Rapid Sequence Intubation Putting It All Together

Rapid Sequence Intubation Putting It All Together
New Hampshire Division of Fire Standards & Training and Emergency Medical Services

“One pound of knowledge takes ten pounds of common sense to apply it.”
The hardest part of RSI to master (as with any advanced skill) is knowing WHEN and WHEN NOT to do it – not knowing HOW to do it.

“To Intubate or not to Intubate?” 6 questions to ask:
Can the patient maintain an airway? Can the patient protect this airway? Is the patient appropriately ventilating? Is the patient appropriately oxygenating? Is the patient’s condition likely to deteriorate? Is the scene appropriate: safety, moving the patient while apneic

Purpose of this Presentation:
FAMILIARIZE Medications used for RSI RSI Procedure RECOGNIZE RSI: “When” and “When not” to perform ANTICIPATE Back-up plan “Murphy’s Law”

What is “RSI” ? “RSI is the near-simultaneous administration of neuromuscular blocking agents and sedative-hypnotic drugs in order to facilitate oral intubation of a patient with the least likelihood of trauma, aspiration, hypoxia and other physiologic complications.” Source: NH EMS protocols

Why use RSI? Maximize probability of a successful intubation RSI:
% success rate (US Air Medical Programs, Sand Diego CA (Ochs, Ann. Emerg. Med, 2002) and Washington state trial (Wayen & Friedland, Prehospital Emerg. Care, 1999) Blind NTI: 72.2% success rate (medical) 66.7% success rate (trauma) Minimize adverse physiologic effects Literature: RSI v. Blind NTI ( *RSI success rates: consistently >95-100% is U.S. Air Medical Programs (multiple studies) (PLUS: Takes less time, and fewer attempts to establish an airway than blind NTI). San Diego CA (Ochs, Ann Emerg Med, 2002) trial with 911 paramedic units from multiple services found a 84.2% success rate in head injured patients (RSI was limited to only head injured pts). WA state trial with 911 paramedics in (Wayen & Friedland, Prehospital Emerg Care, 1999) found 95.5% success in trauma pts and 98% success in medical pts. v. *Blind NTI: avg. 72.2% success rate in medical pts 66.7% success rate in trauma pts One Study (592 pts): Causes for ETT failure (56 pts): Inadequate relaxation (49%) [41% of these were later successfully intubated in the ED with RSI] {the others were intubated w/o RSI – suggesting some amount of inexperience in the field} Difficult anatomy (20%) Obstruction (10%) EMS RSI study: Success rate went up from 83% (pre-RSI) to >90% (post-RSI) SpO2 w/o RSI: 86%; with RSI: 95% On scene time was nearly identical RSI v. sedation-only intubation: RSI: Higher success rate, lower complication rate Sedation-only group: 62-75% success rate. Difficultly rates: %. Conclusion: “Sedation alone for intubation appears to be inadequate to achieve good intubating conditions in a significant proportion of pts.” NAEMSP (National Assoc of Prehosp Physicians) : Support prehospital RSI in their position statement ACEP (American College of Emergency Physicians): Support RSI by ED MDs

Indication “Immediate severe airway compromise in the context of trauma, drug overdose, status epilepticus, etc. where respiratory arrest is imminent.” GCS >3

Examples of RSI Indications
Conditions requiring oxygenation/ventilation control or positive pressure ventilation: Traumatic brain injury with ALOC Severe thoracic trauma (flail chest, pulmonary contusions with hypoxemia) Clinical condition expected to deteriorate Unconscious or ALOC with potential for or actual airway compromise or vomiting And patient has…… A clenched jaw An active gag reflex GCS >3

Contraindication “Extensive burns or crush injuries greater than 24 hours old.”

Other situations where RSI may not be the best choice:
Spontaneous breathing with adequate ventilation and oxygenation i.e. Ability to maintain an effective airway by less invasive means Operator concern that both intubation and BVM ventilation may not be successful due to: Major laryngeal trauma Upper airway obstruction Distorted facial or airway anatomy Operator unfamiliarity with the medications used The patient is a candidate for CPAP

Complications Increased intracranial pressure
Increased intraocular pressure Increased intragastric pressure Aspiration due to decreased gag reflex Malignant hyperthermia Dysrythmias Hypoxemia Airway trauma Failure to intubate / failure to ventilate DEATH

3 Major Assumptions of RSI
1. The patient has a full stomach 2. The operator can secure an airway Failure = DEATH for the patient DO NOT take away what you cannot give back! 3. The operator can resuscitate the patient Equipment & Knowledge readily available Mortality for regurgitation and aspiration is 30-70% For those that don’t die, the hospital stay is about 3 weeks, most of which is in the ICU. **RSI is designed to prevent (or decrease) this incidence

Preparation is the KEY for an organized, smooth intubation
Remember the 7 P’s!! Proper prior planning prevents piss poor performance! Remember the 7 P’s!!

