1 / 50

The ABC of RSI

The ABC of RSI. Jason Boschin Critical Care Paramedic. Advanced Airway. Anatomic Considerations Rapid Sequence induction Neuromuscular Blockade Induction Agents Intubation tricks & thoughts. Indications for Definitive Airway. ANATOMIC CONSIDERATIONS FOR INTUBATION. Mouth: Tongue :

roth-serrano
Download Presentation

The ABC of RSI

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The ABC of RSI Jason Boschin Critical Care Paramedic

  2. Advanced Airway • Anatomic Considerations • Rapid Sequence induction • Neuromuscular Blockade • Induction Agents • Intubation tricks & thoughts

  3. Indications for Definitive Airway

  4. ANATOMIC CONSIDERATIONS FOR INTUBATION • Mouth: • Tongue : • variable in size (angioedema) • attached inferior to epiglottis • Mandible • Uvula • Pharynx • Tonsils • Merges with larynx anterior, esophagus posterior • Epiglottis high long flaccid and narrow in child

  5. ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.) • The Larynx • High relative to mandible in child • Cricoid smaller in child, narrow part of airway • vocal cord narrow part of adult airway • arytenoid cartilages

  6. Netter; Atlas of Human Anatomy

  7. ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.) • Trachea • 12-15 cm. Adult • 4 cm. Newborn • right mainstem larger,shorter and less angle Anderson; Grant’s Atlas of Anatomy

  8. OTHER CONSIDERATIONS FOR INTUBATION (cont.) • Tube Sizes (Kids) • Fit through nose • Age(years)/4 + 4 • Oral tube length • Age(years)/2 + 12 cm. • Nasal add 3 cm. • No cuff under 6 to 8 years

  9. OTHER CONSIDERATIONS FOR INTUBATION (cont.) • Difficult tubes • Immobilized trauma patient • Combative patient • Children, esp. Infants • Short neck • Prominent upper incisors • Receding mandible • Limited jaw opening, limited cervical mobility • Upper airway conditions • Facial, laryngeal trauma

  10. Correct Placement for intubation (b)

  11. Patient in correct position for intubation (sniffing position)

  12. Incorrect airway position (hyperflexed)

  13. Rapid Sequence Induction • Indications • Ventilatory failure (eg’s) • Airway maintenance/protection • Treatment and evaluation • neuro resuscitation(hyperventilate) • shock • drug overdose

  14. Rapid Sequence Induction • Contraindications • Cardiac arrest • Adequate ventilation • Deeply comatose patient, absent tone • Airway Anatomy use LEMON

  15. Whitten; Anyone Can Intubate Rapid Sequence Induction • Contraindications (cont.) • Intubation likely unsuccessful • Partially obstructed airway • Severe facial abnormality(trauma, etc.)

  16. McIntyre; The difficult tracheal intubation

  17. Rapid Sequence Induction • Maintain adequate oxygenation • Airway protection • Prevent regurgitation, aspiration • Obtund adverse cardiovascular and ICP response to intubation • Better early than late • Hypoxemia and acidosis effects

  18. Rapid Sequence Induction • Treatment Algorithm (6 P’s) • Preparation T-10” • Pre-oxygenation( functional reserve capacity) T-5” • Pre-medication T-3” • Paralysis T-0 • Placement of Tube T+45 • Post Management T+2”

  19. DO NO HARM!TAKE AWAY NOTHING FROM THE PATIENT YOU CANNOT REPLACE

  20. Rapid Sequence Induction • Anticipate the difficulties • Identify in advancethe patient who may require RSI • Identify the patient with anatomic difficulty • Have sufficient skill and training : • TRAINING NOT DONE ON SCENE..NO EGO’S!!! • Have apreformulatedplan for potential disaster

  21. Airway Evaluation Problem Airway epiglottis Vocal cords

  22. Rapid Sequence Induction • Be prepared: • Competence with all equipment • Working equipment • Be prepared for surgical management • Master the art of bagging • Have at least one, if not two, working IV lines • STAY ONE STEP AHEAD!!

  23. Rapid Sequence Induction • Equipment: • Suction, Oxygen • Laryngoscope, ET Tubes, Stylet • BVMR • Pharmacologic agents, mixed and ready • Monitoring equipment • Continuous cardiac monitoring • Pulse oximeter (continuous) • NIBP (ideal) • CO2 device (ET confirmation device)

  24. Rapid Sequence Induction • Pre-oxygenation: • Functional residual capacity • Oxygen 6-10 l/min via snug mask • Three minutes ideal, if spontaneous breathing assist only. • BEWARE BVM while spontaneously breathing..Gastric insufflation is real!! • Avoid BVMR if Spo2 >90% if breathing….

  25. ...

