Download Rapid Sequence Intubation

Rapid Sequence
Intubation
Otto Sabando DO FACOEP
Program Director
Emergency Medicine Residency
St. Joseph’s Regional Medical Center
Paterson NJ
Objectives
 Overview of Rapid sequence induction
(RSI)
 RSI Procedure
 Pretreatment agents
 Induction agents
 Paralytic medications
 Case studies: “Pitfalls”
 Questions
Overview of RSI
 1979, Taryle and colleagues reported
complications in 24 of 43 patients
needing an emergent airway
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Improvement of house officer training
More liberal use of procedures used in the
OR
Overview of RSI
 Objectives:
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Immediate airway control necessitating
induction of anesthesia and muscle
relaxation
Provision of anesthesia and sedation to the
awake patient
Minimization of intubation adverse effects,
including systemic and intracranial
hypertension
Overview of RSI
 Prehospital?
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In non-cardiac arrest patients, overall RSI
success rate 92%-98%. Comparable to ED
settings
Without a full compliment of medications,
success rate are ~60% as in ED settings
 i.e.:
Patient combative, intact gag reflex,
preexisting muscle tone
Overview of RSI
 Impact of prehospital intubations on
outcome….Controversial!
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Gausche and Colleagues
 Comparison
bag-mask ventilation and
endotracheal intubation for critically ill and
injured pediatric patients
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820 subjects, no paralytics and sedation used
57% intubation success rate
Similar outcomes for both study groups
Overview of RSI
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Winchell and Hoyt
 Retrospective
review of 1092 blunt trauma
patients with GCS score of less than 9
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Prehospital intubation reduced mortality from
36% to 26% (impact on most severely injured)
Endotracheal intubation without medications
had success rate of 66%
Overview of RSI
 Bochicchio and colleagues
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Compared brain injured patient outcomes
in patients with and without prehospital RSI
 Pre-hospital
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RSI
Higher mortality rate and more ventilator days
 Equivalence
of the patient groups upon
paramedic arrival is unknown
 Study suggest that prehospital RSI and
intubation may adversely affect outcomes
Overview of RSI
 Further prospective evaluations
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Prehospital physiology
Notation of preexisting aspiration
Better prospective studies!
RSI Procedure
 Preoxygenate with 100% NRB if the
patient is spontaneously breathing

No positive pressure ventilations
 Intravenous line: Preferably 2 lines 20
gauge or larger in adults
 Cardiac monitor, pulse oximetry, and
Capnography
 Prepare equipment: suction, difficult
airway cart,
RSI Procedure
 Explain the procedure: Document neurologic
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status
Sedative agent
Defasciculating agent, lidocaine, and or
atropine
Perform Sellick maneuver
Neuromuscular agent
Intubate trachea and release Sellick maneuver
Confirm placement
RSI Procedure
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Sample Rapid Sequence Intubation Using Etomidate and
Succinylcholine: Timed Step
Zero minus 10 min Preparation
Zero minus 5 min Preoxygenation 100% oxygen for 3 min or eight
vital capacity breaths
Zero minus 3 min Pretreatment
as indicated "LOAD“
Zero Paralysis with induction Etomidate, 0.3 mg/kg Succinylcholine,
1.5 mg/kg
Zero plus 45 sec Placement Sellick's maneuver Laryngoscopy and
intubation End-tidal carbon dioxide confirmation
Zero plus 2 min Post-intubation management Midazolam 0.1 mg/kg,
plus Pancuronium, 0.1 mg/kg, or Vecuronium, 0.1 mg/kg
RSI Procedure
 Principal contraindication:
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Any condition preventing mask ventilation
or intubation
Pretreatment agents
 Goal: Attenuate pathophysiologic
responses to Laryngoscopy and
intubation
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Reflex sympathetic response
 Increase
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in heart rate and blood pressure
Children: vagal response predominates
 Bradycardia
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Laryngeal stimulation
 Lanrygospasm,
cough, and bronchospasm
Pretreatment agents
 To be effective, pretreatment agents
should be given 3-5min prior to RSI
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Not practical at times
Pretreatment agents
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Pretreatment Agents for Rapid Sequence Intubation (LOAD)
Lidocaine: in a dose of 1.5 mg/kg, used to mitigate bronchospasm in
