2. The ABC of RSI Jason Boschin Critical Care Paramedic

3. Advanced Airway Anatomic Considerations Rapid Sequence induction Neuromuscular Blockade Induction Agents Intubation tricks & thoughts

4. Indications for Definitive Airway Need for Airway Protection Need for Ventilation UnconsciousApnea Neuromuscular Paralysis Neuromuscular Paralysis Unconscious Unconscious Severe Maxillofacial fx’s Inadequate Respiratory Effort’ Tachypneal Tachypneal Hypoxia Hypoxia Hypercarbia Hypercarbia Cyanosis Cyanosis Risk for aspiration Bleeding Bleeding Vomiting Vomiting Severe closed head injury with need for hyperventilation Risk for obstruction Neck hematoma Neck hematoma Laryngeal, tracheal injury/burn Laryngeal, tracheal injury/burn Stridor Stridor

5. Mouth: –Tongue : variable in size (angioedema) attached inferior to epiglottis –Mandible –Uvula Pharynx –Tonsils –Merges with larynx anterior, esophagus posterior –Epiglottis high long flaccid and narrow in child ANATOMIC CONSIDERATIONS FOR INTUBATION

6. The Larynx –High relative to mandible in child –Cricoid smaller in child, narrow part of airway –vocal cord narrow part of adult airway –arytenoid cartilages ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)

7. Netter; Atlas of Human Anatomy

8. Trachea – 12-15 cm. Adult –4 cm. Newborn –right mainstem larger,shorter and less angle ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.) Anderson; Grant’s Atlas of Anatomy

9. –Tube Sizes (Kids) Fit through nose Fit through nose Age(years)/4 + 4 Oral tube length –Age(years)/2 + 12 cm. –Nasal add 3 cm. No cuff under 6 to 8 years OTHER CONSIDERATIONS FOR INTUBATION (cont.)

10. Difficult tubes –Immobilized trauma patient –Combative patient –Children, esp. Infants –Short neck –Prominent upper incisors –Receding mandible –Limited jaw opening, limited cervical mobility –Upper airway conditions –Facial, laryngeal trauma OTHER CONSIDERATIONS FOR INTUBATION (cont.)

11. Correct Placement for intubation (b)

12. Patient in correct position for intubation (sniffing position)

13. Incorrect airway position (hyperflexed)

14. Rapid Sequence Induction Indications –Ventilatory failure (eg’s) –Airway maintenance/protection –Treatment and evaluation neuro resuscitation(hyperventilate) shock drug overdose

15. Contraindications –Cardiac arrest –Adequate ventilation –Deeply comatose patient, absent tone –Airway Anatomy use LEMON Rapid Sequence Induction

16. Contraindications (cont.) –Intubation likely unsuccessful Partially obstructed airway Severe facial abnormality(trauma, etc.) Rapid Sequence Induction Whitten; Anyone Can Intubate

17. McIntyre; The difficult tracheal intubation

18. Maintain adequate oxygenation Airway protection –Prevent regurgitation, aspiration Obtund adverse cardiovascular and ICP response to intubation Better early than late Hypoxemia and acidosis effects Hypoxemia and acidosis effects Rapid Sequence Induction

19. Treatment Algorithm (6 P’s) –Preparation T-10” –Pre-oxygenation( functional reserve capacity) T-5” –Pre-medication T-3” –Paralysis T-0 –Placement of Tube T+45 –Post Management T+2” Rapid Sequence Induction

20. DO NO HARM! TAKE AWAY NOTHING FROM THE PATIENT YOU CANNOT REPLACE

21. Anticipate the difficulties –Identify in advance the patient who may require RSI –Identify the patient with anatomic difficulty –Have sufficient skill and training : –TRAINING NOT DONE ON SCENE..NO EGO’S!!! –Have a preformulated plan for potential disaster Rapid Sequence Induction

22. Airway Evaluation Problem Airway epiglottisVocal cords

23. Be prepared: –Competence with all equipment –Working equipment –Be prepared for surgical management –Master the art of bagging –Have at least one, if not two, working IV lines –STAY ONE STEP AHEAD!! Rapid Sequence Induction

24. Equipment: –Suction, Oxygen –Laryngoscope, ET Tubes, Stylet –BVMR –Pharmacologic agents, mixed and ready –Monitoring equipment Continuous cardiac monitoring Pulse oximeter (continuous) NIBP (ideal) CO2 device (ET confirmation device) Rapid Sequence Induction

25. Pre-oxygenation: –Functional residual capacity –Oxygen 6-10 l/min via snug mask –Three minutes ideal, if spontaneous breathing assist only. – BEWARE BVM while spontaneously breathing..Gastric insufflation is real!! –Avoid BVMR if Spo2 >90% if breathing…. Rapid Sequence Induction

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27. Pre-medication: –Atropine All children under 12 years Adults with heart rate 100 or less *** Second dose of Succinylcholine Dosage: 0.5 to 1.0 mg adult Dosage 0.01 to 0.02 mg child (1 mg max) Give ideally 2-3 minutes prior to intubation Rapid Sequence Induction

28. Sedation Agents Goal is to blunt the pt’s physiologic responses to intubation ie: minimizes bradycardia, hypoxemia, gag/cough & increases in ICP/IOP/IGP –Selection of agent(s) perfusion state presence of head injury clinical diagnosis Rapid Sequence Induction Paralytics Have No Sedative or Analgesic Qualities!!!