  26. Rapid Sequence Induction • Pre-medication: • Atropine • All children under 12 years • Adults with heart rate 100 or less *** • Second dose of Succinylcholine • Dosage: 0.5 to 1.0 mg adult • Dosage 0.01 to 0.02 mg child (1 mg max) • Give ideally 2-3 minutes prior to intubation

  27. Rapid Sequence Induction Paralytics Have No Sedative or Analgesic Qualities!!! • Sedation Agents • Goal is to blunt the pt’s physiologic responses to intubation ie: minimizes bradycardia, hypoxemia, gag/cough & increases in ICP/IOP/IGP • Selection of agent(s) • perfusion state • presence of head injury • clinical diagnosis

  28. Rapid Sequence Induction • Selection of Sedative (cont.) • Benzodiazepines • Amnestic and at high dose, anesthetic • Little cardiovascular depression if titrated • Midazolam • Rapid onset • Potent amnestic • Moderate decrease in ICP • 1-5 mg IV (adult) as per CPG • 0.1 mg/Kg titrated in kids

  29. Rapid Sequence Induction • Selection of Sedative (cont.) • Narcotics • Potent analgesics/sedatives • Rapid onset w/ brief duration • Effect can be reversed! Fentanyl • Rapid acting (<1min), duration of 30min • No histamine release • May decrease tachycardia and hypertension associated with intubation

  30. Dailey; The airway: emergency management Induction Agents • ACh binds to post synaptic receptors causing depolarization … Contraction of muscle • ACh removed by acetylcholinesterase and by diffusion …. Relaxation of muscle Neuromuscular Junction

  31. Induction Agents • Mechanism of action: • Nondepolarizers • Competitive • Block ACh receptors … paralysis • Depolarizers • Noncompetitive • Persistent stimulation …fasciculations • Unresponsiveness to ACh….Paralysis

  32. Dailey; The airway: emergency management

  33. Induction Agents • Depolarizing • Succinylcholine • Vagal effects • Excessive bronchial secretions (blunted by Atropine?) • Negative inotropic and chronotropic, esp. with repeated dose and in children (Bradycardia..Atropine) • Fasciculations (amelioration) • Malignant hyperthermia? • Complete paralysis w/in 30-45 sec. Lasting 4-6 min • 1.5-2 mg/kg IV

  34. Induction Agents • Succinylcholine (cont.) • Metabolized via Cholinesterase • 0.3% defective enzyme • Contraindications • Absolute - none • Hyperkalemia • Renal failure • Crush injury • Burns • Myotonia • Paraplegia

  35. Induction Agents • Non-depolarizing • Rocuronium • Minimal cardiovascular effect • Long duration of action (may exceed 45 mins) • Shorter onset than Pancuronium/Vecuronium: 1-3 min • 0.6-1.2 mg/kg

  36. Airway Management

  37. Airway Management

  38. Airway Management

  39. Intubation Tricks • Digital Tactile Intubation • Retrograde • Airtraq • Fiberscope • BURP

  40. SURGICAL AIRWAYS • Cricothyrotomy • Indications (Identified need for intubation) • Maxillofacial trauma • Oropharyngeal obstruction • Edema • FBAO • Mass Lesion • Cancer • Unsuccessful oral/nasal tracheal • Difficult anatomy • Massive hemorrhage/regurgitation

  41. SURGICAL AIRWAYS • Cricothyrotomy (cont..) • Contraindications: • Age <10-12 • Laryngeal crush injury • Laryngeal tumor/stricture • Tracheal transsection • subglottic stenosis • Expanding hematoma • Coagulopathy • Unfamiliar w/ procedure

  42. SURGICAL AIRWAYS • Anatomy: • Thyroid cartilage • Cricoid ring • Cricoid cartilage • Thyroid gland • Trachea • Major vessels

  43. Netter; Atlas of Human Anatomy SURGICAL AIRWAYS

  44. SURGICAL AIRWAYS • Procedure: • Identify thyroid cartilage • Cricothyroid membrane • Vertical incision through skin • Prep prior • Incise membrane • Open incision • Dilator/tracheal hook • Insert ETT/Trach tube • Ventilate patient

  45. SURGICAL AIRWAYS • Complications: • Incorrect placement • Long execution time • Hemorrhage • Passage sub Q • Plugging • Pneumomediastinum • Aspiration • etc.

  46. Anderson; Grant’s Atlas of Anatomy SURGICAL AIRWAYS

  47. SURGICAL AIRWAYS • Retrograde Tracheal Intubation (RTI): • Indications • Abnormal anatomy • Pt. W/ epiglottitis • Severe kyphosis • Cervical spondylosis • Trauma • Reasonable alternative to Surg and Needle Crike

  48. SURGICAL AIRWAYS • RTI (cont...): • Contraindications • Trismus (w/o paralytic) • Coagulopathy • Enlarged thyroid • Procedure: • Supplemental O2 • Catheter over needle into CTM • Insert guidewire through catheter • Visualize guidewire and pass tube

  49. Dailey; The airway: emergency management

  50. QUESTIONS ?? Defasiculating Doses (priming with 10% NDNMB) Ketamine Braeslow system for Kids

More Related