Rapid Sequence Intubation

1. Rapid Sequence Intubation Delon F.P. Brennen, MD MPH Pediatric Emergency Medicine Morehouse School of Medicine

2. Outline • Definition • Indications • Method

3. Definition • The induction of a state of unconsciousness with complete neuromuscular paralysis to achieve intubation without interposed mechanical ventilation in efforts to facilitate the procedure and minimize risks of gastric aspiration

4. Indications • Failure of airway maintenance/protection - lost or diminished gag reflex • Failure of oxygenation/ventilation - asthma, aspiration, pneumonia • Anticipated clinical course - multiple trauma, head injured - intoxication, air transport

5. Method (6P’s) • Preparation: T-10mins • Positioning • Preoxygenation: T-5mins • Premedication: T-3mins • Paralysis: T-1min • Placement of tube: T-0mins • Post management

6. Preparation • Evaluate • LEMON • Equipment Check • Positioning • Drug Selection • IV’s, monitor, oximetry • Ancillary Staff • Anticipate alternative airway maneuver

7. LEMON • LEMON • L-Look • E-Evaluate • M-Mallampati • O-Obstruction • N-Neck mobility

10. Preoxygenation • 100% O2 for 5 minutes or 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs • NOT Positive Pressure Ventilation • If possible

12. Premedication • Goal • blunt the patient’s physiologic responses to intubation • Which are ? • bradycardia • hypoxemia • cough/gag reflex • increases in intracranial, intraocular, and intragastric pressures

13. Premedication • Lidocaine • Opioid • Atropine • Defasciculating doses “priming”

14. Lidocaine • Thought to blunt the rise in ICP associated with airway manipulation and the use of depolarizing neuromuscular blocking agents • Dose: • 1.5 - 3 mg/kg (3 mins prior to intubation)

15. Atropine • Minimize vagal effects, bradycardia, secretions • Infants and children < 8 yrs may develop profound bradycardia during intubation • 0.02 mg/kg (minimum 0.1 mg IV, max 1 mg) 3 minutes prior to intubation

16. Defasciculating Doses • Decreases muscle fasiculations caused by the depolarizing agents (succinylcholine) • Attenuates rise in intracranial pressure • Agents - non-depolarizing blocking agents (vecuronium, pancuronium, etc.) • Usually 1/10 of standard dose

17. Sedation • Sedative agents administered at doses capable of producing unconsciousness with little or no cardiovascular effects • No ideal agent exists • Sedation should nearly always be used when paralyzing the patient

18. Sedation • Barbiturates/hypnotics • Non-barbiturate • Neuroleptics • Opiates • Benzodiazepines

19. Barbiturates/Hypnotics • Thiopental (Pentothal), Methohexital (Brevital) • Short onset - 10-20secs, • Duration - 5-10 mins • May reduce ICP, cerebro-protective • Histamine release, hypotension, bronchospasm

20. Barbiturates/Hypnotics • Etomidate (Amidate) • nonbarbiturate hypnotic • Rapid onset, short duration • Decreases ICP/IOP • Minimal hemodynamic effects • No histamine release • Increases seizure threshold

21. Etomidate • No malignant hyperthermia reported • Watch for myoclonus, vomiting • May decrease cortisol synthesis (adrenal insufficiency) • Dose 0.3 mg/kg IV

22. Barbiturates/Hypnotics • Propofol (Diprivan) • sedative hypnotic • Extremely rapid onset (10 sec), • Duration of 10-15 minutes • Decreases ICP, Can cause profound hypotension • Dose 1-3 mg/kg IV for induction • Dose: 100-200 mcg/kg/min for maintenance

23. Ketamine • Ketamine • dissociative anesthetic, not a sedative • Rapid onset (1-2mins), short duration (~15mins) • Potent bronchodilator, useful in asthmatics • Increases ICP, IOP, IGP, (beware in head injuries) • Increases bronchial secretions • “Emergence” phenomenon • rarely in children <10 yrs , common in adults • Dose: 1-2 mg/kg

24. Opiates

25. Fentanyl • Rapid onset (<1 min), long duration - 30 min • Does not release histamine • May decrease tachycardia and hypertension associated with intubation • Seizures and chest wall rigidity • Can be reversed with Naloxone • Dose: 2-10 mcg/kg IV

26. Morphine Sulfate • Longer onset (3-5) minutes and duration (2-6) hours • May not blunt the rise in ICP, hypertension and tachycardia as well as fentanyl • Histamine release • Dose 0.1-0.2 mg/kg IV

