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Rapid Sequence Intubation and Difficult Airway Andrew Scordato EMT-P EMS Instructor Learning objectives Define RSI List Indications and Contraindications Describe Basic Airway Anatomy Identify and Describe RSI Pharmacology Identify and Describe the seven P’s of RSI Differentiate between properly place and improperly placed ET tubes Discuss Difficult Airway Factors Solutions: extraglotic airways RSI? What is RSI Sedatives and NMBA same time Protect airway/minimize hypoxia Who is it for Unable to maintain airway GCS <8 Pt. may lose the ability to protect their airway Others? Who is it not for Inexperience Difficult airway? No “back-up” capabilities Airway Anatomy Upper airway Normal VS. Abnormal Abnormal Airway Anatomy Lower Airway Airway Anatomy Properly placed ET Tube What are the Drugs Doing? Cellular level Neuron Action Potential Ion channels Synapse Neuron Action Potentials Ion Channels The Synapse The Usual Suspects Atropine Names-Atropine Sulfate Actions-parasympatholytic, Blocked vagal effects result in increased HR, decreased secretions Indication-Bradycardia, used to pre-medicate Contraindications-Acute hemorrhage, tachycardia, narrow angle glaucoma Lidocaine Names-Xylocaine Actions-Antidysrhythmic properties, Local Anesthetic, Blunts ICP Indications-pre-medicate in RSI Contraindications-Second or third degree heart block in the absence of artificial pacemaker. Caution-apnea induced with suxs may be prolonged with large doses of lidocaine. TUS II Vercuronium Names-Norcuron Actions-Provides muscle relaxation by competing with ACH receptors on the nerve, result is muscle paralysis. Does not cause that initial depolarization wave that is common with SUCCS. Indications-Temporary paralysis where muscle tone or szr prevent Dosage-Defasciculating dose 1mg/ivp Paralytic dose= .1mg/kg Contraindications-monitor for bradycardia and hypotension. Certain drugs can enhance the effect including lidoccaine. Lasts-25-30 minutes Versed Names-Midazolam hydrochloride Actions-Short acting benzo, conscious sedation and impairs memory Indications-Premedication for Intubation, SZR Contraindications-shock, Alcohol intoxication (relative), Concurrent use with other barbiturates, alcohol, narcotics and CNS depressants. TUS III Etomidate Names-Amidate Actions-Hypnotic, Anesthetic, Sedation, impairs memory,inhibits postsynaptic current Indications-Medication for Endotracheal intubation Contraindications-L and D, effects may be enhanced when given with other CNS depressants. Succinycholine Names-Anectine Actions-Neuromuscular blocker-bind to ACH sites cause muscle to relax Indications-facilitate intubation, muscle relaxation Contraindications-skeletal muscle myopathies, Inability to control airway and or support ventilations with 02 or BVM Ketamine Ketamine is a non-competitive NMDA receptor antagonist and dissociative, amnestic, analgesic anesthetic agent. Onset & Duration Onset: 1-5 minutes. Duration: 10-15 minutes Contraindications Relatively contraindicated in penetrating eye trauma, patients with known cardiovascular disease. (ketamine causes tachycardia) Side Effects Laryngospasm: this very rare adverse reaction presents with stridor and respiratory distress. After every administration of ketamine: a. Prepare to provide respiratory support including bag-valve-mask ventilation and suction which are generally sufficient in rare cases of laryngospasm. b. Institute cardiac monitoring, pulse oximetry and continuous waveform capnography c. Establish IV or IO access, check blood glucose Emergence reaction: presents as anxiety, agitation, apparent hallucinations or nightmares as ketamine is wearing off. For severe reactions, consider benzodiazepine. Nausea and Vomiting/Hypersalivation: Suction usually sufficient. Pharmacology Paralytics