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Rapid Sequence Intubation In the Emergency Department Rapid Sequence Intubation RSI The use of medication to facilitate passing the endotracheal tube Analgesics Sedatives Paralytics CONTROLLED procedure Will take several minutes to accomplish Requires a team effort The ultimate goal is to secure an airway without having the patient vomit and aspirate. Indications for RSI Impending airway obstruction Facial fractures…no excessive oral bleeding Facial burns…inhalation injury Expanding retropharyngeal hematoma Excessive work of breathing Example…the exhausted asthmatic Shock GCS <8 Persistent hypoxia (<90%) 6 P's of RSI Preparation Preoxygenation Pretreatment Paralysis (with induction) Placement of the tube Post intubation management Preparation Oxygen Source Pulse oximeter Suction Equipment End-tidal CO² Endotracheal tubes monitor Temperature probe (LONG TERM) Alternative airway equipment-laryngeal mask airway or jet ventilator or crich tray Bag-valve-mask device Glidescope Cardiac Monitor Preparation Assign roles and responsibilities Leader Intubationist Cricoid pressure Monitoring Medications Documentation 2. Preoxygenate 3-5 minutes with 100% O2 bag mask to ensure adequate oxygen reservoir in lungs during apnea Assure age appropriate fitting mask 3. Pre-treatment Laryngoscopy causes stimulation of afferent receptors in the posterior pharynx, hypopharynx and larynx. Reflexes can cause: – Increased intracranial pressure (ICP) – Stimulation of upper & lower respiratory tract increasing airway resistance. – Stimulation of autonomic nervous system, with increase heart rate and BP (vagal stimulation cause decrease in pediatric!) Pre-treatment Attenuate (weaken) normal physiologic & pathophysiological reflex responses caused by airway manipulation during laryngoscope and insertion of an endotracheal tube. - Lidocaine - Atropine - Defasiculating agent Pre-treatment meds Atropine – Treats brady response to SUX, and in young children. Lidocaine – Helps decrease ICP associated with intubation. Vecuronium (defasiculationg dose)keeps muscles from fasiculating (twitching) when using “Succs” 4. Paralysis (with induction) Check patency of line first! Make sure everyone is ready Give IV pushes rapidly and flush Anesthesia before paralysis! *Induction agent is followed immediately by the paralytic without waiting to see if ventilation can be maintained Hallmark of RSI Anesthesia Etomidate Short acting sedative hypnotic Dose=0.3 mg/kg Induction time= 5-10 min. *Myoclonus Ketamine IM or IV Glazed eyes & Dissociative nystagmus Watch for agitated recovery *Increased BP, HR,tonic/clonic,N/V, hypersalivation anesthesia Dose = 1-2 mg/kg (IV)/ 4-10mg/kg IM Lasts approx. 30” Anesthesia Versed Benzodiazepine, Sedative 1-2 mg IV Onset 1.5 min. to 2H *Hypotension Anesthesia Fentanyl Narcotic analgesic 50-100 mcg/kg Lasts 30 min. *Resp. depression Propofol (Diprivan) Induction agent Standard dose: 2 mg/kg Rapid onset, short duration Considerations: *Hypotension,apnea Paralytic (Neuromuscular block) VECURONIUM Skeletal Muscle Relaxer 0.1 MG/KG IV(PARALYZING DOSE) Lasts 25 to 45 min. Paralytic SUCCINYLCHOLINE Side effects: Neuromuscular Fasciculations, blocking agent Dose: 1 mg/kg Duration: 5 min. muscle pain,rhabdo, hyper K, brady, vent. Dysthythmias Malignant Hyperthermia Paralytic Contraindications – Personal or family history of malignant hyperthermia – Significant, verified, hyperkalemia is an absolute contraindication – End-stage renal disease / dialysis dependent patients with unknown potassium level 5. Placement of Tube Position patient • Do not bag unless SpO2 < 90% • Sellick’s Maneuver (Cricoid pressure) Placement of tube Placement and Proof Confirm tube placement – ETCO2 – Bilateral breath sounds – Absent epigastric sounds Failed attempt What if the intubation attempt is not successful? 1st step = bag/mask ventilation for support Rescue Maneuvers – The first rescue from failed intubation is bagging – The first rescue from failed bagging is better bagging 6. Post-intubation Management Secure tube ETCO2 Chest x-ray Long acting sedation (+/- paralysis) – Midazolam 0.2mg/kg – Propofol 25-50μg/kg/min Establish ventilator parameters 6P’s RSI Summary • Preparation (zero – 10 minutes) • Preoxygenation (zero – 5 minutes) • Pretreatment (zero – 3 minutes) • Paralysis with induction (time zero) • Positioning (zero + 30 seconds) • Placement (zero + 45 seconds) • Post-tube management (zero + 90 seconds) Questions?