27. Benzodiazepines

28. Benzodiazepines • Midazolam, Diazepam, Lorazepam • Provide excellent amnesia and sedation • Broad dose-response relationship • Reversed with Flumazenil • Doses required are higher for RSI than for general sedation

29. Midazolam • Slower onset (3-5) min than the barbiturate/hypnotic agents • Considered short-acting (30-60 min) • Does not increase ICP • Causes respiratory and cardiovascular depression • Dose: 0.1-0.4mg/kg IV

30. Diazepam and Lorazepam • Moderate/long acting agents • Longer onset time than midazolam • May be more beneficial post-intubation for sedation

31. Paralysis

32. Neuromuscular Blocking Agents • Chemical paralysis facilitates intubation by allowing visualization of the vocal cords and optimizing intubating condition • Only CONTRAINDICATION is anticipated difficult airway • Mallampati Class (I-IV) • Thyromental Distance

33. Depolarizing Agents • Exert their affect by binding with acetylcholine receptors at the neuromuscular junction, causing sustained depolarization of the muscle cell

34. Nondepolarizing • Bind to acetylcholine receptors in a competitive, non-stimulatory manner, no receptor depolarization • Histamine release • Reversed with edrophonium or neostigmine • Caution with myasthenia gravis

35. Agents • Depolarizing agents • Succinylcholine (Anectine) • Nondepolarizing Agents • Pancuronium (Pavulon) • Vecuronium (Norcuron) • Atracurium (Tracrium) • Rocuronium (Zemuron) • Mivacurium (Mivacron)

36. Succinylcholine • Gold standard for >50 years • Stimulates nicotinic/muscarinic cholinergic receptors • Onset 45 secs, duration 8-10 mins • Dose: Children 2.0 mg/kg IV • (adults 1.5 mg/kg IV) • Inactivated by pseudocholinesterase

37. Succinylcholine cont • Prolonged paralysis seen with: • Pregnancy • Liver disease • Malignancies • Cytotoxic drugs • Certain antibiotics • Cholinesterase inhibitors • Organophosphate poisoning

38. Succinylcholine • Adverse reactions • Muscle fasiculations • Hyperkalemia • Bradycardia • Prolonged neuromuscular blockade • Trismus • Malignant hyperthermia

39. Depolarizing Agents • Muscle fasiculations • Thought to increase ICP/IOP/IGP • Causes muscle pain • Minimized by “priming” dose of non-depolarizing NMB • Hyperkalemia • Average increase in potassium of 0.5-1 mEq/L • Burns, crush injuries, spinal cord injuries, neuromuscular disorders, chronic renal failure

40. Depolarizing agents • Bradycardia • Most common in kids <10 yrs 2o higher vagal tone • Especially w/ repeated doses of succinylcholine • Premedicate with atropine

41. Depolarizing Agents • Malignant hyperthermia • From excessive calcium influx through open channels • Genetic predisposition • Rapid rise in temperature, rhabdomyolysis, muscle rigidity, DIC • 60% mortality • Treatment: IV Dantrolene

42. Depolarizing Agents • Trismus (Masseter spasm) • Usually in children • Unknown cause • Treat with a nondepolarizing NMB

43. Pancuronium • Slow onset (1-5 min) • Long-acting agent (45-90 min) • Renal excretion • Vagolytic tachyarrythmias common • Dose: 0.10-0.15 mg/kg IV

44. Vecuronium • Onset of 1-4 min • Duration of 30-60 min • Hypotension may occur from loss of venous return and sympathetic blockade • Mostly biliary excretion • Dose 0.1 mg/kg • “priming dose” 0.01 mg/kg

45. Rocuronium • Shortest onset of the nondepolarizing agents (1-3 min) • Duration 30-45 min • Tachycardia can occur • Dose: 0.6-1.2 mg/kg (1mg/kg)

46. Placement of Tube • Allow medications to work and assure complete neuromuscular blockade of the patient • Maintain Sellick maneuver until cuff inflated • Ventilate with bag-valve mask if unsuccessful • Additional doses of sedatives/NMB may be necessary • Confirm tube placement

47. Post Intubation Management • Secure tube • Continuous pulse oximetry • Reassess vital signs frequently • Obtain chest x-ray, ABG • Restrain (physical/chemical)patient • Consider long term sedation

48. Questions?? Thank You!