Notes Choice is between Depolarizing or Non-Depolarizing Rapid paralysis with rapid recovery Depolarizing persistent stimulation/Unresponsive to ACH/Fasciculation Fasciculation-What? Muscle contraction cannot reoccur leading to relaxation Example-Succinylcholine Non-depolarizing Blocks ACH sites Slower onset No fasciculation Longer duration of Action Example-Vecuronium Depolarizing/Non-Depolarizing Pharmacology Pre-Medicating Agents Atropine Bradycardia (Peds) Decrease Vagal tone/secretions Dose=.02mg/kg Lidocaine Head injury/ other conditions? It’s believed to blunt ICP/open smaller airways Dose=1mg/kg 3-5 minutes prior to intubation Defasciculating agents Vecuronium-Head Injury/ Penetrating Eye Injury Pharmacology Induction agents (sedation) Notes Review VS Paralyzed and Sedated not paralyzed alone Multiple Agents available Versed Benzodiazepine/Short Acting onset=1-3 minutes/ duration 2-6 hours 2-2.5mg sivp Etomidate=Rapid onset, short acting, sedative hypnotic Onset=10-15 seconds/duration 5-15 minutes Dosage=0.3mg/kg Pharmacology Succinylcholine Depolarizing Primary agent with NDMB as secondary Onset=within 1 minute/Duration=2-5 minutes Dosage=1.5mg/kg Pt.'s with burn >24 hours/precaution difficult intubations Vecuronium NDMB Onset approx. 3 minutes Dosage= Defasciculating 1mg/ivp Paralytic=0.1mg/kg The Seven P’s of RSI 1.Prepare 2.Pre-Oxygenate 3.Pre-medicate 4.Put under=sedate 5.Paralyze 6.Pass the tube 7.Post-Intubation Management Prepare Assess Difficult Airway? Gather Equipment=“Soap me” Suction/02/Airway equipment/Pharmacology/Monitoring Equipment Prep the Patient Difficult Airway Predictors of a difficult airway Short Fat neck Small receding chin Presence of a beard Large tongue Trauma Infection or tumor Spinal disease Low set ears Swelling of the face or neck What do you see? Pedictors Mnemonics, Mnemonics, Mnemonics! What are our tools to assess the difficult airway and problems we may encounter-What are the chances for success? Lemon-intubation L=Look Externally-abnormal face, sunken cheeks, narrow mouth, receding mandible, obesity Evaluate the 3-3-2 rule=3 pt. sized fingers in mouth/Hyoid to chin 3 fingers/ 2 fingers from thyroid cart. to floor of mouth Mallampati Obstruction Neck Mobility=can you extend and flex the neck 3-3-2 332 Mallampati Mallampati scoring Class I and II Can see Soft palate Uvula Class III and IV Can see Hard palate Base of uvula Obstructed Airway Four Main signs Muffled Voice Difficulty Swallowing/Secretions Stridor Sensation of Dyspnea Mnemonics Moans=ventilating Mask seal Obstruction Age No teeth Stiff Neck RODS=extraglottic device Restricted-mouth opening Obstruction Distorted-tumor or surgery Stiff lungs-asthma ,COPD, ARDS Pre-Oxygenate Two to Five minutes before the initiation of sedation and Neuromuscular blockade Buys time during patients period of Apnea before they de- saturation Allows for “Nitrogen Washout” 100% 02 via NRB or BVM Make sure equipment is operating 02 sat and Capnography Desaturation Curve Pre-Medicate Why are we pre-medicating the patient? What are we pre-medicating them with? Atropine-Peds/Bradycardia Lidocaine-Head Injury Defasciculating Agents What are they? Vecuronium Allow 2-3 minutes for them to take effect. Put Under Sedate If pt. is paralyzed then they must be sedated Multiple sedative agents available(Thiopental, Midazolam, lorazepam, fentanyl, ketamine, Etomidate, and propofol) MCEMD agents Etomidate and Versed Etomidate-Rapid onset, short acting, sedative-hypnotic agent Onset-10-15 seconds Duration 5-15 minutes Dosage 0.3mg/kg Versed-short acting rapid onset benzodiazepine Onset-1-3 minutes Duartion-2-6 hours Dosage 2-2.5 mg slow ivp Paralyze Neuromuscular blocking agents Depolarizing Non-depolarizing Examples Succinylcholine Precaution in burn patients/Patients with Renal Failure/Hyperkalemia