patients with reactive airways disease and to attenuate ICP response to
Laryngoscopy and intubation in patients with elevated ICP
Opioid: Fentanyl, in a dose of 3 μg/kg, attenuates the sympathetic
response to Laryngoscopy and intubation and should be used in
patients with ischemic coronary disease, intracranial hemorrhage,
elevated ICP, or aortic dissection
Atropine: 0.02 mg/kg is given to prevent bradycardia in children ≤ 10
years old who are receiving succinylcholine for intubation
Defasciculation: a Defasciculating dose (1/10 of the paralyzing dose) of
a competitive neuromuscular blocker is given to patients with elevated
ICP who will be receiving succinylcholine to mitigate succinylcholineinduced elevation of ICP
Induction agents
 Ketamine: 1-2mg/kg, onset 1min, duration 5
min
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Phencyclidine derivative
 Potent bronchodilator
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Status asthmaticus
Hypertension, increased ICP
 Increase secretions
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Emergence phenomenon
Contraindications
 Elderly “Cautious”
 Head injury (ICP increase), increase IOP
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Atropine to offset
Induction agents
 Etomidate: 0.3mg/kg.Onset <1min,
duration 10-20min.
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Non-barbiturate, non-receptor hypnotic
Water and lipid soluble and reaches the
brain quickly
 Sedation
comparable to barbiturates
 Acts on CNS to stimulate ∂-aminobutyric acid
receptors and depress the RAS
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No analgesic activity
Induction agents
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Decreases cerebral oxygen consumption,
cerebral blood flow and ICP
 Best
used in patients with head injury and
hypovolemia
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Side effects
 Nausea,
vomiting, myoclonus
 Inhibition of adrenal cortical function (not
really seen with one dose induction)
Induction agents
 Propofol : 0.5-1.5mg/kg IV onset 20-40
seconds, duration 8-15 minutes
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Highly lipophylic
Alkylphenol sedative-hypnotic
 Has
amnestic effect but no analgesic effects
 Dose dependant depression of
consciousness ranging from light sedation to
coma
 Lowers intracranial pressure
 Anti seizure effects
Induction agents
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Side effects
 Direct
myocardial depression leading to
hypotension especially in the elderly
Induction agents
 Opioids
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Not first line selections
Fentanyl: 3-10µg/kg IV. Onset 1-2min,
duration 20-30min
 Highly
lipophylic, rapid serum clearance, high
potency, and minimal histamine release
 50-100 times more patent than morphine
 Best used for hypotensive patients in pain
Induction agents
 Side effects:
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Chest wall rigidity (>15µg/kg IV)
ICP variable
Respiratory depression (seen with other
sedatives)
Induction agents
 Barbiturates:
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Thiopental: 3-5mg/kg IV. Onset 30-60sec.
Duration 10-30 minutes
Methohexital (brevital): 1mg/kg IV. Onset
<1min. Duration 5-7 min.
 CNS
depressant that leads to deep sedation
and coma
 Best indication is for status epilepticus, ICP
related to trauma or HTN emergency
Induction agents
 Side effects
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Myocardial depression leading to
hypotension (MAP decrease by 40mm/hg)
Decreased respiratory drive
Lanrygospasm
Paralytic Medications
 Depolarizing agents
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Succinylcholine: 1-1.5mg/kg. Onset 4560sec, duration 5-9 min.
 Most
commonly used agent for paralysis
 Chemical structure similar to acetylcholine
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Depolarize postjuctional neuromuscular
membrane
Rapidly hydrolyzed by pseudocholiesterase
Paralytic Medications
 Complications:
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Bradyarrythmias
Masseter spasm
ICP?, IOP, increase intragastric pressure
Malignant hyperthermia
 Tx: Dantrolene
Hyperkalemia
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Increase 0.5mEq/ml
Histamine release
Fasciculation induced musculoskeletal trauma
 Prevent by using defisciulating dose of nondepolorizing
agent (10% of normal dose)
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Prolonged apnea with pseudocholinesterase deficiency
Paralytic Medications
 Contraindications:
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Major burns
Muscle trauma
Crush injuries
Myopathies
Rhabdomyolysis
Narrow angle
glaucoma
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Renal failure
Neurologic disorder
Spinal cord injury
Guillian-Barre
Syndrome
Children with
undiagnosed
myopathies?
