1. Rapid Sequence Intubation Joshua Rocker, MD Pediatric Emergency Medicine Schneider Children’s Hospital

2. What is it?

3. NPO status is unknown NPO status is unknown Meds same but precautions increased Meds same but precautions increased Cricoid pressure Cricoid pressure Try not to Bag Try not to Bag

4. Why intubate? Airway Protection Airway Protection –GCS <8, lack of gag Control CO2 Control CO2 –Head Injury Decrease work of breathing Decrease work of breathing Bronchopulmonary Toilet Bronchopulmonary Toilet Failure to Oxygenate Failure to Oxygenate Failure to Ventilate Failure to Ventilate

6. But before we intubate… Have we exhausted our options… Have we exhausted our options… Adjuvants Adjuvants –CPAP –BiPAP –Oral-pharyngeal Airway –Nasal-pharyngeal Airway –LMA

7. RSI Check List Patient Airway Evaluation Patient Airway Evaluation Preparation Preparation Personnel Personnel Pre-oxygenation Pre-oxygenation Pre-medication Pre-medication Suction / Sedative Suction / Sedative Paralytic Paralytic 6Ps and 2Ss

8. Patient Airway Evaluation Facial, cervical or neck trauma Facial, cervical or neck trauma Short neck, micrognathia, dysmorphic facial features, low set ears Short neck, micrognathia, dysmorphic facial features, low set ears Limited mouth opening, small mouth, large tongue or loose teeth Limited mouth opening, small mouth, large tongue or loose teeth Stridor, history of obstructive sleep apnea or loud snoring Stridor, history of obstructive sleep apnea or loud snoring Previous traumatic attempts at intubation Previous traumatic attempts at intubation Mallampati classification class III-IV Mallampati classification class III-IV

9. Patient Airway Evaluation Mallampati classification Mallampati classification

10. Preparation Space Space Monitor Monitor –Pulse ox –EKG leads –ET CO2 Material Material –O2, NRB, BVM –Suction –Laryngoscope –ETT: size estimate +/- 0.5 –Stylet –Oral/nasal Airway –Capnography

11. Personnel Medication Administration Medication Administration Cricoid Pressure Cricoid Pressure Watching monitor/patient Watching monitor/patient Paralyzing? Paralyzing? –Make sure someone who can handle difficult intubations or who can get an emergency airway is around!!!!!!

12. Pre-Oxygenate 100% NRB 100% NRB –Make sure connected –Make sure reservoir inflated Avoid BVM Avoid BVM

13. Pre-medicate Atropine Atropine –Prevent Vagal response –Reduce secretions Lidocaine Lidocaine –Blunt Increase in ICP

14. Suction Secretions Secretions Vomitus/Food Vomitus/Food

15. Sedate Opiates (Fentanyl) Opiates (Fentanyl) –Chest wall rigidity Etomidate Etomidate –Myoclonus, adrenal suppression Ketamine Ketamine –laryngospasm., secretions, sympathomimetic Benzodiazepines Benzodiazepines Barbituates Barbituates Propofol Propofol

16. Paralytic Depolarizing Depolarizing –Succinylcholine  Fasciculations, hyperkalemia, malign hyperthermia, MG Non-depolarizing Non-depolarizing –Rocuronium –Vecuronium –Pancuronium –Atracurium

17. Scenarios

18. Scenarios Head trauma Head trauma –Concern of Increased Intracranial pressure (ICP)  Pre-medicate –Lidocaine  Sedation –Avoid: Ketamine (Incr ICP) –Avoid: Benzo, Barbit (possible hypotension)  Thiopental- Cerebral protective  Paralysis –Avoid: Succinylcholine (fasciculations)

19. Head Trauma Lidocaine Lidocaine –Theoretically blunts ICP response  Cough suppression  Brain stem depression  Decreased cerebral metabolism  Cell membrane stabilization –Not well demonstrated in human studies and still controversial

20. Scenarios Asthmatic Asthmatic –Sedation  Ketamine –Bronchodilator –SE: laryngospasm  Chances increased if history of asthma or mild symptoms  BUT if paralyzing no issues, just be aware

21. Scenarios Shock/Hypotension Shock/Hypotension –Sedation  Benzodizapines –May cause hypotension  Barbituates –May cause hypotension  Ketamine –CV stimulant  Etomidate –CV neutral

22. Cases

23. Case 1 14 y/o in MVA comes in with GCS of 6 with gross deformity of R femur and a taught belly. HR-125 BP-94/55 Pulse ox- 94%. 14 y/o in MVA comes in with GCS of 6 with gross deformity of R femur and a taught belly. HR-125 BP-94/55 Pulse ox- 94%. What to do? What to do?