IF Endotracheal Intubation fails, you must have a back-up plan...
King-LTD LMA BVM Combi-Tube Cricothyrotomy

RSI Procedure: The Seven P’s
1. Preparation 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

1. Preparation A two-part process: Assess the risks
Prepare the equipment

Assess the Risks Mandibulohyoid Distance = more difficult
Class 1 easiest Tumor = obstruction and increased difficulty Uvula Ring = Expect the unexpected! Bushy beards can obstruct your field of vision

Difficult Airways - Assess the Risks
“The difficult airway is something one anticipates; the failed airway is something one experiences.” -Walls 2002

How do you know if your patient is going to be difficult to intubate…
…and does it really matter? ? In most pre-hospital cases the airway needs managing regardless of the level of difficulty, and the provider is expected to do that, regardless of difficulty ….so what is the benefit of knowing a fancy system?

Identifying a potentially difficult airway is essential to preparing and developing a strategy for successful ETI and also preparing an alternate plan in the event of a failed ETI. The American Society of Anesthesiology (AMA) has noted: “… there is strong agreement among consultants that preparatory efforts enhance success and minimize risk.” And “…the literature provides strong evidence that specific strategies facilitate the management of the difficult airway “ Well, many Anesthesiologists have the option to “Abort” induction, or to work through a problem with as much assistance as needed. In the REAL WORLD of EMS that is seldom the case. However many of the BASIC principles are valid in the clinical evaluation of patients, and thus valuable in our education as medics. Knowing these principles will improve our decision making process and Patient Care.

Some Predictors of a Difficult Airway
C-spine immobilized trauma patient Protruding tongue Short, thick neck Prominent upper incisors (“buckteeth”) Receding mandible High, arched palate Beard or facial hair Dentures Limited jaw opening Limited cervical mobility Upper airway conditions Face, neck, or oral trauma Laryngeal trauma Airway edema or obstruction Morbidly obese Trauma: immobilized – cannot align axis Peds: anterior and cephalad airway, large tongue, large occiput, small mouth, stiff/floppy omega shaped epiglottis (more horizontal) Obesity or very small Short Muscular neck Large breasts Prominent Upper Incisors (Buck Teeth) Receding Jaw (Dentures) Burns Facial Trauma S/S of Anaphylaxis Stridor FBAO Blood Vomitus Epiglottitis Dentures Tumors Impaled Objects Spinal Precautions Lack of adequate access

Additional Predictors: Medical History
Previous problems in surgery Diabetes Pregnancy Obesity Pain issues Joint disease Acromegaly Thyroid or major neck surgeries Tumors, known abnormal structures Genetic anomalies Epiglottitis Rheumatoid Arthritis Ankylosing Spondylitis: Painful Stiffening of the joints Cervical Fixation Devices Klippel-Fiel Syndrome: Short wide neck, reduction in number of cervical vertebrae, and possible fusion of vertebrae. Thyroid or major neck surgeries Pierre Robin Syndrome: Small Jaw, cleft Palate, No Gag reflex, downward displacement of tongue Acromegaly: Thickening of Jaw, Soft tissue structures of the face, associated with middle age

Objectives Identify 4 areas of airway difficulty
Difficult to ventilate with a BVM Difficult laryngoscopy Difficult to intubate Difficult to perform cricothyrotomy Predict a difficult airway using the following mnemonics: MOANS LEMONS DOA

Difficult to Bag (MOANS)
Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff

Difficult Laryngoscopy & Intubation
LEMONS Look Externally Evaluate 3-3-2 Mallampati Score Obstruction Neck Mobility Scene and Situation

Difficult Cricothyrotomy
DOA Disruption or Distortion Obstruction Access Problems If you can’t bag and can’t cric, they’re DOA This is an important assessment tool as it picks up on patients you may not be able to cric. if you have a failed airway.

Disruption / Distortion
Surgeries Radiation Therapy Scarring Burns

Disruption / Distortion
Hanging Crush Injuries Penetrating Trauma Other Soft Tissue Trauma Burns Laceration

Obstructions Hematoma Abscess Tumor
Tumors can also create distortions & extra bleeding

Access Issues Obesity Halo Short neck SC Emphysema Bushy beard
Flexion deformity of the spine

So, give me some good news: The 3-3-2 Rule
Bottom of Jaw/Chin to Neck > 3 fingers Jaw/Palate > 3 fingers wide Mouth opens > 2 fingers wide Thyromental Distance Measure from upper edge of thyroid cartilage to chin with the head fully extended. A short thyromental distance equates with an anterior larynx that is at a more acute angle and also results in less space for the tongue to be compressed into by the laryngoscope blade. > 7 cm is usually a sign of an easy intubation < 6 cm is an indicator of a difficult airway Relatively unreliable unless combined with other tests Any single indicator has poor specificity