Vecuronium Passing the Tube Take a deep breath/relax Make sure equipment is ready Maintain c-spine & Monitor VS (ekg and Sp02) Pad behind the Pt. head to line up airway Have partner use the BURP method Relax BURP B=Backwards U=upwards R=right P=pressure Line Up Lining up airway axis Pad behind Pt.'s head Head extension Tragus with chest Tragus to chest Post-Intubation 1.Confirm Placement Tools Visualize Auscultate Secondary devices 2.Protect Placement Secure 3.Management DOPE Capnography What are good values=What to What Is this a good tracing? Why? Esophageal 1st, 2nd 3rd attempts? 1st attempt Reposition patient Pad more under head Lift shoulder off the floor Intubator same level as the Patient 2nd Change blades Hyper-flex the neck Tools 3rd Back-Up airways BVM Cricothyroidotomy Back-Up airways Combitube LMA King Airway King Airway Cricothyroidotmoy CICO event=Can’t intubate-can’t oxygenate Placement-find cricothyroid membrane Equipment=scalpel et tube or quicktrach kit Technique=Protocol dependent Cric AP Cric Pediatric Airway Adults VS. Pediatric Larger tongue Cricothyroid narrowest More anterior BVM VS. Intubation? Transport=Time and distance? Key Points Premedicate Atropine Positioning Padding under shoulders Madison RSI Look at handouts Precautions Preparation Procedure Airway Protection other than RSI GMVEMS {Sedate to intubate may only be utilized with department and medical director approval. Do not attempt if successful intubation is unlikely due to foreseeable complications.} ADULT ONLY: A Must be trained on, approved on and have equipment to perform a cricothyrotomy either open surgical or by device. A Pre-oxygenate the patient. In order to reduce gastric distention, avoid using a BVM. Apply a cardiac monitor and pulse oximeter.With suspected stroke, intracranial hemorrhage, head injury, or signs of increased intracranial pressure, administer Lidocaine 100 mg, IV. Administer Etomidate 0.3 mg/kg, IV (average initial dose is 15-25 mg). Repeat initial dose within 2 minutes as needed. Apply cricoid pressure to reduce the possibility of aspiration and to facilitate intubation Scenarios #1 Dispatched for MVA. Occupant ejected from vehicle. Arrival-2 minor patients and another patient was ejected he is lying in a cornfield. Patient is unresponsive GCS of 5, RR of 8. Drivers license states his weight approx. 160lbs bruising and swelling noted to face. What airway problems do you expect? How would you control this patients airway? If you RSI this patient what medications would you give him? What back-up airways would you consider? Scenarios #2 Dispatched for ATV roll over. Family members are driving them to St. 291 Arrival-One minor patient. Second patient is a 4 year old child located in the back of a pick-up. Patient is found to be unresponsive with a GCS of 3, RR of 4-5, and has blood flowing from his nose and right ear. His jaw appears to be clenched. No swelling or other injury noted to face. Dad tells you he weighs 42 lbs.What airway problems do you expect? How would you control this patients airway? If you RSI this patient what medications would you give him? What back-up airways would you consider? In a Pediatric airway are there other issues to consider? Ten Tips (adapted from Scott Synder article) 1-Place the patient in an optimal position to open airway Sniffing/head elevated position Tips 2-Use a BLS airway adjunct Use several!!!!! A OP and 2 NPA (wtf) 3- Use a jaw thrust maneuver 4-Use two rescuer BVM and Thenar eminence TIPS 5-Long inspiration small tidal volumes Manometer/SPO2/Capnography, conjunction. 6-Did we mention positioning 7-Apneic Oxygenation during intubation 8-Use external manipulation No cricoid pressure. Operator moves airway. 9-Endotracheal introducer (bougie) Study-Increase from 66% to 96% 10-Confirm Placement!!!!!!!!!!!!!!!!