Rapid Sequence Intubation What Every Emergency physician Must Know

1. Rapid Sequence Intubation What Every Emergency physician Must Know Abdullah ALsakka EM Consultant KKUH

2. What do the following have in common? • 37 year old asthmatic man in extremis • 22 year old overdose patient - barely arouses to pain • 30 year old multiple trauma patient • 67 year old man in cardiogenic shock • 80 year old woman in refractory pulmonary edema

3. Key Questions: Objectives • What exactly is “RSI”? • Why use drugs? • Can I mitigate adverse effects? • What induction agent do I use? • What NMBA do I use?

6. Key Questions • What exactly is “RSI”? • Why use drugs? • Can I mitigate adverse effects? • What induction agent do I use? • What NMBA do I use?

7. Rapid Sequence Intubation Definition The virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

8. History • 1979 first series of ED intubations – Taryle, 1979 • 1982 first series of intubations using succinylcholine in the ED – Thompson, 1982

9. History • 1997 ACEP RSI policy statement: “physicians performing RSI should possess training, knowledge, and experience in the techniques and pharmacologic agents used to perform RSI” “NMBA and appropriate sedative and induction agents should be immediately available in the ED and accessible to all physicians who perform RSI in the ED” Reaffirmed, 2000

10. Rapid Sequence Intubation Definition Incorporates: • Patient has a full stomach • Preoxygenation • No interposed ventilation • Sellick’s maneuver

11. Rapid Sequence Intubation Advantages of RSI • Rapid control of the airway • Minimizes risk of aspiration • Highest success rates • Lowest complication rates • Optimal intubating conditions • Adaptable to patient condition

12. The Evidence • Prospective observational and retrospective studies • National Emergency Airway Registry (NEAR) • Series of > 6000 ED intubations • 26 teaching hospitals • 88.1% adult and 81.1% pediatric intubations performed by the EP

13. The Evidence “NEAR” data: Walls et. al., 1999-2000 ABSTRACT

14. The Evidence Sakles et. al. , 1998 * ½ RESIDENT FAILURE Success rate: 99.4% with RSI vs. 91.4% with Sedation

15. The Evidence • 1999 Li et. al. prospective airway data • 3 months prior and 6 months post implementation of an RSI protocol • Results: * 15% aspiration, 28% airway trauma, 3% death – NOT SEEN IN THE RSI GROUP

16. RSI What are the contraindications to RSI?

17. RSI • The predicted difficult airway • Inexperience • Inadequate difficult airway tools and techniques

18. Rapid Sequence Intubation The Seven Ps of RSI Preparation Preoxygenation Pretreatment Paralysis with induction Positioning Placement with proof Post-Intubation Management

19. Rapid Sequence Intubation The Sequence Zero: the time of administration of succinylcholine.

20. Rapid Sequence Intubation The Sequence Zero - 10 minutes Preparation • Assess airway difficulty (LEMON) • Plan approach • Assemble drugs and equipment • Establish access • Establish monitoring

21. Rapid Sequence Intubation The Difficult Airway Rule L ook externally E valuate 3-3-2 M allampati O bstruction? N eck mobility

23. Airway Anatomy

24. Airway Anatomy

25. Occipital prominence Nasal vsmuoth breathing Dentition Adenoid tissue and friable mucosa Aryepiglottic folds more midline Epiglottic shape (longer, narrower, stiffer) Laryngeal position (anterior) Vocal cords (anterior angle) Epiglotticvagalinnervation Lung compliance Diaphragmatic muscle fibre type Increased metabolic rate Narrowest point is at cricoid Pediatric Airway

26. Rapid Sequence Intubation The Difficult Airway Rule L ook externally E valuate 3-3-2 M allampati O bstruction? N eck mobility

28. Airway Assessment

29. Airway Assessment

31. Airway Assessment

33. Rapid Sequence Intubation The Sequence Zero - 5 minutes Preoxygenation • 100% oxygen for five minutes • 8 vital capacity breaths • Provides essential apnea time • Apnea time varies

34. Rapid Sequence Intubation Time to Desaturation From: Benumoff

36. Rapid Sequence Intubation The Sequence Zero - 3 minutes Pretreatment • Lidocaine • Opioid • Atropine • Defasciculation “LOAD the patient before intubation.”

37. Rapid Sequence Intubation The Sequence Zero!! Paralysis with induction • Induction agent IV push • Neuromuscular blocking agent IV push

38. Rapid Sequence Intubation INTUBATION

39. Rapid Sequence Intubation The Sequence Zero + 30 seconds Protection • Sellick’s Maneuver • Position patient • Do not bag unless S O < 90% p 2

40. Sellick Maneuver

42. CRICOID PRESSURE IN EMERGENCY RAPID SEQUENCE INTUBATION • CONCLUSIONS: Although application of cricoid pressure has been described as the "linchpin of RSI" and has come to be a widely accepted practice, there is no clear evidence to suggest that it reduces the risk of aspiration during RSI. • Butler, J., Emerg Med J 22:815, November 2005

43. LARYNGEAL VIEW DURING LARYNGOSCOPY: A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE, BACKWARD-UPWARD-RIGHTWARD PRESSURE, AND BIMANUAL LARYNGOSCOPY • CONCLUSIONS:bimanual laryngoscopy was more effective than cricoid pressure or the BURP maneuver in improving laryngoscopic visualization for intubation • Levitan, R.M., et al, Ann Emerg Med 27(6):548, June 2006 CONCLUSIONS: In this cadaver

44. Rapid Sequence Intubation The Sequence Zero + 45 seconds Placement • Check mandible for flaccidity • Intubate, remove stylet • Confirm tube placement - ET CO2 • Release Sellick’s maneuver

45. ‘BURP’ • Technique • Blade (type, size, placement)

46. Confirmation of Tube Position • Visualize through cords • ETCO2 • Listen over stomach • Compliance with bagging • B/S over chest • Esophageal detector device • Bilateral chest rise • Tube condensation • Sats improve • Bronchoscope • CXR (lateral)

47. Rapid Sequence Intubation The Sequence Zero + 90 seconds Post-intubation Management • Secure tube • Chest x-ray • Long acting sedation/paralysis • Establish ventilator parameters

48. Rapid Sequence Intubation Summary The Seven Ps of RSI Preparation Preoxygenation Pretreatment Paralysis with induction Protection Placement Post-Intubation Management

49. Rapid Sequence Intubation Failed Attempt Rescue Maneuvers • The first rescue from failed intubation is bagging • The first rescue from failed bagging is better bagging

50. Key Questions • What exactly is “RSI”? • Why use drugs? • Can I mitigate adverse effects? • What induction agent do I use? • What NMBA do I use?