Mallampati Classification
Pt should be sitting, head in sniffing position, mouth wide open, and tongue extended out as far as possible. The number classification is based on the posterior pharyngeal structures that are visible. A tongue blade is not used. A Class I view is a Grade I Intubation 99% of the time A Class IV view is a Grade III or IV intubation 99% of the time Class IV: <1% prevalence (hard palate only visible) Severe Difficulty Intubating Class III: <13% prevalance (soft palate, base of uvula visible) Moderate Difficulty Intubating Class II: 40% prevalence (soft palate, uvula, fauces visible) No Difficulty Intubating Class I: 46% prevalence (soft palate, uvula, fauces, pillars visible) No Difficulty Intubating Increased success/ease Decreased success/ease

Cormack & Lehane Grading
Grade I =  success & ease of intubation <1% <5% 10-30% Grade I: full aperture is visible Grade II: Lower portion of cords visible Grade III: Epiglottis only visible Grade IV: Epiglottis not visible Grades III & IV are rare. So, if you frequently see Grade III or IV – consider revisiting your technique. % listed = incidence

What do we do when we have a difficult airway?
The ASA calls a Failed/Difficult Laryngoscopy an: Any airway that takes more than 3 attempts Any airway that takes more than 10 minutes to secure an airway No wonder they say they have a 90% success rate If we had those standards our Pt’s would be dead. Seriously, our field patients are often compromised to begin with – they have very little reserve, and deteriorate rapidly.

Always have a back-up plan.
Plans “A”, “B”, and “C” Know the answers before you begin

Plan “A”: (ALTERNATIVES)
Different: Size of blade Type of blade Miller Macintosh Specialty Position (patient & provider) Hockey stick bend in ETT or Directional tip ETT Gum Elastic Bougie or Flex-guide Endotracheal Tube Introducer Remove the stylette as you pass through the cords “BURP” 2-person technique “cowboy” or “skyhook” Have someone else try Type of blade Miller: anterior airway, big teeth, immobilized pt, floppy epiglottis Macintosh: better tongue control Specialty: Grand View; View Max, etc. It is important that the assistant be intimately familiar with all of these devices. The assistant should be able to identify and prepare the devices for the assistant, if asked. The assistant should be able to identify and prepare the devices for the advanced provider, if asked.

“BURP” Backward, Upward, Rightward Pressure: manipulation of the trachea 90% of the time the best view will be obtained by pressing over the thyroid cartilage 90% of the time the best view will be obtained by pressing over the thyroid cartilage – because, anatomically, the vocal cords are connected here. “BURP”-backwards, upwards, right, pressure May help with difficult intubation Differs from the Sellick Maneuver

Plan “B”: (BVM and BACKUP AIRWAY Techniques )
Can you ventilate with a BVM? (Consider two NPA’s and an OPA, + Cricoid pressure w/ gentle ventilation) Gum Elastic Bougie Combitube KING – LT-D LMA? Practice should include a failed intubation attempt and the assistant preparing the backup airway. The assistant can also practice with the backup airways per his/her level of licensure.

What do we do when faced with a “Can’t Intubate Can’t Ventilate” situation?
Plan “C”: (CRIC) Needle, Surgical Last resort… The assistant should be able to identify and prepare the cricothyrotomy devices for the advanced provider, if asked.

Always expect the unexpected!
Mandibular Aplasia

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care We are still at PREPARATION

1. Preparation A two-part process: Assess the risks
Prepare the equipment

Prepare the Equipment

Prepare the Equipment Adequate Ambu-mask/oxygen sources/suction
2 laryngoscope handles Assortment of blades Assortment of ET tubes, stylette, syringe Two assistants familiar with the procedure 1-2 secure IV lines All pharmaceutical agents needed for the procedure Back-up plan and rescue airway devices Oximetry and capnography monitoring Bulb-style tube checker Obviously the assistant should be able to perform any of these skills up to their level of licensure and be familiar with the set up of the advanced devices. Basics and Intermediates CANNOT prepare or administer RSI Medications, as it is outside the protocol.

Monitor the Patient Cardiac monitor
Monitor for dysrythmias bradycardia, tachycardia, ectopy Blood Pressure monitoring (manual or NIBP) Monitor for hypo- or hypertension Pulse oximetry Monitor for hypoxia Capnography Monitor for hypo- or hypercarbia

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care

2. Preoxygenation Pre-oxygenate with 100% O2 via non-rebreather mask for at least 3-5 minutes Replaces the patient’s functional residual capacity (FRC) of the lung with oxygen “Nitrogen Washout” If done properly, this will permit as much as 3-4 minutes of apnea before hypoxia develops Rise of PaCO2 in apnea is not usually a significant concern unless the patient has a TBI or is severely compromised prior to intubation. PaCO2 rises about 3mmHg/min when the patient is apneic. FRC (functional residual capacity) in infants: 25 cc/kg (42 cc/kg in adults) Goal in preoxygenation is to replace the N2 in in the FRC with O2 O2 Consumption in infants: 5-8 cc/kg/min (gradually decreases with age to 2-3 cc/kg/min) **This predisposes peds to desaturation Most fully preoxygenated, healthy infants desaturate within seconds! In emergent cases, three mask breaths with 100% oxygen may have to suffice. Assistant: Will most likely be responsible for the preoxygenation of your patient.

