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Rapid Sequence Intubation Erik D. Barton, MD, MS, MBA

Rapid Sequence Intubation Erik D. Barton, MD, MS, MBA University of Utah Affiliated Emergency Medicine Residency Program. The Decision to Intubate. Four Reasons for Intubation. Establish, maintain or protect airway Failure to ventilate Failure to oxygenate

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Rapid Sequence Intubation Erik D. Barton, MD, MS, MBA

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  1. Rapid Sequence Intubation Erik D. Barton, MD, MS, MBA University of Utah Affiliated Emergency Medicine Residency Program

  2. The Decision to Intubate Four Reasons for Intubation • Establish, maintain or protect airway • Failure to ventilate • Failure to oxygenate • Anticipated clinical course

  3. First ProviderIntubations Sagarin, Barton, et al, Ann Emer Med, 2005

  4. RescueIntubations Sagarin, Barton, et al, Ann Emer Med, 2005

  5. 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.

  6. Rapid Sequence Intubation Just like Skydiving…. Skydiving is lethal unless one deploys a parachute… RSI is lethal unless you rescue the airway!

  7. Rapid Sequence Intubation Just like Skydiving…. • Redundancy of safety (primary & backup) • Planned, stepwise approach to primary system • Simple, fast backup system • Attention to monitoring • Equipment vigilance Levitan, RM. Ann Emerg Med. 2003;42:81-87.

  8. Rapid Sequence Intubation Definition Incorporates: • Every patient has a full stomach • Preoxygenation • No interposed ventilations • Sellick’s maneuver

  9. 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 • Can mitigate adverse effects

  10. Rapid Sequence Intubation The Six Ps of RSI Preparation Preoxygenation Pretreatment Paralysis with Sedation Protection Placement

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

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

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

  14. 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

  15. Rapid Sequence Intubation Time to Desaturation

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

  17. THE AIRWAY COURSE PRETREATMENT AGENTS National Emergency Airway Management Course

  18. THE AIRWAY COURSE PRETREATMENT AGENTS • Lidocaine • Opioid • Atropine • Defasciculation Give 3 minutes before SCh National Emergency Airway Management Course

  19. THE AIRWAY COURSE PRETREATMENT AGENTS LIDOCAINE 1.5 mg/kg • Increased intracranial pressure • Bronchospasm National Emergency Airway Management Course

  20. THE AIRWAY COURSE PRETREATMENT AGENTS OPIOID Fentanyl 3 mg/kg • Cardiovascular disease • Intracranial hypertension Caution: sympathetic drive National Emergency Airway Management Course

  21. THE AIRWAY COURSE PRETREATMENT AGENTS ATROPINE 0.01 mg/kg • Children < 10 years who receive Sch National Emergency Airway Management Course

  22. THE AIRWAY COURSE PRETREATMENT AGENTS DEFASCICULATION 10% of the paralyzing dose: • Vecuronium (0.01 mg/kg) • Pancuronium (0.01 mg/kg) • Rocuronium (0.06 mg/kg) • Intracranial hypertension National Emergency Airway Management Course

  23. THE AIRWAY COURSE INDUCTION AGENTS National Emergency Airway Management Course

  24. THE AIRWAY COURSE INDUCTION AGENTS HEALTHY, STABLE PATIENTS • Etomidate 0.3 mg/kg • Midazolam 0.2 mg/kg • Ketamine 1.5 mg/kg • Propofol 1 mg/kg • Pentothal 3 mg/kg National Emergency Airway Management Course

  25. THE AIRWAY COURSE INDUCTION AGENTS COMPROMISED/UNSTABLE PATIENTS • Etomidate 0.1 mg/kg • Midazolam 0.1 mg/kg • Ketamine 1 mg/kg • Propofol 0.5 mg/kg • Pentothal 1.5 mg/kg National Emergency Airway Management Course

  26. THE AIRWAY COURSE INDUCTION AGENTS FOR SPECIFIC CONDITIONS • Reactive airways ketamine • ICP etomidate, pentothal • Hypotensive ketamine • Operator preference National Emergency Airway Management Course

  27. Rapid Sequence Intubation The Sequence Zero!! Paralysis with sedation • Induction agent IV push • Succinylcholine 1.5 mg/kg IVP Entering the red zone...

  28. THE AIRWAY COURSE NEUROMUSCULAR BLOCKADE • Depolarizing • succinylcholine • Competitive (nondepolarizing) • Aminosteroids • Benzylisoquinolines National Emergency Airway Management Course

  29. Rapid Sequence Intubation Succinylcholine • Still the ED NMB of choice • Rapid effect • Short duration • Generally well tolerated • A few important side effects

  30. THE AIRWAY COURSE NEUROMUSCULAR BLOCKADE SUCCINYLCHOLINE • Rapid onset / brief duration • May ICP • Fatal hyperkalemia • burns beyond day one • active neuromuscular disease • crush injuries • intra-abdominal sepsis (7D) National Emergency Airway Management Course

  31. THE AIRWAY COURSE NEUROMUSCULAR BLOCKADE Aminosteroids Benzylisoquinolines • atracurium • cisatracurium • mivacurium • metocurine • DTC • rocuronium • pancuronium • vecuronium • rapacuronium National Emergency Airway Management Course

  32. THE AIRWAY COURSE NEUROMUSCULAR BLOCKADE Summary • SCh for RSI • Competitive for pre-treatment • Rocuronium for competitive RSI National Emergency Airway Management Course

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

  34. Rapid Sequence Intubation The Sequence Zero + 45 seconds Placement • Check mandible for flaccidity • Intubate, remove stylet • Confirm tube placement - E CO • Release Sellick’s maneuver • Long acting agents/ventilator t 2

  35. Rapid Sequence Intubation Failed Attempt Rescue Maneuvers • Plan in advance • Systematic approach essential • Equipment • Training • …remember “Skydiving!!”

