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RSI sheet-2007
1. 12/15/2007
RSI in Emergency Department
Rapid Sequence Intubation (RSI) Outline
in
Emergency Room • Indications for intubation
• Considerations in Emergency intubation
• Rapid Sequence Intubation (RSI)
Siriporn Pitimana-aree, MD • The Failed Airway
Dept. of Anesthesiology, • Defining the Difficult Airway
Faculty of Medicine Siriraj hospital. • Rescue Devices
(The Royal College of Anesthesiologists of Thailand)
Indications for ETT intubation Emergency ETT intubation:
Considerations
• Time pressure
• Absent or inadequate respiration
• Unstable patient
• Impending airway obstruction • Physiologic responses
• Inability to protect airway • Possibly difficult situation
• Uncooperative / combative
• Not fasted
• Difficult airway
Emergency ETT intubation:
Physiologic responses to intubation
• Incidence of difficult & failed intubation: 8%
•Gagging • Frequency of esophageal intubation: 8%
•Rise in ICP 40% of these - difficult intubation
almost all recognized by clinical criteria
•Rise in BP but 3, decrease saturation detected by SpO2
•Tachycardia / Bradycardia • Incidence of pulmonary aspiration: 4%
•Dysrhythmias
• Hemodynamic consequences:
3% died during or within 30 min. of intubation
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2. 12/15/2007
Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI)
Definition
Definition Incorporates:
The virtually simultaneous administration • Every patient has a full stomach
of a potent sedative agent • Preoxygenation
& a neuromuscular blocking agent • No interposed ventilations
to induce unconsciousness • Sellick’s maneuver
& motor paralysis for tracheal intubation.
Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI)
Contraindications:
Advantages of RSI
Anticipate of difficult airway& intubation
•Minimizes risk of aspiration
•Facilitate intubation Staff inexperienced in RSI
•Blunt untoward physiologic responses
•Avoid awake intubation Patients allergic or contraindication to
drugs used in RSI
Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI)
The Six Ps of RSI 10 min
The Sequence
Preparation Preparation
Preoxygenation
Paralysis with Sedation Preoxygenation
Protection
Placement the time of
administration of ………..Zero
Postintubation care Succinylcholine.
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3. 12/15/2007
Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI)
The Sequence …10 minutes ---- Zero The Sequence …5 minutes ---- Zero
Preparation Preoxygenation
• Assess airway difficulty (LEMON)
• 100% oxygen for five minutes
• Plan approach
• 8 vital capacity breaths
• Assemble drugs and equipments
• Provides essential apnea time
• Establish access
• Apnea time varies
• Establish monitoring
Rapid Sequence Intubation (RSI)
The Sequence Zero!!
Paralysis with Sedation
• Sedative / Induction agent IV push
• Succinylcholine 1.5 mg/kg IV push
Entering the red zone...
Rapid Sequence Intubation (RSI)
The Sequence …Zero + 30 seconds
Protection
• Sellick’s Maneuver
• Position patient Optimal External Sellick’s maneuver
• Do not bag unless SpO2 < 90% Laryngeal Manipulation (Cricoid pressure)
(Backwards, Upwards,
Rightwards Position (BURP)
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4. 12/15/2007
Rapid Sequence Intubation (RSI)
The Sequence …Zero + 60 seconds
Placement
• Check mandible for flaccidity
• Intubate, remove stylet
• Confirm tube placement – EtCO2
• Release Sellick’s maneuver
“ Sniffing position ”
Rapid Sequence Intubation (RSI)
The Sequence
Experinced Inexperinced
Postintubation care
Auscultation 100% 68% •Ongoing sedation and/or paralysis
ETCO2 100% 100% •Mechanical ventilation (if needed)
Self inflating bulb 96% 98% •Further investigations (CXR, ABG)
Trachlight 84% 87% •Postintubation hypotension
Rapid Sequence Intubation (RSI)
“Failed intubation”
What do you do?
If you can not intubate
after RSI? Rescue Maneuvers
• The first rescue from failed intubation is
“Failed intubation” bagging.
• The first rescue from failed bagging is
better bagging.