2. Preoxygenation Resist the use of positive pressure ventilation (PPV). Use only if the patient is not ventilating adequately. PPV leads to gastric distention  regurgitation  aspiration If PPV is necessary, utilize cricoid pressure Place NG/OG if prolonged use of BVM

Rapid Sequence Intubation Medications

Note about Medications
Medications are ONLY to be drawn, prepared, and administered by paramedics. The Basic or Intermediate Assistance cannot prepare RSI Medications, as they are not protocoled for their use.

3. Premedication These medications are given 2 minutes prior to intubation to reduce/blunt the patient’s physiologic responses to the subsequent intubation Possible physiologic responses include: Bradycardia Tachycardia Hypertension Hypoxia Increased intracranial and intraocular pressures Cough and gag reflexes Bradycardia – especially in peds and infants (with the use of Succs, and vagal stimulation) Tachycardia Hypertension Hypoxia Increased intracranial and intraocular pressures Cough and gag reflexes

Lidocaine Dose: 1.5 mg/kg IVP
When: At least 2 minutes prior to intubation Why: May prevent a rise in ICP in TBI patients Onset: immediate Duration: minutes Mixed results regarding efficacy in decreasing ICP spike Standardized therapy at present – primarily for patients with suspected traumatic brain injury Also decreases the cough reflex and may decrease the incidence of post-laryngoscopy hypertension and tachycardia associated with intubation May also be give directly squirted into the posterior pharynx and trachea – may produce as much ICP spike, etc. as direct laryngoscopy Studies show ET suctioning and laryngeal manipulation cause an average ICP rise of 22 mmHg Assistant: Will not see any major change in patient.

Lidocaine Lidocaine for head injuries, non-traumatic head bleeds and asthma patients (Tight head, tight chest) Takes 3 minutes to work, so may not be worthwhile if time is critical…….. Use your judgment

Atropine Dose: 0.5 mg IVP When: Prior to intubation for bradycardic adults Why: Given to prevent worsening bradycardia From Succs, vagal stimulation during direct visualization, and hypoxia Atropine Onset: Immediate Duration: 4-6 hours Assistant: Will not see any major change in patient.

4. Paralyze A three step process: Induction Cricoid Pressure Paralytic

Induction with Etomidate
Hypnotic induction agent No analgesic properties Dose: 0.3 mg/kg IV Onset: seconds Duration: 3-5 minutes Should always be given prior to paralytic Causes a slight elevation in arterial PaCO2, transient lowering of cerebral blood flow, moderate lowering of ICP lasting several minutes Etomidate: Dose Range: mg/kg. Some protocols call for a dose of 0.15 mg/kg in elderly or SBP<90. Ultrashort acting, nonbarbiturate hypnotic induction agent. Onset: seconds. Duration: <10 minutes. Half-life: 2.6 minutes. Does not cause hypotension or cardiovascular depression. Will lower ICP through reduced cerebral blood flow (20-30%) (also decreases O2 consumption). Etomidate decreases cerebral oxygen consumption, cerebral blood flow, and ICP but appears to have minimal effects on cerebral perfusion pressure. At therapeutic doses, etomidate is characterized by hemodynamic stability without significant changes in mean arterial pressures, although a slightly increased heart rate may be observed. Has a tendency to induce vomiting – esp. if given rapidly. (*Also can causes adrenalcortical suppression - reduced cortisol and aldosterone - for up to 8 hours even after a single induction dose & unresponsive to ACTH stimulation -can be significant in pts with catecholamine depletion disease processes.) NOT effective at attenuating the hyperdynamic response to tracheal manipulation. Reports of hypertonus, coughing, laryngospasm, hiccoughs, and involuntary muscle movements(32% of pts) in 14-70% of pts. Premed with fentanyl 1mcg/kg helped. Etomidate + Fentanyl – study showed its efficacy when HTN and tachycardia are undesirable. Hepatic metabolism Assistant: Will see the patient become less responsive; more relaxed.

Cricoid Pressure Also known as “Sellick’s Maneuver”
Should be automatic Begin just as Etomidate is administered Maintained until ETT placement is confirmed and tube is secure (cuff inflated) Used to occlude the esophagus and prevent passive regurgitation common with Succs If patient starts to actively vomit – RELEASE! and suction oropharnyx. Otherwise, can lead to esophageal rupture Assistant: This an important role for you!