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

  37. Rapid Sequence Intubation How do we know that RSI really works?

  38. The “Science” of Airway Management • The problems… • Self-reporting • Emergency conditions • Multiple factors influence each course: • highly variable • operator dependent • “Jargon” not standardized • Wang, HE. Acad Emerg Med. 2003;10:644-5.

  39. NEAR 6294 ED Intubations from the second report of the ongoing National Emergency Airway Registry Study (NEAR II)

  40. 6294 Intubations from the National Emergency Airway Registry Methods: Prospective, observational study from 8/97 to 4/00 of 26 teaching hospitals in the U.S. during the second phase of the ongoing National Emergency Airway Registry (NEAR II) study.

  41. 6294 Intubations from the National Emergency Airway Registry Personnel Performing ED Intubations

  42. 6294 Intubations from the National Emergency Airway Registry Demographics of Cases: Indication Cases Female Male Unknown Trauma1605 (22%) 349 (22%) 1059 (65%) 97 (3%) Medical4286 (72%) 1740 (40%) 2194 (51%) 352 (9%) Not Provided 277 (6%) 84 (2%) 166 (3%) 27 (1%) TOTAL 6294 (100%) 1642 (36%) 2545 (55%) 415 (9%)

  43. 6294 Intubations from the National Emergency Airway Registry Oral RSI 4377 (69%) Oral no meds 1088 (17%) Oral induction without paralysis 427 (7 %) Nasal awake with topical 206 (3%) Nasal no meds 69 (1%) Nasal induction without paralysis 45 Surgical cric/tracheotomy 39 (0.6%) Other 16 Oral awake with topical 21 Unknown 5 TOTAL 6294

  44. 6294 Intubations from the National Emergency Airway Registry 1st Course Success Rates: Medical Trauma Oral RSI 99.8%97.7% Oral no meds 94.7% 96.3% Oral induction without paralysis 95.0% 93.7% Nasal awake with topical 97.2% 98.1% Nasal no meds 91.3% 45.4% Nasal induction without paralysis 97.0% 100% Oral awake with topical 93.7% N/A Other 50.0% 100% Surgical cricothyrotomy 60.0% 68.7% Unknown 50.0% N/A TOTAL 94.7% 96.2%

  45. 6294 Intubations from the National Emergency Airway Registry Success Rates by Intubator: First pass Overall EM 84.7% 98.5% Anesthesia 93.5% 93.5% Other 64.9% 97.4% Attending EM 90.2% 97.9% PGY 3 or 4 87.2% 98.4% PGY 1 or 2 77.5% 98.7% Other 81.1% 98.5%

  46. NEAR • Other Studies: • Analysis of failed intubations and rescue techniques • - Bair, AE, et al. J Emerg Med. 2002;23:131-40. • Sedative agents facilitate intubations with NMB • - Sivilotti, MLA, et al. Acad Emerg Med. 2003;10:612-20. • Underdosing of midazolam in 92% of adults, 56% of kids - Sagarin, MJ, et al. Acad Emerg Med. 2003;10:329-38. • Benchmarking intubation data for North American EM residents - Sagarin, MJ, et al. Ann Emerg Med. 2004.

  47. Air Medical Research Collaborative (AMTC) • Golden Hour Data Systems project • Prospectively collect data on all intubations in the field by air medical personnel • 13 Helicopter and air ambulance companies in the U.S. • “RSI” defined as the use of Suxx + an induction agent

  48. Air Medical Research Collaborative (AMTC) • Results: • Over 30,000 patient transports from 1998-2004 • 2853 patients had intubations (9%) • RSI = 68% (1944 patients) • Non-RSI = 32% (909 patients)

  49. Air Medical Research Collaborative (AMTC) SuccessFailureTotalSuccess Rate Trauma/Burn RSI (58%) 1542 115 1657 93.1% Trauma/Burn non-RSI (22%) 532 92 624 85.3%* Medical RSI (10%) 265 22 287 92.3% Medical non-RSI (9%) 238 30 268 88.8% Total RSI (68%) 1807 137 1944 93.0% Total non-RSI (32%) 777 132 909 85.5%* (*p<0.05) Surgical Cric/tracheotomy 45 (1.6%)

  50. The “Science” of Airway Management The Future: • Standardize the jargon • What is an intubation attempt? • Immediate vs. long-term complications • Difficult airway assessments • Rapid and predictive • Universally applied

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