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Rapid Sequence Intubation Delon F.P. Brennen, MD MPH Pediatric Emergency Medicine Morehouse School of Medicine Outline • Definition • Indications • Method Definition • The induction of a state of unconsciousness with complete neuromuscular paralysis to achieve intubation without interposed mechanical ventilation in efforts to facilitate the procedure and minimize risks of gastric aspiration Indications • Failure of airway maintenance/protection - lost or diminished gag reflex • Failure of oxygenation/ventilation - asthma, aspiration, pneumonia • Anticipated clinical course - multiple trauma, head injured - intoxication, air transport Method (6P’s) • Preparation: T-10mins – Positioning • • • • • Preoxygenation: T-5mins Premedication: T-3mins Paralysis: T-1min Placement of tube: T-0mins Post management Preparation • Evaluate – LEMON • • • • • • Equipment Check Positioning Drug Selection IV’s, monitor, oximetry Ancillary Staff Anticipate alternative airway maneuver LEMON • LEMON – L-Look – E-Evaluate – M-Mallampati – O-Obstruction – N-Neck mobility Preoxygenation • 100% O2 for 5 minutes or 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs • NOT Positive Pressure Ventilation – If possible Downloaded from: Rosen's Emergency Medicine (on 6 August 2006 02:03 PM) © 2005 Elsevier Premedication • Goal – blunt the patient’s physiologic responses to intubation • Which are ? – bradycardia – hypoxemia – cough/gag reflex – increases in intracranial, intraocular, and intragastric pressures Premedication • • • • Lidocaine Opioid Atropine Defasciculating doses “priming” Lidocaine • Thought to blunt the rise in ICP associated with airway manipulation and the use of depolarizing neuromuscular blocking agents • Dose: – 1.5 - 3 mg/kg (3 mins prior to intubation) Atropine • Minimize vagal effects, bradycardia, secretions – Infants and children < 8 yrs may develop profound bradycardia during intubation • 0.02 mg/kg (minimum 0.1 mg IV, max 1 mg) 3 minutes prior to intubation Defasciculating Doses • Decreases muscle fasiculations caused by the depolarizing agents (succinylcholine) • Attenuates rise in intracranial pressure • Agents - non-depolarizing blocking agents (vecuronium, pancuronium, etc.) – Usually 1/10 of standard dose Sedation • Sedative agents administered at doses capable of producing unconsciousness with little or no cardiovascular effects • No ideal agent exists • Sedation should nearly always be used when paralyzing the patient Sedation • • • • • Barbiturates/hypnotics Non-barbiturate Neuroleptics Opiates Benzodiazepines Barbiturates/Hypnotics • Thiopental (Pentothal), Methohexital (Brevital) • Short onset - 10-20secs, • Duration - 5-10 mins • May reduce ICP, cerebro-protective • Histamine release, hypotension, bronchospasm Barbiturates/Hypnotics • Etomidate (Amidate) – nonbarbiturate hypnotic • Rapid onset, short duration • • • • Decreases ICP/IOP Minimal hemodynamic effects No histamine release Increases seizure threshold Etomidate • No malignant hyperthermia reported • Watch for myoclonus, vomiting • May decrease cortisol synthesis (adrenal insufficiency) • Dose 0.3 mg/kg IV Barbiturates/Hypnotics • Propofol (Diprivan) – sedative hypnotic • Extremely rapid onset (10 sec), • Duration of 10-15 minutes • Decreases ICP, Can cause profound hypotension • Dose 1-3 mg/kg IV for induction • Dose: 100-200 mcg/kg/min for maintenance • Ketamine Ketamine – dissociative anesthetic, not a sedative • Rapid onset (1-2mins), short duration (~15mins) • Potent bronchodilator, useful in asthmatics • Increases ICP, IOP, IGP, (beware in head injuries) • Increases bronchial secretions • “Emergence” phenomenon – rarely in children <10 yrs , common in adults • Dose: 1-2 mg/kg Opiates Fentanyl • Rapid onset (<1 min), long duration - 30 min – Does not release histamine • May decrease tachycardia and hypertension associated with intubation • Seizures and chest wall rigidity – Can be reversed with Naloxone • Dose: 2-10 mcg/kg IV Morphine Sulfate • Longer onset (3-5) minutes and duration (2-6) hours • May not blunt the rise in ICP, hypertension and tachycardia as well as fentanyl • Histamine release • Dose 0.1-0.2 mg/kg IV Benzodiazepines Benzodiazepines • • • • • Midazolam, Diazepam, Lorazepam Provide excellent amnesia and sedation Broad dose-response relationship Reversed with Flumazenil Doses required are higher for RSI than for general sedation Midazolam • Slower onset (3-5) min than the barbiturate/hypnotic agents • Considered short-acting (30-60 min) • Does not increase ICP • Causes respiratory and cardiovascular depression • Dose: 0.1-0.4mg/kg IV Diazepam and Lorazepam • Moderate/long acting agents • Longer onset time than midazolam • May be more beneficial post-intubation for sedation Paralysis Neuromuscular Blocking Agents • Chemical paralysis facilitates intubation by allowing visualization of the vocal cords and optimizing intubating condition • Only CONTRAINDICATION is anticipated difficult airway – Mallampati Class (I-IV) – Thyromental Distance Depolarizing Agents • Exert their affect by binding with acetylcholine receptors at the neuromuscular junction, causing sustained depolarization of the muscle cell Nondepolarizing • Bind to acetylcholine receptors in a competitive, non-stimulatory manner, no receptor depolarization • Histamine release • Reversed with edrophonium or neostigmine • Caution with myasthenia gravis Agents • Depolarizing agents – Succinylcholine (Anectine) • Nondepolarizing Agents – Pancuronium (Pavulon) – Vecuronium (Norcuron) – Atracurium (Tracrium) – Rocuronium (Zemuron) – Mivacurium (Mivacron) Succinylcholine • Gold standard for >50 years • Stimulates nicotinic/muscarinic cholinergic receptors • Onset 45 secs, duration 8-10 mins • Dose: Children 2.0 mg/kg IV – (adults 1.5 mg/kg IV) • Inactivated by pseudocholinesterase Succinylcholine cont • Prolonged paralysis seen with: – Pregnancy – Liver disease – Malignancies – Cytotoxic drugs – Certain antibiotics – Cholinesterase inhibitors – Organophosphate poisoning Succinylcholine • Adverse reactions – Muscle fasiculations – Hyperkalemia – Bradycardia – Prolonged neuromuscular blockade – Trismus – Malignant hyperthermia Depolarizing Agents • Muscle fasiculations – Thought to increase ICP/IOP/IGP – Causes muscle pain – Minimized by “priming” dose of non-depolarizing NMB • Hyperkalemia – Average increase in potassium of 0.5-1 mEq/L – Burns, crush injuries, spinal cord injuries, neuromuscular disorders, chronic renal failure Depolarizing agents • Bradycardia – Most common in kids <10 yrs 2o higher vagal tone – Especially w/ repeated doses of succinylcholine – Premedicate with atropine Depolarizing Agents • Malignant hyperthermia – From excessive calcium influx through open channels – Genetic predisposition – Rapid rise in temperature, rhabdomyolysis, muscle rigidity, DIC – 60% mortality – Treatment: IV Dantrolene Depolarizing Agents • Trismus (Masseter spasm) – Usually in children – Unknown cause – Treat with a nondepolarizing NMB Pancuronium • Slow onset (1-5 min) • Long-acting agent (45-90 min) • Renal excretion • Vagolytic tachyarrythmias common • Dose: 0.10-0.15 mg/kg IV Vecuronium • Onset of 1-4 min • Duration of 30-60 min • Hypotension may occur from loss of venous return and sympathetic blockade • Mostly biliary excretion • Dose 0.1 mg/kg – “priming dose” 0.01 mg/kg Rocuronium • Shortest onset of the nondepolarizing agents (1-3 min) • Duration 30-45 min • Tachycardia can occur • Dose: 0.6-1.2 mg/kg (1mg/kg) Placement of Tube • Allow medications to work and assure complete neuromuscular blockade of the patient • Maintain Sellick maneuver until cuff inflated • Ventilate with bag-valve mask if unsuccessful • Additional doses of sedatives/NMB may be necessary • Confirm tube placement Post Intubation Management • Secure tube • Continuous pulse oximetry • Reassess vital signs frequently • Obtain chest x-ray, ABG • Restrain (physical/chemical)patient • Consider long term sedation Questions?? 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