Cricoid Pressure Use thumb and forefinger to apply pressure directly backward/posterior over the cricoid cartilage. Frequently applied incorrectly. If too much pressure is applied, will obscure view of the cords

Cricoid Pressure The patient MAY become apneic shortly after receiving Etomidate, and will be completely paralyzed seconds after Succinylcholine An assistant MUST perform cricoid pressure at the first sign of sedation and continue until the airway is secure

Anectine (Succinylcholine) SCh or “Succs”
The only depolarizing paralytic in clinical use Benefits: Rapid onset Short duration Succs attaches to the acetylcholine receptors of nerves and causes the nerves to depolarize – seen as muscle fasciculations. It remains until it is metabolized. Will cause “fasciculations”

Fasciculations Muscular twitching involving the simultaneous contraction of contiguous groups of muscle fibers Merriam-Webster Dictionary

Succinylcholine Dose: 1.5mg/kg IV When: Immediately after Etomidate
Onset: rapid, usually secs Duration: short acting, 3-5 mins One Study: Trauma pts with RSI – Succs was associated with fewer difficult intubations that non-depolarizing NMBs May be given IM (not in state protocol) 3-4 mg/kg (max 150 mg total) onset: 2-5 minutes duration: 4-6 minutes Vial: 20mg/ml **“ONSET” for all of the paralytics = less time than it takes for there to be “optimum intubating conditions” Assistant: You will likely see the patient go through a brief period of fasciculations followed by complete flaccidity,as the patient become paralyzed.

Contraindications Severe burns > 24 hours old
Massive crush injuries >8 hours old Spinal cord injury >3 days old Penetrating eye injuries Narrow angle glaucoma Hx of malignant hyperthermia patient or family Pseudocholinesterase deficiency Neuromuscular disease Hyperkalemia May precipitate fatal hyperkalemia! K+ may rise up to 1mEq (Typical rise: ) {study: 46% increased, 46% decreased, 8% no change} Increased risk in chronic disease states & acute injury SEVERAL DAYS after the insult (perists for several weeks) Generally safe to administer within 24 hours of injury High incidence of undiagnosed muscular dystrophy in peds makes Succs use “relatively contraindicated” in “elective” peds RSI (esp. males <8)

Complications Cardiovascular Effects Muscle Pain Hyperkalemia
Minimal in adults Muscle Pain From the fasciculations Hyperkalemia Not a significant issue in the acute period Should be considered in patients with known hyperkalemia, acute renal failure Can cause bradycardia in peds (esp. 1-7 y/o age group) DO NOT give a repeat dose – may cause severe bradycardia/asystole Fasciculations Usually less severe in Peds than adults Abolished with defasciculating dose of neuromuscular blocking drugs Use of defasciculating doses prior to Succs is thought to be controversial and relatively unnecessary

Complications Increased intraocular pressure
May be a concern for those with penetrating globe injuries – theoretically can lead to expulsion of intraocular contents No documented cases found Defasciculating dose of a non-depolarizing neuromuscular blocker and lidocaine pretreatment may abolish this complication Effect is modest. Starts at 1 min; lasts for 5-7 minutes. Increase is approx. 3-8 mmHg (Blinking alone may raise IOP by 10 to 15 mm Hg, whereas more vigorous activity such as coughing, gagging, or crying may elevate IOPs by up to 70 mm Hg.) The increase is less than direct laryngoscopy, coughing, vomiting, a blink, or hypoxemia. Use of succs in open-eye injury is controversial, but there are no documented cases of intraocular expulsion.

Complications Increased intracranial pressure Controversial
May be a concern for those with suspected traumatic brain injury Lidocaine administration is thought to blunt the ICP spike The effects of direct laryngoscopic intubation, coughing, hypercarbia, or hypoxia vastly outweigh the effects of succs. This effect is abolished by the use of deep anesthesia, IV Lido, or defasciculating doses of NMBs prior to succs.

Complications Increased intragastric pressure
Passive regurgitation from fasciculations Importance of Cricoid Pressure / Sellick’s maneuver

Complications Malignant Hyperthermia Very rare condition – 1:15,000
Patient experiences a rapid increase of temperature, metabolic acidosis, rhabdomyolysis, and DIC Treatment includes administration of Dantrolene and external means of temp. reduction Malignant hyperthermia is a rare complication with an autosomal dominant inheritance pattern. It occurs in approximately 1 in 15,000 children and 1 in 50,000 adults. The clinical syndrome consists of high fever, tachypnea, tachycardia, cardiac arrhythmias, hypoxia, acidosis, myoglobinuria, and impaired coagulation. Unabated muscle contractions mediated by abnormal calcium channels are believed to be the physiologic basis for this condition. Treatment includes aggressive cooling measures, volume replacement, and correction of hypoxia and acid-base and electrolyte abnormalities. Dantrolene sodium, a direct-acting skeletal muscle relaxant, has been shown to be effective in reducing the muscle hypermetabolism that causes the fever.

Complications Prolonged paralysis Masseter muscle rigidity
In patients with: A deficiency of pseudocholinesterase Certain meds: magnesium, lithium, quinidine Cocaine Masseter muscle rigidity Masseter muscle rigidity very rare occurrence. More common in peds. 5,641 pts – 3 pts had it An associated abnormal response to succinylcholine is isolated masseter spasm. Barlow and Isaacs reported two cases in which masseter spasm was the first abnormality noted in fatal episodes of malignant hyperthermia. Masseter spasm may be more common in patients with neuromuscular disorders such as myotonia congenita.

