/50, RR 22, O2 sat 99% on O2.

53. Emergency RSI Status asthmaticus severus 50 yr old asthmatic x years, never admitted O/N. SOB x 2d despite prednisone, antibiotics, and salbutamol q1h. Despite continuous salbutamol, epi s/c x 2, and SoluMedrol iv, begins to fatigue. pH 7.22, pCO2 70, pO2 140.

54. Emergency RSI Collapse at bank 38 year old male, standing in line at bank, complained of sudden severe HA and collapsed. On arrival, HR 55 BP 170/100 RR 12 decorticate posturing.

55. Emergency RSI NOT renal colic 68 year old male, hypertensive, no past history of urolithiasis, presents with R flank pain and hematuria. While you are booking the spiral CT, he complains of increasing back pain, then vomits. HR 140 BP 85/palp diaphoretic ++. And then he gets worse.

56. Emergency RSI Overdue for dialysis 68 yr old hemodialysis-dependent pt in florid pulmonary edema and decreasing LOC. HR 120 reg, BP 220/120, O2 sat 85% on non-rebreather 15L/min.

57. Emergency RSI Too much Nintendo 14 year old known epileptic on multiple meds, still seizing after diazepam, phenobarb and over 30 minutes in the ED. 160 100/50 37.2 99% sat. Small jaw.

58. Emergency RSI “ I would especially commend the physician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.” Hippocrates