29. Selection of Sedative (cont.) –Benzodiazepines Amnestic and at high dose, anesthetic Little cardiovascular depression if titrated Midazolam –Rapid onset –Potent amnestic –Moderate decrease in ICP –1-5 mg IV (adult) as per CPG –0.1 mg/Kg titrated in kids Rapid Sequence Induction

30. Selection of Sedative (cont.) –Narcotics Potent analgesics/sedatives Rapid onset w/ brief duration Effect can be reversed! Fentanyl –Rapid acting (<1min), duration of 30min –No histamine release –May decrease tachycardia and hypertension associated with intubation Rapid Sequence Induction

31. Induction Agents ACh binds to post synaptic receptors causing depolarization … Contraction of muscle ACh binds to post synaptic receptors causing depolarization … Contraction of muscle ACh removed by acetylcholinesterase and by diffusion …. Relaxation of muscle Neuromuscular Junction Dailey; The airway: emergency management

32. Mechanism of action: –Nondepolarizers Competitive Block ACh receptors … paralysis –Depolarizers Noncompetitive Persistent stimulation …fasciculations Unresponsiveness to ACh….Paralysis Induction Agents

33. Dailey; The airway: emergency management

34. Depolarizing –Succinylcholine Vagal effects –Excessive bronchial secretions (blunted by Atropine?) Negative inotropic and chronotropic, esp. with repeated dose and in children (Bradycardia..Atropine) Fasciculations (amelioration) Malignant hyperthermia? Complete paralysis w/in 30-45 sec. Lasting 4-6 min –1.5-2 mg/kg IV Induction Agents

35. –Succinylcholine (cont.) Metabolized via Cholinesterase –0.3% defective enzyme Contraindications –Absolute - none –Hyperkalemia Renal failure Crush injury BurnsMyotoniaParaplegia Induction Agents

36. Non-depolarizing –Rocuronium Minimal cardiovascular effect Long duration of action (may exceed 45 mins) Shorter onset than Pancuronium/Vecuronium: 1-3 min 0.6-1.2 mg/kg Induction Agents

37. Airway Management

40. Digital Tactile Intubation RetrogradeAirtraqFiberscopeBURP Intubation Tricks

41. SURGICAL AIRWAYS Cricothyrotomy –Indications (Identified need for intubation) Maxillofacial trauma Oropharyngeal obstruction –Edema –FBAO –Mass Lesion –Cancer Unsuccessful oral/nasal tracheal Difficult anatomy Massive hemorrhage/regurgitation

42. SURGICAL AIRWAYS Cricothyrotomy (cont..) –Contraindications: –Age <10-12 –Laryngeal crush injury –Laryngeal tumor/stricture –Tracheal transsection –subglottic stenosis –Expanding hematoma –Coagulopathy –Unfamiliar w/ procedure

43. SURGICAL AIRWAYS Anatomy: –Thyroid cartilage –Cricoid ring –Cricoid cartilage –Thyroid gland –Trachea –Major vessels

44. SURGICAL AIRWAYS Netter; Atlas of Human Anatomy

45. SURGICAL AIRWAYS Procedure: –Identify thyroid cartilage Cricothyroid membrane –Vertical incision through skin Prep prior Incise membrane –Open incision Dilator/tracheal hook –Insert ETT/Trach tube Ventilate patient

46. SURGICAL AIRWAYS Complications: –Incorrect placement –Long execution time –Hemorrhage –Passage sub Q –Plugging –Pneumomediastinum –Aspiration –etc.

47. SURGICAL AIRWAYS Anderson; Grant’s Atlas of Anatomy

48. SURGICAL AIRWAYS Retrograde Tracheal Intubation (RTI): –Indications Abnormal anatomy –Pt. W/ epiglottitis –Severe kyphosis –Cervical spondylosis Trauma Reasonable alternative to Surg and Needle Crike

49. SURGICAL AIRWAYS RTI (cont...): –Contraindications Trismus (w/o paralytic) Coagulopathy Enlarged thyroid –Procedure: Supplemental O 2 Catheter over needle into CTM Insert guidewire through catheter Visualize guidewire and pass tube

50. Dailey; The airway: emergency management

51. QUESTIONS ?? Defasiculating Doses (priming with 10% NDNMB) Ketamine Braeslow system for Kids