Anybody still awake?

5. Pass the Tube Intubation is performed when there is full relaxation of the airway muscles About 90 seconds after Succs If intubation fails, maintain cricoid pressure and ventilate with BVM After patient is reoxygenated, reattempt or move to a different airway adjunct Assistant: You are still performing the cricoid pressure at this point.

Direct Visualization…

Hold manual in-line axial stabilization (MIAS)
Suspected Cervical Injury? Hold manual in-line axial stabilization (MIAS) Myth that pts with c-sp injuries cannot be safely intubated orally with RSI – FALSE!! BUT – you must have MIAS in place.

Pass the Tube COMPLICATIONS:
If you miss or are unable to intubate after 30 seconds…… Ventilate with BVM / high flow O2 with cricoid pressure maintained Make ONE more attempt to intubate If still unsuccessful – continue BVM / Cricoid pressure Secure Airway with backup device (CombiTube, LMA or King-LT-D) Assistant: The advanced provider may ask you to perform the “BURP” maneuver to better visualize the cord.

If Unable If unable to intubate, unable to secure the airway with backup device, and unable to maintain an SpO2 of >90% with a BVM Contact Med Control Consider surgical airway: Surgical Cric Commercial Cric. Device Needle Cric

1. Preparation - CONTINUED 2. Preoxygenation 3. Premedication 4. Paralyze 5. Pass the tube 6. Proof of placement 7. Post intubation care We are still at PREPARATION

6. Proof of Placement OBJECTIVE Direct visualization BEST CXR (in hospital) Pulse oximetry Capnography CO2 detectors Easy Cap - colormetric Self-inflating bulb SUBJECTIVE Absence of abdominal sounds while ambu- bagged Mist in the tube Bilateral breath sounds Rise/fall in chest USE at least 3 OBJECTIVE METHODS OF ETT CONFIRMATION, including capnography waveform when possible: direct visualization SIB CO2 detectors CXR Confirm placement using at least 3 methods, including capnography waveform. Assistant: Be familiar with the set-up and/or assembly of the various confirmation devices as you will likely be called upon to connect them.

SpO2 (Pulse Oximetry) Provides quick estimate of PaO2
Often referred to as an additional vital sign Non-invasive

Waveform Capnometry Number of important applications Limitations:
Monitor & Confirm ETT placement Useful to document adequacy of ventilation during mechanical ventilation Limitations: For patients with impaired pulmonary function or hemodynamic instability Assistant: Become familiar with the appropriate waveform for a properly ventilated patient.

The Capnogram Represents the Respiratory Cycle Exhalation Inhalation
A to D Inhalation D to E

Waveform Capnometry Prerequisite Requirement
Becoming a standard of care Easy to Use Good measure of Pulmonary Perfusion Relates well to PaCO2 Does have limitations

After confirming placement:
Secure airway device Immobilize the head Verify correct placement each time the patient is moved Document appropriately Assistant: Again, be familiar with these steps and be able to perform.

7. Post Intubation Care Medicate: Consider wrist restraints Sedation
midazolam ( mg/kg IVP) or lorazepam (1-2 mg IV) fentanyl ( mcg may be considered prn) Paralysis (with online medical control) vecuronium (0.1 mg/kg IVP) or rocuronium (1 mg/kg IVP) Consider wrist restraints

Midazolam: Faster onset, shorter duration than lorazepam
Midazolam & Lorazepam Benzodiazepines Provide sedation, amnesia, and anticonvulsant properties No analgesia Midazolam: Faster onset, shorter duration than lorazepam Lorazepam: may be the preferred agent due to its longer action duration Midazolam: 2x as potent as diazepam *Induction dose: benzo of choice. In the well-premedicated, healthy patient, 0.2 mg/kg over 5-15 seconds – induction occurs in 28 seconds The stresses of intubation are not blocked by midazolam – so adjuvant anesthetics, usually opioids, are often combined with benzos (but combo of versed + fentanyl or sufentanyl produces greater decreases in systemic BP than each drug alone) (there is evidence that midazolam and diazepam decrease catecholamine – use with caution in certain pt populations who are surviving on catecholamines…) Decrease in SVR results in a slight decrease in arterial BP (12-26% reduction in MAP) More than the other benzos “despite the hypotension, midazolam, even in doses as high as 0.2 mg/kg, is safe and effective for induction of anesthesia…” – Miller, anesthesia book In pts with elevated left ventricular filling pressures, midazolam produces a “NTG-like” effect by lowering the filling pressure and increasing CO. Study: 0.1 mg/kg v. 0.1 mg/kg with a max of 5mg for RSI. 219 patients. Results: statistically significant relationship between versed use and hypotension and SBP decrease following RSI Sign/symptoms: Movement, Increase in heart rate Pay close attention to the patient’s level of consciousness. Should the patient at anytime show any signs/symptoms of discomfort (movement, increase heart rate, increased blood pressure) consider further sedation.

