1. Rapid Sequence Intubation Anthony G. Hillier, D.O. EM Resident St. John West Shore

2. Rapid Sequence Intubation • 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

3. Rapid Sequence IntubationIndications • Failure of airway maintenance/protection - lost or diminished gag reflex • Failure of oxygenation/ventilation - pulmonary edema, COPD • Anticipated clinical course - multiple trauma, head injured - intoxication, air transport

4. Preparation: T-10” Positioning Preoxygenation: T-5” Premedication: T-3” Paralysis:T-0 Placement of tube: T+45 Post management: T+2” Rapid Sequence Intubation“6 P’s”

5. Preparation

6. Preparation • Evaluate • LEMON • Equipment Check • Positioning • Drug Selection • IV’s, monitor, oximetry • Ancillary Staff • Anticipate alternative airway maneuver

7. Preparation • LEMON • L-look • E-evaluate the 3-3-2 rule • M-Mallampati • O-Obstruction • N-Neck mobility

9. PREOXYGENATION

10. Preoxygenation • 100% O2 for 5 minutes of 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs

12. Preoxygenation • “nitrogen wash-out” • Avoid bagging the patient if adequately preoxygenated

13. PREMEDICATION

14. Premedication • Goal is to blunt the patient’s physiologic responses to intubation • Minimizes bradycardia, hypoxemia, cough/gag reflex, increases in intracranial, intraocular, and intragastric pressures

15. Premedication • Lidocaine • Opioid • Atropine • Defasciculating doses “priming”

16. Lidocaine • Thought to blunt the rise in intracranial pressure associated with airway manipulation and the use of depolarizing neuromuscular blocking agents • 1.5-3.0 mg/kg (average 100mg) three minutes prior to intubation

17. Atropine • 0.02 mg/kg, minimum 0.1 mg IV, max 1 mg, three minutes prior to intubation • Can minimize vagal effects, bradycardia and secretions • Infants and children < 8 years may develop profound bradycardia during intubation

18. Defasciculating doses • Decreases muscle fasiculations caused by the depolarizing agents (succinylcholine) • Attenuates rise in intracranial pressure • Agents used are the non-depolarizing blocking agents (vecuronium, pancuronium etc.) usually 1/10 of standard dose

19. 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

20. Sedation • Barbiturates/hypnotics • Non-barbiturate • Neuroleptics • Opiates • Benzodiazepines

21. Barbiturates/Hypnotics • Thiopental (Pentothal), Methohexital (Brevital) • Short onset (10-20) seconds, duration 5-10 minutes • May reduce intracranial pressure, cerebro-protective • Histamine release, hypotension, bronchospasm

22. Barbiturates/Hypnotics • Etomidate (Amidate) a nonbarbiturate hypnotic • Decreases ICP/IOP • Rapid onset, short duration • Minimal hemodynamic effects • No histamine release • Increases seizure threshold

23. Etomidate • No malignant hyperthermia reported • Watch for myoclonus, vomiting • May decrease cortisol synthesis (adrenal insufficiency) • Dose 0.3 mg/kg IV

24. Propofol • 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

25. Ketamine • Ketamine-dissociative anesthetic • Rapid onset, short duration • Potent bronchodilator, useful in asthmatics • Increases ICP, IOP, IGP • Contraindicated in head injuries • Increases bronchial secretions

26. Ketamine • “Emergence” phenomenon can occur though rarely in children less than 10 years • Emergence reactions occur in up to 50% of adults • Dose: 1-2 mg/kg

27. Opiates

28. Fentanyl • Fentanyl • Broad dose-response relationship • Can be reversed with naloxone • Fentanyl is rapid acting (<1 min), duration of 30 min • Does not release histamine

29. Fentanyl • May decrease tachycardia and hypertension associated with intubation • Seizures and chest wall rigidity have been reported • Dose: 2-10 mcg/kg IV

30. Morphine Sulfate • Longer onset (3-5) minutes and duration (4-6) hours • May not blunt the rise in ICP, hypertension and tachycardia as well as fentanyl • Dose 0.1-0.2 mg/kg IV • Histamine release

31. Benzodiazepines

32. Benzodiazepines • Midazolam, Diazepam, Lorazepam • Provide excellent amnesia and sedation • Broad dose-response relationship • Reversed with Flumazenil (Romazicon) • Doses required are higher for RSI than for general sedation

33. 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

34. Diazepam and Lorazepam • Moderate/long acting agents • Longer onset time than midazolam • May be more beneficial post-intubation for sedation

35. Paralysis

36. 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 • Thyromental Distance

39. Depolarizing Agents • Exert their affect by binding with acetylcholine receptors at the neuromuscular junction, causing sustained depolarization of the muscle cell

40. Nondepolarizing • Bind to acetylcholine receptors in a competitive, non-stimulatory manner, no receptor depolarization • Histamine release • Agents can be reversed with edrophonium or neostigmine • Caution with myasthenia gravis

41. Depolarizing agents • Succinylcholine (Anectine) • Nondepolarizing Agents • Pancuronium (Pavulon) • Vecuronium (Norcuron) • Atracurium (Tracrium) • Rocuronium (Zemuron) • Mivacurium (Mivacron)

42. Succinylcholine • Stimulates nicotinic/muscarinic cholinergic receptors • Gold standard for 50 years • Onset 45 seconds, duration 8-10 minutes • Dose: (adults 1.5 mg/kg IV) • Children 2.0 mg/kg IV • Inactivated by pseudocholinesterase

43. Succinylcholine cont • Prolonged paralysis seen with: • Pregnancy • Liver disease • Malignancies • Cytotoxic drugs • Certain antibiotics • Cholinesterase inhibitors • Organophosphate poisoning

44. Succinylcholine • Adverse reactions • Muscle fasiculations • Hyperkalemia • Bradycardia • Prolonged neuromuscular blockade • Trismus • Malignant hyperthermia

45. Depolarizing Agents • Muscle fasiculations • Thought to increase ICP/IOP/IGP • Causes muscle pain • Minimized by “priming” dose of NMB • Hyperkalemia • Average increase in potassium of 0.5-1 mEq/L • Burns, crush injuries, spinal cord injuries, neuromuscular disorders, chronic renal failure

46. Depolarizing agents • Bradycardia • Most common in children <10 years due to higher vagal tone • Also with repeated doses of succinylcholine • Premedicate with atropine

47. Depolarizing Agents • Malignant hyperthermia • From excessive calcium influx through open channels • Genetic predisposition • Rapid temperature, rhabdomyolysis, muscle rigidity, DIC • 60% mortality • Treatment: IV Dantrolene

48. Depolarizing Agents • Trismus (Masseter spasm) • Usually in children • Unknown cause • Treat with a nondepolarizing NMB

49. Pancuronium • Long-acting agent (45-90 min) • Slow onset (1-5 min) • Renal excretion • Vagolytic tachyarrythmias common • Dose: 0.10-0.15 mg/kg IV

50. Vecuronium • Duration of 30-60 min • Onset of 1-4 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