1. A Review of Rapid Sequence Intubation
Scott Bouton, M.D.

2. Principles of RSI
RSI is a process designed to rapidly gain control of an airway in patients who require timely intubation without the benefit of prior patient planning and preparation.
Utilizes medications to rapidly induce unconsciousness and paralysis while at the same time blunting or avoiding some of the undesirable physiologic responses to ETI.
Incorporates pre oxygenation with minimal to no positive pressure ventilation and cricoid pressure (Sellick maneuver) to minimize the chance of aspiration
Sellick / Cricoid pressure is controversial (more in a min)
* RSI is not necessary for intubation in cardiac arrest or comatose patients / without a gag reflex

3. Potential Risks and Pitfalls

4. Potential Risks and Pitfalls
Aspiration –
patients requiring emergency intubation must be assumed to have a full stomach, and are therefore at a much higher risk of aspiration.
Patients frequently also have complicating variables such as oral, facial or neck trauma.
Increased ICP -
Can result from pain, agitation, gagging or retching during laryngoscope use and ETT placement if not properly medicated.
Problematic especially in those with underlying head trauma.
Secondary Cervical Spine Injury –
in those with underlying C-spine injury

5. More Risks and Pitfalls

6. More Risks and Pitfalls
Hypoxemia
all patients requiring RSI are under tremendous physiologic stress.
lessens their oxygen reserve
shortens the time required to become hypoxemic.
Children have an even higher metabolic O2 demand compared to adults and thus desaturate quickly.
Cardiac Instability –
can result from medications
More common in children due to the potential for rapid progression of hypoxemia.

7. Initial Assessment & Preparation
History – if time allows focus on allergies, underlying medical problems, and the immediate circumstances which led to the patients condition (sepsis, head trauma, asthma, etc.)
PE – Focus on factors which may complicate intubation (facial or neck trauma, congenital facial anomalies, etc.)
Assemble all supplies (Bag and mask, ETT’s, suction, stylets, O2, Drugs, etc.)

8. Initial Assessment & Preparation
Positioning
Sniffing Position
– external auditory meatus (ear) level w/ sternal notch.
Overextension can occlude visualization of infants airway (big tounge / oral ratio)
Towel under infants shoulders (raise chest) due to large occiput
Can exacerbate aupper Cspine injuries
Jaw Thrust / Chin Lift
Can exacerbate lower Cspine injuries (even with rigid collar use)
In Trauma / Cspine injury – use in line immobilization, position patient close to head of bed, raise bed to waist level (or higher)

9. Preintubation Therapy
Preoxygenate as early as possible. This fills lungs with 100% O2 by washing out nitrogen, and allows patient to tolerate a longer period of apnea without hypoxia.
Avoid BMV (if possible) as this distends the stomach and potentiates vomiting and aspiration. Consider NGT or OGT placement BMV is required

10. Endotracheal Tubes
Cuffed ETT’s are appropriate in any age (except newborn)
Shown to decrease aspiration risk (after intubation)
Better air seal for PPV
“new” low pressure tubes do not cause increased tracheal injury or swelling / extubation stridor
Uncuffed ETT’s can (also) be used < 8yrs old due to seal formed by funnel shaped sub glottis.
ETT size = Age (yrs) + 16 / 4
Proper depth = 3x ETT size

11. Medications
Atropine can be used in children < 5yrs – used to reduce airway secretions and prevent vagal mediated bradycardia (ideally 3-5min before ETI)
Lidocaine can be used if increased ICP to blunt effects of laryngoscopy on ICP (ideally 5 min before ETI).

12. Sedative / Hypnotics Midazolam (versed) Etomidate
short acting
anticonvulsant and amnestic properties
Minimal cardiovascular effects.
Etomidate
rapid onset short acting
No significant cardiovascular or respiratory depression.
Can cause vomiting and myoclonus if not paralyzed
Decreases ICP (at least equal to lidocaine)
Can suppress cortisol synthesis in one dose (tx with corticosteroids) .

13. Sedative / Hypnotics Thiopental Propafol Ketamine Rapid acting
Anticonvulsant properties.
Decreases ICP
Myocardial depression
Can potentiate hypotension (vasodilator) if volume depleted or in shock.
Can induce histamine mediated bronchospasm
Propafol
rapid onset, short acting.
Prone to causing hypotension and myocardial depression.
Minimal respiratory depression.
Ketamine
rapid acting sedative / analgesic.
Sympathomimetic Agent: Bronchodilates, stabilized BP, increases ICP.

14. Paralytics Nondepolarizing agents (vecuroneum, rocuroneum)
competitive antagonists of Ach at the NMJ.
Bind to nicotinic receptors and blocks binding of acetylcholine.
Does not stimulate ion channel opening.
Diffuses away and metabolized by liver, ending neuromuscular blockade.
Depolarizing agents (succinylcholine)
competitive agonist of Ach at the NMJ
Binds and stimulates nicotinic receptor causing initial fasciculations
prolonged receptor binding blocks further stimulation by acetylcholine causing flaccid paralysis.
Broken down by cholinesterase.
Fasciculations and the associated muscular pain can be avoided (if time allows) by premedicating with a small (1/10) dose of a nondepolarizing agent.

15. Depolarizing agent Succinylcholine
fast acting (<1min), short duration (3-10min).
1 – 2 mg/kg/dose
Can cause parasympathetic mediated bradyarrhythmias and asystole in infants and young children (premedicate w/ atropine).
Can cause sympathetic stimulation in older children resulting in tachycardia and HTN
Can induce malignant hyperthermia (tx with dantroline)
Can increase K+ (avoid in burns, crush injury etc.)
Can increase ICP and intraoccular pressure

16. Nondepolarizing Agents
Vecuroneum (Norcuron)
Long onset (1-2min), long duration (> 20min)
0.1 – 0.2 mg/kg/dose IV
Rocuroneum (Zemuron)
Rapid Acting (< 1min), shorter duration (approx 20min)
Can be used to intubate anyone, relative lack of contraindications
RSI paralytic of choice
mg/kg/dose
2mg/kg IM if IV not available in time

17. Tracheal Manipulation
Sellick Maneuver (Cricoid Pressure)
Currently there is insufficient evidence to recommend routine use
Can potentially cause Tracheal Rupture or obscure the airway if done too forcefully (…inexperienced providers???)
Can also potentially cause esophageal rupture in patients who are actively vomiting (….. Paralytic???)
Consider Using (gently / properly)
To prevent passive regurgitation of stomach contents in paralyzed patients
* Especially if BMV required
To aid in visualization of cords
No compelling data against proper use …. Only “isufficient evidence to recommend routine use” (remember PALS Class target audience… community hospitals, EMS, etc.)
“Cricoid Pressure should be used after a thorough evaluation of the risks and benefits”

18. Tracheal Manipulation
ELM (external Laryngeal Manipulation)
BURP Maneuver
Aids in glottis visualization
B – back (towards the spine)
U – up (towards the head)
R P– rightward pressure
* With finger (laryngoscope hand) - Push thyroid cartillage slightly down, Pull towards patients right shoulder

19. Proposals for Special situations
Head injury (increased ICP)
Lidocaine (dec ICP)
Etomidate (dec ICP)
Rocuroneum (no cardiovascular effects to decrease cerebral perfusion pressure)
Asthma
Ketamine (bronchodilator)
Rocuroneum
Status Epilepticus
Versed (anti convulsant)
Sepsis / Hypotension
Ketamine (sympathomimetic, cardiovascular stabilizer)
Rocuroneum (no cardio effects)

20. Questions?