Sedation Assessment Sign/symptoms Movement Increase in heart rate
Increase in blood pressure Decrease in SpO2 Changes in muscle tone Facial muscle tension

Midazolam (Versed) Dose: 0.05-0.1 mg/kg IVP Rapid onset – 1-2 minutes
Single dose duration: minutes In the prehospital setting, hypotension with midazolam was found to be dose related and thus should be used cautiously in patients with hypovolemia or traumatic brain injury, or both.

Midazolam Duration: 1-4 hours Hepatic clearance
Decreased dose needed (longer half life) Obese Geriatric CHF Hepatic or renal insufficiency Midazolam HCl should only be administered IV or IM. Also available as versed syrup for PO use Don’t use in pregnancy – increased congenital malformations

Lorazepam (Ativan) Post-RSI sedation:
Lorazepam 1-2 mg IV push q 5 min prn Titrate to keep patient sedated and SBP >90 Onset: 5 minutes Duration: 6-8 hours, dose dependant

Fentanyl Class 25-100 mcg may be considered prn
Anesthetic Induction / Maintenance Narcotic mcg may be considered prn

Fentanyl Opioid agonist Dampens sympathetic (catecholamine) response
Does not release histamine May cause stiff chest in doses >500mcg Caution in hypotension / hypovolemia

Vecuronium & Rocuronium
Non-Depolarizing Paralytics Provide paralysis, but NO sedation, amnesia, or analgesia properties

Vecuronium (Norcuron)
Considered safe without many contraindications May be used in most patients including cardiovascular, pulmonary, and neurological emergencies Must be reconstituted from powdered form Vial: 10 mg/10 ml Structural analog to pavulon – but not vagolytic

Vecuronium Dose: 0.1mg/kg IVP Repeat/maintenance dose: 0.01 mg/kg
Onset: 2-3 minutes Duration: approx minutes Repeat dose not part of NH EMS protocol Vec may be given with on-line medical consultation for continued paralysis

Vecuronium Metabolized by the liver and kidneys
Use with caution in patients with liver failure May have 2x the recovery time Patients with renal or hepatic failure will need less medication to maintain paralysis Does not cause hypotension or tachycardia Associated with prolonged blockade after med is DC’d – All steroid-based NMBAs have been associated with prolonged recovery time and myopathy – undergo extensive hepatic metabolism, producing active drug metabolites Vec produces 3 active metabolites – one as 80% as strong as Vec. Accumulates in pts with renal failure (hepatic elimination is decreased in pts with uremia) So, lessening in popularity in the ICU

Rocuronium (Zemuron) Very similar properties to Vecuronium
Does not need to be mixed, can be stored at room temp for 60 days Less vagolytic properties

Rocuronium Onset: 30-60 seconds Dose: 1 mg/kg IVP
Fastest onset of all non-depolarizing NMBs Dose related Dose: 1 mg/kg IVP Duration: minutes Repeat/maintenance dose is the same as the initial dose Vial: 10mg/ml vials of 50 mg (or 10mg/ml vials of 100 mg) Repeat dose not part of NH EMS protocol Roc may be given with on-line medical consultation for continued paralysis *Raising the dose of Roc from 0.6 to 0.9 mg/kg nearly halves the time for suitable intubating conditions, but it also increases the duration. Nevertheless, most studies concur Roc 0.9 mg/kg or higher should be used for “crash” RSI conditions.

Feeling overloaded? Little humor

Review: Sequence of Administration
Time -5 minutes Preoxygenation Time -2 minutes Premedication Time -0 minutes Sellick Maneuver, Induction Agent, Paralytic Time +1 minutes Intubation T (5 minutes before RSI) Preoxygenation T-3 (3 minutes before RSI) Premedication T-0 (at time of RSI) Sellick maneuver, Induction agent, paralytic T+1 (1 minute after above medications given) Intubation

Medication Sequence Oxygen Lidocaine and/or Atropine if indicated
Etomidate Cricoid Pressure Succinylcholine INTUBATION Lorazepam / Fentanyl prn Rocuronium or Vecuronium prn

IMPORTANT REMINDERS!! Always remember (and suggest) the use of sedatives before giving paralytics, and allow them to take effect Sedatives and paralytics do not have any analgesic properties, evaluate patient response and possible need for analgesia vital signs, skin signs

This is the typical RSI sequence. Atropine for the pediatric patients
This is the typical RSI sequence. Atropine for the pediatric patients. Longer acting paralytic (Rocuronium or Vecuronium) for the longer transports after contacting medical control.

“Failed Airway” Worst case scenario:
Can't Intubate Can't Ventilate

Know Your Options!!! & Don’t hesitate to use them!

Failed Airway Unable to intubate (including blind devices) and unable to ventilate with a BVM and maintain an Sp02 > 90 %.

