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Rapid Sequence Intubation

Rapid Sequence Intubation

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Rapid Sequence Intubation

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  1. Rapid Sequence Intubation In the Emergency Department

  2. 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.

  3. 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%)

  4. 6 P's of RSI • Preparation • Preoxygenation • Pretreatment • Paralysis (with induction) • Placement of the tube • Post intubation management

  5. Oxygen Source Suction Equipment Endotracheal tubes Bag-valve-mask device Glidescope Cardiac Monitor Pulse oximeter End-tidal CO² monitor Temperature probe (LONG TERM) Alternative airway equipment-laryngeal mask airway or jet ventilator or crich tray Preparation

  6. Preparation • Assign roles and responsibilities • Leader • Intubationist • Cricoid pressure • Monitoring • Medications • Documentation

  7. 2. Preoxygenate • 3-5 minutes with 100% O2 bag mask to ensure adequate oxygen reservoir in lungs during apnea • Assure age appropriate fitting mask

  8. 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!)

  9. 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

  10. 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”

  11. 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

  12. Anesthesia • Etomidate • Short acting sedative hypnotic • Dose=0.3 mg/kg • Induction time= 5-10 min. • *Myoclonus

  13. IM or IV Dissociative anesthesia Dose = 1-2 mg/kg (IV)/ 4-10mg/kg IM Lasts approx. 30” Glazed eyes & nystagmus Watch for agitated recovery *Increased BP, HR,tonic/clonic,N/V, hypersalivation Ketamine

  14. Anesthesia • Versed • Benzodiazepine, • Sedative • 1-2 mg IV • Onset 1.5 min. to 2H • *Hypotension

  15. Anesthesia • Fentanyl • Narcotic analgesic • 50-100 mcg/kg • Lasts 30 min. • *Resp. depression

  16. Propofol (Diprivan) • Induction agent • Standard dose: 2 mg/kg • Rapid onset, short duration • Considerations: *Hypotension,apnea

  17. Paralytic (Neuromuscular block) • VECURONIUM • Skeletal Muscle Relaxer • 0.1 MG/KG IV(PARALYZING DOSE) • Lasts 25 to 45 min.

  18. SUCCINYLCHOLINE Neuromuscular blocking agent Dose: 1 mg/kg Duration: 5 min. Side effects: Fasciculations, muscle pain,rhabdo, hyper K, brady, vent. Dysthythmias Malignant Hyperthermia Paralytic

  19. 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

  20. 5. Placement of Tube • Position patient • Do not bag unless SpO2 < 90% • Sellick’s Maneuver (Cricoid pressure)

  21. Placement of tube

  22. Placement and Proof • Confirm tube placement • – ETCO2 • – Bilateral breath sounds • – Absent epigastric sounds

  23. 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

  24. 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

  25. 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)

  26. Questions?