RSI

1. Presented By: Dr. Mohamad Husain Ahmad Supervised By: Dr. Manal Al-Maskati RSI

2. Introduction • Airway management is the most important skill for an emergency practitioner to master because failure to secure an adequate airway can quickly lead to death or disability.

3. Introduction • Despite the existence of the guidelines, little data exist about RSI and most of the data comes from anaesthesia literature.

4. RSI in comparison to regular intubation • RSI is superior in terms of higher success rate, better intubation conditions and lower incidence of complications. Proved by: • Clinical experience. • randomized, controlled trials describing intubating conditions for patients intubated in the operating room have consistently reported a significantly higher frequency of excellent intubation conditions with deep sedation plus paralysis (80 to 98 percent) versus that observed with deep sedation alone (0 to 30 percent).

5. RSI • Stands for: • Rapid Sequence Intubation. • Rapid Sequence Induction.

6. Definition • The process of administering a sedative and muscle relaxant to induce a state of unconsciousness and complete neuromuscular paralysis to facilitate the process of endotracheal intubation.

7. Aim • To take: • An awake patient. • With assumed full stomach. • Very quickly induce a state of unconsciousness and paralysis and securing the airway. • Without using positive pressure ventilation as much as possible.

8. Major Advantages • Decreases the stimulation of potentially harmful autonomic reflexes ass e intubation: • E.g elevated intracranial pressure, HTN & brady. • Controls the clinical environment: • In case of anxious, frightened or uncooperative. • Minimizes the risk of pulmonary aspiration: • If done along with cricoid pressure.

9. Major Advantages • Provides better intubation conditions: • Complete jaw relaxation, open and immobile vocal cords, and no coughing, bucking or diaphragmatic movement in response to intubation. • Minimizes the psychic trauma: • Cuz the p.t will be unconscious.

10. Indications • Indicated for almost all the patients undergoing emergent endotracheal intubation.

11. Contraindications • Total upper airway obstruction (requires surgical airway) • Total loss of facial/oropharyngeal landmarks (requires surgical airway)

12. Used e Caution • In patients e H/O or F/H/O allergy to anesthetic agents. • In patients known to have a difficult airway: • Cuz the patient will be irreversibly paralyzed for few minutes after administering the NMB agent.

13. Unnecessary • Although not contraindicated, it is unnecessary and time wasting in unconscious patients.

14. Time needed • In the majority of situations, RSI, from the decision to intubate to successful intubation, is accomplished in 10 minutes

15. Steps 6 Ps • Preparation (T: -10m). • Pre-oxygenation (T: -5m). • Pre-medication (T: -3m). • Paralysis (T: 0). • Placement of tube (T: +45s). • Post management (T: +2m).

16. Preparation • Preparation of equipment: • Best remembered by the mnemonic (SOAP-ME): • S: Suction. • O: Oxygen. • A: Airway equipments. • P: Pharmacology agents. • ME: Monitoring Equipment.

17. Preparation • Equipments: • Available. • Proper size. • Functioning. • Assess for the possibility of difficult intubation or bag-mask ventilation. • Decide which sedative and paralytic agents you will use: • Dose. • Keep them ready and drawn in syringes. • IV access (preferable 2).

18. Rapid Review • Rapid review includes: • Rapid and specific history taking. • Rapid and specific physical examination.

19. Rapid Review • Purpose: • Identify or current conditions that may adversly affected by medications or airway manipulation (NM diseases, cardiovascular compromise, increased ICP or bronchospasm). • Clinical features that may make laryngoscopy and/or tracheal inubation difficult. • Coditions that may interfere with bag mask ventilation.

20. Rapid Review • History: • Allergies to medications. • History or F.history of malignant hyperthermia. • History of asthma. • Previous intubations. • Siezure disorders. • Noisy breathing suggestive of upper airway obstruction.

21. Rapid Review • Physical examination: • Clinical features suggestive of NM disorders. • Increased ICP. • Bronchospasm. • Cardiovascular compromise: • Unexplained tachcardia, poor peripheral perfusion, and hypotension.

22. Pre-Oxygenation • Benefit: • To establish a reservoir of oxygen within the lungs, as well as an oxygen surplus throughout the body. So the patient can then tolerate several minutes of apnea without oxygen desaturation, allowing intubation to be safely performed without bag-mask ventilation.

23. Pre-Oxygenation • Ways: • Hypoxic, in respiratory failure, or have insufficient respiratory reserve to achieve adequate preoxygenation with spontaneous respirations: • careful bag-mask ventilation with small tidal volumes (while maintaining cricoid pressure) should be performed for several minutes to achieve adequate preoxygenation. • Breathing spontaneously: • nonrebreather mask for a minimum of three minutes.

24. Pre-Oxygenation • Oxygen concentration used: • The highest concentration available.

25. Pre-Treatment • Agents: • Atropine. • Lidocaine.

26. Pre-Treatment • Atropine: • Indicated in p.ts receiving ketamine to reduce the risk of excessive secretions. • Indicated in p.ts at risk of developing bradycardia: • Children < 1yr. • Children < 5 yrs receiving succinylcholine. • Children receiving a second dose of succinylcholine. • Timimg: • 1-2 min prior to inubation.

