RSI: Rapid Sequence Intubation What, When, Where, Why & How

1. RSI: Rapid Sequence IntubationWhat, When, Where, Why & How Michael T. Czarnecki, MD 265

2. Objective • What is RSI? • Discuss the “7 P’s” of RSI • Review RSI pharmacologic agents • Highlight current controversies with RSI

3. RSI Defined “Virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation”

4. Why Bother with RSI? • Rapid airway control • Less risk of aspiration • Highest success rates/lowest complications • More controlled • Optimal intubating conditions

5. What are The Problems Inherent to Intubation? • Laryngoscopy and Intubation • Increased bronchospasm • Increased ICP • Increased catecholamine release

6. Beneficial Effects of RSI • “Tight Heads” • Intracranial pathology • “Tight Hearts” or “Tight Vessels” • Cardiovascular disease • “Tight Lungs” • Reactive airway disease

7. Assumptions in Airway Management • Pt. has a full stomach • Pt. is preoxygenated • Pts. do not receive BVM ventilation unless necessary to keep O2 sat. over 90% • Sellick’s maneuver always used

8. RSI: “7 P’s” • P = Preparation • P = Preoxygenation • P = Pretreatment • P = Paralysis with induction • P = Protection • P = Placement of the tube • P = Post-Intubation management

9. RSI: Timeline T – 10 minutes Prepare T – 5 minutes Preoxygenate T – 3 minutes Pretreat T = 0 Paralysis with induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation management

10. Preparation: T – 10 minutes • Prepare the patient • Monitoring/access • Positioning • Assess for difficult airway • “4 D’s”,“LEMON”, “BONES”, “SHORT” • Mallampati • Prepare your equipment • Prepare yourself (mental checklist) • Prepare your personnel

11. Difficult Airway Assessment • 4 D’s • Distortion, Disproportion, Dysmobility, Dentition • BONES • Beard, Obese, No teeth, Elderly, Snores (sleep apnea) • SHORT • Surgery (head/neck/jaw), Hematoma, Obese, Radiation, Tumor • LEMON • MALLAMPATI • Always have a “Rescue Airway” technique ready JUMP AHEAD

12. MALLAMPATI SCORE Class I Class II Class III Class IV JUMP BACK

13. 60-SECOND EXAM “LEMON” • Look for external difficulty • Evaluate using 3=3=2 rule • Mallampati (Class I & II) • Obstruction • Neck Mobility • 3 fingers fit in mouth • 3 fingers fit from mentum to hyoid cartilage • 2 fingers fit from mandible to top of thyroid cartilage JUMP BACK

14. Rescue Airways • Gum Elastic Bougie (GEB) • Laryngeal Mask Airway (LMA/ILMA) • Combitube • Surgical Cricothyrotomy JUMP BACK

15. Preoxygenate: T – 5 minutes • Provides reservoir of oxygen during apnea • If pt. spont. breathing – then NRB for 5’ • Provides maximum of 70% FiO2 • Avoid bagging the spont. breathing patient • If needed, use sellick & airway adjunct • 8 effective Vital Capacity breaths provides best preoxygenation

16. Pretreat: T – 3 minutes • L - Lidocaine • O - Opiates • A - Atropine • D – Defasiculating Agent

17. Lidocaine (1.5 mg/kg) • Consider in “Tight Head” or “Tight Lungs” • Blunts ICP rise (??) • Suppress cough response • may blunt bronchospasm • may blunt sympathetic response • Does Lido help in head trauma? • No clinical trials have answered question • Not proven to change outcome • Little downside in using Robinson, Emeg Med J 2001; 18:453

18. Opioids • Fentanyl (3 mcg/kg slow IV over 3’) • Consider in “Tight Heads”, “Tight Heart”, & “Tight Vessels” • Beware: cautious use in pt’s dependent on sympathetic drive (aka, trauma)

19. Atropine • Only needed in: • Children under 10 y.o. • Adults receiving 2nd dose of succinylcholine • 0.01 mg/kg IV push • Minumum dose: 0.1 mg

20. Defasiculating Agent • Use any paralytic at 10% paralyzing dose • Consider in “Tight Heads” • Beware: may cause hypoventilation and frank paralysis – be prepared • Who needs defasiculation? • Helps mitigate ICP rise with succinylcholine • Not really useful in any other ICU situation

21. Paralysis with Induction: T = 0 • Tailor inducing agent to specific needs • Barbituates • Etomidate • Midazolam • Ketamine • Propofol JUMP AHEAD