• Rescue devices
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5. 12/15/2007
The “Failed” Airway The “Failed” Airway
• Multiple Definitions… Clinically, 2 types of “failed” airways:
– Number of failed attempts (e.g., three)
– Failure to ventilate with a BVM 1. Cannot intubate, but can oxygenate
– Failure to oxygenate
– Failure to visualize the larynx 2. Cannot intubate, and cannot
oxygenate
The Difficult Airway The Difficult Airway
Identification of the Difficult Airway
The DIFFICULT AIRWAY is something you 3 Key Attributes
PREDICT…
A FAILED AIRWAY is something you • Difficult Bag/Mask Ventilation
EXPERIENCE!! • Difficult Intubation
• Difficult Cricothyrotomy
The Difficult Airway
The Difficult Airway
Difficult Bag Mask Ventilation Difficult Cricothyrotomy
Mask seal Surgery scar
Obesity Hematoma
Aged (>55) Obesity
No teeth Radiation
Stiff lungs Tumor
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7. 12/15/2007
Difficult Intubation Difficult Intubation
Identification of the Difficult Airway Identification of the Difficult Airway
M allampati O bstruction?
Difficult Intubation
Difficult Intubation
Identification of the Difficult Airway Management of the Difficult Airway
N eck mobility • Need a consistent approach
• Awake techniques by default
• Need definition of and preplanned
approach to failed airway
• No “one trick pony” approach
• Alternative devices
Difficult Intubation
Management of the Difficult Airway
• Alternative/Rescue devices?
– Supraglottic: LMA, Combitube
– Stylet, Gum elastic bougie; GEB
– Lighted stylets: Trachlight, Lightwand
– Fiberoptic devices: flexible, rigid, hand-held
– Surgical: open, transtracheal
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8. 12/15/2007
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Combitube I n s e r t i o n
Emergency ETT intubation:
Team members & their roles
Time Airway doctor/nurse Doctor / Nurse Nurse (Scribe)
Preparation IV access Document
(drugs/equipments) All events
Assist with
preparation Assist with
Assess airway
& drugs admin. Monitor &
Plan approach
preparation
Preoxygenation
Cricoid
pressure
Needle ETT placement
Cricothyrotomy Confirmation of ETT placement
Emergency ETT intubation (RSI) Emergency ETT intubation (RSI)
The commonly used drugs The commonly used drugs
Onset Onset
Drug Dose; mg/kg
(Sec)
Precaution/Contraindication Drug Dose; mg/kg (Sec) Precaution/Contraindication
Induction agents: Sedation/Analgesia:
Midazolam 0.1-0.3 60-90 Long onset / no
Thiopental 3-5 10-15 Hypotension/ Porphyria
Fentanyl (mcg/kg) 1-2 30-45 Chest wall rigidity / no
Propofol 1-2 10-15 Hypotension/Age< 2 yrs.
Morphine 0.1-0.2 10-15 Long onset / no
Etomidate 0.2-0.6 10-15 Adrenal insufficiency/
Pretreatment:
Ketamine 1-2 30-45 ICP / Head injury Lidoocaine 1-1.5 3-5 min. Bradycardia / no
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9. 12/15/2007
Emergency ETT intubation (RSI) Emergency ETT intubation (RSI)
The commonly used drugs The commonly used drugs
Dose Onset Duration Precaution/ Drug Dose; mg/kg Considerations
Drug (mg/kg) (sec) (min) Contraindication
Emergency drugs:
Muscle relaxants:
Atropine 0.02 Pediatric intubation
Succinylcholine 1-2 60 5-10 N-M disease /
Severe burn,
Hyperkalemia Adrenaline Standard resuscitation
Intra-ocular injury Incremental
cart in hand
dose
Levophed (emergency intubation)
Rocuronium 0.6-0.9 45-60 45-60 to target
BP
Metaraminol
Can’t intubate Seek HELP
The Emergency Difficult
Ventilation effective
Airway Algorithm ? Can ventilate
Maintain Sellick’s
Maintain oxygenation
Reposition head Unable to ventilate
By BVM
Use oral/nasal
Reattempt intubation airway
by rescue devices
• Emergency airway management is different
• Emergency Airway Algorithm necessity Maintain oxygenation LMA / Combitube
By BVM
• Prediction tools have limitations:
• LEMON criteria cannot be universally applied Emergency
LMA / Combitube Unable to ventilate
• Consistent use will predict most of the difficult Airway
Maintain oxygenation Algorithm
Intubation through
LMA Cricothyrotomy
Await expert help Jet ventilation
“ True success is not
in the learning,
But in it’s application
to the mankind
F
F F F
F F F
F F
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