27. Pre-Treatment • Dose: • 0.02 mg/kg IV (max 1 mg & min 0.1 mg too small doses can cause paradoxical bradycardia).

28. Pre-Treatment • Disadvantages: • In too small doses can cause paradoxical bradycardia. • The effect of atropine on heart rate may persist for several hours and prevent the bradycardic response to hypoxemia. • Dilates the pupils, thus interfering with pupillary response to light as a means to evaluate a change in neurologic status once the patient is paralyzed.

29. Pre-Treatment • Lidocaine: • Indicated in all p.ts to reduce the risk of increase in ICP associated with laryngoscopy and intubation (vagal nerve stimulation). • Timing: • 2-5 min prior to intubation. • Dose: • 1.5 mg/kg IV (max 100 mg)

30. Pretreatment • Controversies: • Although widely used, there are no studies that assess the efficacy of lidocaine to improve neurologic outcome in patients undergoing RSI in acute brain traumatic injury.

31. Pre-treatment • In systematic review of studies of adult patients, Robinson et al, it showed conflicting results on the ability of lidocaine to blunt the increase in ICP in patients who were being intubated or undergoing endotrachial suctioning.

32. Premedication • Groups of patients going for RSI can be divided into: • Head trauma without shock. • Shock. • Asthmatic. • Non of the above.

33. Premedication • Agents: • Etimodate. • Thiopental. • Ketamine. • Propofol. • Midazolam.

34. Premedication • Criteria to choose the sedative agent: • Availability. • Institutional policy. • Familiarity. • Clinical advantages/disadvantages with respect to the clinical requirements of the patients.

35. Etimodate • Onset of action: • < 1 min. • Duration: • 10-20 min. • Intubation conditions: • 75% success rate. • 1st most common agent used in united states cuz it is hemodynamically neutral.

36. Etomidate • CNS: • Pros: lowers ICP, protective against generalized siezure activity. • Cons: lowers the threshold for convulsion in p.ts with focal siezure disorders. • CVS: • Pros: hemodynamically neutral.

37. Etimodate • Adrenals: • Effect: • Increase the risk of adrenal suppression leading to decrease in cortisol level (one prospective randomized controlled study of 31 adults compared etimodate and midazolam specifically to assess for adrenal function. It showed that although there was significant decrease in adrenal function in the 1st 4hr in etimodate group, there was no diffrence at 12 or 24hr and measured cortisol levels remained within normal ranges).

38. Etimodate • Significance: • Not to be used in cases of sepsis or in patients known to have adrenal insufficiency. • If there is no alternative: • Give a single dose of corticosteroids.

39. Etimodate • Preferred in: • As a 1st choice unless contraindicated. • Better avoid in: • Focal siezure disorders. • Adrenal insufficiency. • Severe sepsis.

40. Thiopental • Onset of action: • 30-40 s. • Duration: • 10-30 min. • Intubation conditions: • 73 - 100% success rate (better than etimodate). • The best success rate of 1st attempt in RSI. • 2nd most common agent used in united states.

41. Thiopental • CNS: • Pros: lowers ICP, anticonvulsant properties. • CVS: • Cons: hypotension (bradycardia and vasodilation). • Chest: • Cons: laryngo and bronchospasm (causes histamine release).

42. Thiopental • Preferred in: • Cases of ICP without hypotension. • Cases in which etimodate is contraindicated or not available and patient is hemodynamically stable. • Better avoid in: • Hemodynamically unstable patients. • Bronchial asthma patients.

43. Ketamine • Onset of action: • 1 min. • Duration: • 30-60 min.

44. Ketamine • CNS: • Controversial: increases ICP (very weak data) • Pros: has anticonvulsant properties, increase cerebral perfusion. • CVS: • Cons: hypertension (tachcardia and vasoconstriction). • Chest: • Pros: bronchodilator. • Cons: laryngospasm.

45. Ketamine • Eyes: • IOP. • Salivation: • Cons: hypersalivation (better to pre-treat with atropine).

46. Ketamine • Prefered in: • Bronchial asthma, anaphylactic shock. • Avoid in: • Aortic dissection, abdominal aneurism or acute myocardial infarction. • Penetrating eye trauma. • HTN. • Controversial: • ICP.

47. Midazolam • Onset of action: • 1-2 min. • Duration: • 20-30 min.

48. Midazolam • CNS: • Pros: anticonvulsant properties. • CVS: • Cons: hypotension. • Chest: • Cons: causes respiratory depression, so p.ts may develop apnea before receiving the paralytic agent which interferes with the effectiveness of pre-oxygenation.

49. Propofol • Onset of action: • 10 s. • Duration: • 10-15 m.

50. Propofol • CNS: • Pros: anticoncvulsant properties, lowers ICP. • CVS: • Cons: hypotension (vasodilatation and bradycardia). • Other: • It contains egg lecithen, egg yolk phospholipids and soybean oil.