22. Barbituates • Decreases GABA dissociation at receptor • Rapid onset sedation • Decreases ICP • Hypotension (especially in hypovolemia) • Choices: • Thiopental, pentobarbital, methohexital Overall – Etomidate is better that Barbs JUMP BACK

23. Thiopental • Onset 15 seconds, duration 3-5 minutes • Cardiac depressant, venodilator • Hypotension • Dose depedent on pt. profile • Euvolemic adult (3-5 mg/kg IV) • Hypovolemic adult (1-3 mg/kg IV) JUMP BACK

24. Etomidate • Nonnarcotic, nonbarbituate, nonanalgesic • Minimal cardio effects, lowers ICP • Is it the ideal agent for RSI? • May cause critical adrenal suppression • Inhibits adrenal mitochondrial hydroxylase activity • Occurs after both single bolus and infusions • Infusions incr. ICU death rate & incr. infections • Clinical significance is unclear • Randomized, controlled trials on outcomes needed Malerba, et al: Intensive Care Med 2005

25. Etomidate (con’t) • Induction dose: 0.2 – 0.3 mg/kg IV • Onset: 20 – 30 seconds • Duration: 7 – 15 minutes • May cause myoclonic jerking, hiccups, injection pain, N/V (also on emergence) • Risk for adrenal insufficiency incr. 12-fold Jackson, Chest 2005 MarMurray, Chest 2005 Mar; 127:707-709 JUMP BACK

26. Midazolam • Nonanalgesic sedative, anxiolytic, amnestic • Respiratory depressant and hypotension • Give slow IV • Give ½ the dose in elderly or COPD • Rapid onset (< 1 minute) • Induction dose (0.1 - 0.3 mg/kg) DIFFERENTthan sedation dose (0.01 – 0.03 mg/kg) • In RSI, 92% of adults are underdosed Sagarin, et al: Acad Emerg Med 2003 Apr; 10:329-38 JUMP BACK

27. Ketamine (1 – 2 mg/kg) • Dissociative, analgesic, amnestic • Causes catecholamine release • Incr. BP, HR, ICP, Laryngospasm risk • Bronchodilator →induction agent in asthma • Onset: 15 – 30 seconds • Duration: 10 – 15 minutes JUMP BACK

28. Propofol(0.5 – 1.2 mg/kg)(white magic, milk of amnesia) • Sedative-hypnotic • Cardiac depressant, venodilator • Hypotension • Decr. ICP at expense of CPP JUMP BACK

29. NMBs: Neuromuscular Blocking Agents • Depolarizing • Succinylcholine • Non-Depolarizing • Pan/Vec/Atra/Rocuronium • Potential Problems • Inadequate pre-intubation neuro exam • Failure to sedate • Inadequate pre-treatment or inadequate dosing • Aspiration and Dysrhythmias • Failed intubation → surgical airway needed

30. Succinylcholine(1.5 – 2.0 mg/kg) • Onset: 15 – 30 sec; Duration: 5 – 12 min • Contraindications: • FHx malignant hyperthermia, burns, crush injuries, progressing neuromuscular disease • Side Effects: • Brady, hyper-K+, fasciculations, MH • ↓HR: pretreat all kids; adults 2nd dose with atropine • ↑K+: peaks in 5’, resolves in 15’ • Treat like any hyperkalemia case • Use actual-body weight for dose Rose, et al: Anesth Analg 2000

31. Non-depolarizing NMBs • Longer duration than SUX, onset about equal • Aminosteroid compounds • Pan/Vec/Rocuronium • Benzylisoquinolinum compounds • Atracuronium

32. Rocuronium • Is it equivalent to SUX? • Meta-analysis 1600 pts → equivalent in: • Acceptable conditions for intubation • Rates of intubation success • But SUX is BEST at creating EXCELLENT conditions Perry, AEM 2002

33. RSI: Timeline T – 10 minutes Prepare T – 5 minutes Preoxygenate T – 3 minutes Pretreat T = 0 Paralysis with induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation management

34. Align the 3 axes – critical for success • Sellick’s maneuver

35. Confirm placement/review CXR • Secure tube • Vent Settings • Administer sedation • Maintain paralysis if indicated And…..

36. Don’t Ever Forget the “7 Ps” • P = Preparation • P = Preoxygenation • P = Pretreatment • P = Paralysis with induction • P = Protection • P = Placement of the tube • P = Post-Intubation management

37. WHEN IN DOUBT, PULL IT OUT!