Paralytic Medications
 Nondepolorizing agents:
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Vecuronium 0.08 mg/kg-0.15mg/kg, 0.150.28mg/kg. Onset 2-4min, duration 25120min
Rocuronium 0.6mg/kg. Onset 1-3min.
Duration 30-45 min
Atracurium 0.4-0.5mg/kg. Onset 2-3min.
Duration 25-45 min.
Pancuronium 0.1mg/kg. Onset 2-5min.
Duration 40-60 min.
Paralytic Medications
 Competitive agents that block the effects
of acetylcholine at the neuromuscular
junction
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Rocuronium is the alternative medication
when succinylcholine is contraindicated
Paralytic Medications
 Reversal agents:
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Mostly in OR anesthetized patients, rarely used in
the ED setting
Neostigmine 0.02mg-0.04mg slow IVP
 Additional doses of 0.01 to 0.02 mg/kg slow IVP
can be given if reversal is incomplete
 Total dose not to exceed 5mg in an adult
Give atropine 0.01mg/kg to block cholinergic
effects of Neostigmine
 Max adult dose 1mg
 Minimum pediatric dose 0.1mg
Paralytic Medications
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Complications
 Vecuronium
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Prolonged recovery time in elderly and obese
patients or hepatorenal dysfunction
 Rocuronium
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Tachycardia
 Atracurium
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Hypotension, histamine release,
bronchospasm
 Pancuronium
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Hypertension, tachycardia, histamine release
Cases
Case 1
 A 24 y.o. male with a medical history of
asthma is short of breath secondary to
his asthma. You note that the patient is
hypoxic and getting tired.
 Which RSI Medications for sedation
would be best for this case?
 Answer
Case 2
 A patient is hit in the head by a bat. His
GCS is 8. You decide to RSI this patient
as he is combative and altered. Which
medications would be best in this
situation?
 Sedative
 Paralytic
 adjunct
Case 3
 A 45 y.o. male in respiratory distress with
crush injuries to his legs needs to be
intubated. Which of the following
paralytics are indicated in this case?
 Succinylcholine
 Rocuronium
 Vecuronium
 Pancuronium
Questions
References
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Yano M, et al: Effect of lidocaine on ICP response to endotracheal
suctioning. Anesthesiology 64:651, 1986
Kirkegaard-Nielsen H, et al: Rapid tracheal intubation with rocuronium.
Anesthesiology 91:131, 1999
Schneider RE, Caro D: Pretreatment agents. In Walls RM, et al (eds):
Manual of Emergency Airway Management. Philadelphia, Lippincott
Williams & Wilkins, 2004
Gausche M. Lewis RJ, Stratton SJ et al. Effect of out of Hospital
Pediatric Endotracheal Intubation on Survival and Neurologic Outcome:
A controlled Clinical Trial. JAMA 283:783,2000
Bochicchio GV, Ilahi O,Joshi M et al. Endotracheal intubation in the field
does not improve outcome in trauma patients who present without an
acutly lethal traumatic brain injury. J Trauma 54:307, 2003
Winchell RJ, Hoyt DB: Endotracheal intubation in the field improves
survival in patients with severe head injury. Arch Surg 132:592, 1997
References
 Roberts and Hedges. Clinical Procedures in Emergency
Medicine. Edition 4. Saunders, 2004
 Tintnalli J et al. Emergency Medicien: A comprehensive study
guide. Edition 6. McGraw Hill, 2004
 Rosen’s Emergency Medicine: Concept in Clinical Practice.
Edition 6. Elsevier, 2006
 Etomidate
 Propofol
 barbiturate
Lidocaine
1.5 mg/kg
Suppresses cough
Suppress ICP?
Decrease pressor response secondary to
intubation?
Use with paralytics?