Rescue Airway Management
Have a back-up plan Algorithmic approach BVM Gum Elastic Bougie Laryngeal Mask Airway (LMA) Esophageal Tracheal Combitube King-LT-D Discuss drawbacks and benefits of each Assistant: Be familiar with the set-up and/or assembly of the various backup devices as you will likely be called upon to assist with them.

BVM Can you obtain a good mask seal? Adequate chest rise & fall?
Adequate oxygenation & ventilation? Assistant: You will most likely be performing this skill.

Gum Elastic Bougie (GEB) or Flex-guide (FG) Endotracheal Tube Introducer
First introduced in 1949 Useful in failed intubation with Grade III or Grade IV laryngoscopic view Might be helpful in the immobilized trauma patient Has been found to reduce the incidence of failed intubation 96% success rate On average, use if an FG instead of a stylet only requires 10 seconds longer to perform intubation Providers must receive training in the use if the FG FG: 60cm long disposable, semirigid, latex-free polyethylene instrument that is narrow enough to be passed through a 6mm ID ETT. Both ends are smooth and rounded to avoid tissue injury. The tip is angulated to approx. 45 degrees which facilitates passage of the FG anteriorly into the trachea when only the epiglottis is visualized. An ETT is then passed over the FG into the trachea. Following placement of the ETT, the FG is removed

LMA Good temporizing measure Multiple sizes
Aspiration likely if vomiting occurs Pre-Hospital use unproven/unpublished Risk of aspiration Controversy: The design of the mask makes aspiration likely if vomiting or regurgitation occur during ventilation through the mask.

Combitube Especially suited for… Patients with difficult anatomy
Reduced access spaces Reduced illumination (bright light) 95% of time will pass into the esophagus

King-LT-D

Failed Airway Management

Cricothyrotomy Airway of last resort Low frequency/high risk skill
Can be complex and confound decisions Refer to BEMS Cricothyroidotomy power point training module

Cricothyrotomy Relatively contraindicated by anatomic disruption of the cricothyroid region of the airway (Lack of landmarks)

Final Thoughts on the “Failed Airway”
In all cases of a failed airway, the operator must continually assess the adequacy of oxygenation and ventilation 7% of all trauma patients will require intubation

Additional Documentation Items
Why was the decision made to RSI Pre & Post O2 and CO2 levels Airway Grading/scales Unsuccessful Attempts

Case Studies

Case 1 67 y/o female “code blue” – in asystole. PLAN?
ETI needed, no RSI meds needed

Case 2 72 y/o female with Hx fever, productive cough and progressive dyspnea. Lethargic, perioral cyanosis. RR 34 and labored, HR 114, BP 117/76. Lung sounds equal with scattered rhonchi. PLAN? Pt needs RSI – her condition is likely to deteriorate. Medicate with Etomidate and Succs.

Case 3 41 y/o female with c/o “asthma attacks” x20 minutes. Severe respiratory distress. RR 32, HR 127, BP 160/92. Bilateral I/E wheezes. Within 10 minutes, she becomes lethargic and her RR slows. PLAN? Needs RSI. Etomidate and Succs.

Case 4 46 y/o male with a Hx of EtOH and drug abuse. Presents with “had a seizure” per bystanders. Pt is responsive to pain, but does not follow commands or answer questions. RR 18, HR 109, BP 120/80. Within minutes, he has 2 episodes of vomiting and “gurgling respirations”. PLAN? Needs RSI – cannot protect his airway, ALOC. May have a CHI. Consider pre-treating with Lido. Medicate with Etomidate and Succs. Lido for possible CHI/ICP.

Case 5 25 y/o male with GSW to abdomen. Pt is intoxicated, decreased LOC, minimal gag reflex. RR 8-10, HR 120, BP 100/80. PLAN? Needs RSI – condition likely to deteriorate, needs surgical intervention, unable to protect his airway. Medicate with Etomidate and Succs.

Case 6 87 y/o male MVC, high-speed, unrestrained. Patient gasping for air, able to talk, c/o right side CP. RR 32, HR 120, BP 186/92. Multiple deformities to face and chin. Ecchymosis and swelling to neck and anterior chest. Large flail segment to ant/lat chest. Decreased BS on the right. No stridor, but some gurgling in throat. PLAN? Needs ETI. Awake oral would be preferred – his airway is most likely distorted and his muscle tone may be the only thing keeping his airway open. He needs rapid evaluation and + pressure ventilation for his flail chest. He also needs a chest tube on the right. Know you might not succeed with RSI. Have rescue devices ready.

References Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc. Miller: Miller's Anesthesia, 6th ed., Copyright © 2005 Elsevier Roberts: Clinical Procedures in Emergency Medicine, 4th ed., Copyright © 2004 Elsevier

Rapid Sequence Intubation Putting It All Together

Similar presentations

Presentation on theme: "Rapid Sequence Intubation Putting It All Together"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Rapid Sequence Intubation Putting It All Together

Similar presentations

Presentation on theme: "Rapid Sequence Intubation Putting It All Together"— Presentation transcript:

Similar presentations

About project

Feedback