24. Case 1 14 y/o in MVA comes in with GCS of 6 with gross deformity of R femur and a taught belly. HR-125 BP-100/75 Pulse ox- 94%. 14 y/o in MVA comes in with GCS of 6 with gross deformity of R femur and a taught belly. HR-125 BP-100/75 Pulse ox- 94%. What to do? What to do?NEURO-INTUBATION

25. What meds should I use? A. Ketamine, Roc A. Ketamine, Roc B. Ketamine, Lidocaine, Roc B. Ketamine, Lidocaine, Roc C. Etomidate, Lidocaine, Roc C. Etomidate, Lidocaine, Roc D. Etomidate, Atropine, Lidocaine, Roc D. Etomidate, Atropine, Lidocaine, Roc E. Propofol, Lidocaine, Roc E. Propofol, Lidocaine, Roc

26. Case 2 3 y/o asthmatic with hx of 3 previous intubations presents in respiratory distress. Sat 75%. Tachypneic to 65 with grunting. Obtunded. 3 y/o asthmatic with hx of 3 previous intubations presents in respiratory distress. Sat 75%. Tachypneic to 65 with grunting. Obtunded.

27. What meds should I use to intubate? A. Roc and Succ A. Roc and Succ B. Versed and Etomidate B. Versed and Etomidate C. Etomidate and Roc C. Etomidate and Roc D. Ketamine and Atropine D. Ketamine and Atropine E. Ketamine and Atropine and Roc E. Ketamine and Atropine and Roc

28. Case 3 6 mo old male with fever for 3 days and purpuric rash has a pulse of 60 and a BP of 50/palp. 6 mo old male with fever for 3 days and purpuric rash has a pulse of 60 and a BP of 50/palp. SO… SO…

29. What meds now? A. Etomidate and Atropine A. Etomidate and Atropine B. Atropine, Ketamine and Roc B. Atropine, Ketamine and Roc C. Atropine, Etomidate and Versed C. Atropine, Etomidate and Versed D. Versed, Fentanyl and Succ D. Versed, Fentanyl and Succ E. Motrin, Tylenol and Miralax E. Motrin, Tylenol and Miralax

30. Case 4 17 y/o involved in MVA, his body was ejected through the windshield head first. He has a weak pulse with a 70/palp BP. His face anatomy is distorted and his L globe is clearly ruptured. 17 y/o involved in MVA, his body was ejected through the windshield head first. He has a weak pulse with a 70/palp BP. His face anatomy is distorted and his L globe is clearly ruptured. Ouch… Ouch…

31. Next?

32. Next? Lung exam and Tracheal position Lung exam and Tracheal position –Pneumothorax? –Hemothorax? –Pneumohemothorax? –Tension pneumothorax? His exam is normal…

33. What to do next? A. Oral intubation A. Oral intubation B. Nasal intubation B. Nasal intubation C. Wait for back-up C. Wait for back-up D. Surgical Airway D. Surgical Airway E. Soil yourself and then do surgical airway E. Soil yourself and then do surgical airway F. Do surgical airway, then soil self F. Do surgical airway, then soil self

34. Case 5 3 mo old presents DOA. Temperature is 34 degrees Celsius. Rigor Mortis has set in. 3 mo old presents DOA. Temperature is 34 degrees Celsius. Rigor Mortis has set in.

35. What do I intubate with? A. No meds needed A. No meds needed B. Atropine, Succ B. Atropine, Succ C. Epi only C. Epi only D. Propofol and Roc D. Propofol and Roc

36. Thanks Thanks Any questions... Any questions...