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• Anticipated clinical course
Sagarin, Barton, et al, Ann Emer Med, 2005
First Provider Intubations
Sagarin, Barton, et al, Ann Emer Med, 2005
Rescue Intubations
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.
Just like Skydiving….
Skydiving is lethal unless one deploys a parachute…
RSI is lethal unless you rescue the airway!
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.
Rapid Sequence Intubation
Rapid Sequence Intubation
Definition Incorporates:
• Every patient has a full stomach• Preoxygenation• No interposed ventilations• Sellick’s maneuver
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
Rapid Sequence Intubation
The Six Ps of RSI
PreparationPreoxygenationPretreatmentParalysis with SedationProtectionPlacement
Rapid Sequence Intubation
The Sequence
Zero:
the time of administration of succinylcholine.
Rapid Sequence IntubationThe Sequence
Zero - 10 minutes
Preparation
• Assess airway difficulty (LEMON)• Plan approach• Assemble drugs and equipment• Establish access• Establish monitoring
Rapid Sequence IntubationThe Difficult Airway Rule
L ook externallyE valuate 3-3-2M allampatiO bstruction?N eck mobility
Rapid Sequence Intubation
Zero - 5 minutes
Preoxygenation
• 100% oxygen for five minutes• 8 vital capacity breaths• Provides essential apnea time• Apnea time varies
The Sequence
Rapid Sequence IntubationTime to Desaturation
Rapid Sequence Intubation
Zero - 3 minutes
Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation
“LOAD the patient before intubation.”
The Sequence
THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
THE AIRWAY COURSE
National Emergency Airway Management Course
• L idocaine• O pioid• A tropine• D efasciculation
Give 3 minutes before SCh
PRETREATMENT AGENTS
THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
1.5 mg/kg
• Increased intracranial pressure• Bronchospasm
LIDOCAINE
THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
OPIOID
Fentanyl 3 g/kg
• Cardiovascular disease• Intracranial hypertension
Caution: sympathetic drive
THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
ATROPINE
0.01 mg/kg
• Children < 10 years who receive Sch
THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
10% of the paralyzing dose:• Vecuronium (0.01 mg/kg)• Pancuronium (0.01 mg/kg)• Rocuronium (0.06 mg/kg)
• Intracranial hypertension
DEFASCICULATION
THE AIRWAY COURSE
National Emergency Airway Management Course
INDUCTION AGENTS
THE AIRWAY COURSE
National Emergency Airway Management 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
THE AIRWAY COURSE
National Emergency Airway Management Course
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
INDUCTION AGENTS
THE AIRWAY COURSE
National Emergency Airway Management Course
INDUCTION AGENTS
FOR SPECIFIC CONDITIONS
Reactive airways ketamineICP etomidate, pentothalHypotensive ketamineOperator preference
Rapid Sequence Intubation
Zero!!
Paralysis with sedation
• Induction agent IV push • Succinylcholine 1.5 mg/kg IVP
Entering the red zone...
The Sequence
THE AIRWAY COURSE
National Emergency Airway Management Course
NEUROMUSCULAR BLOCKADE
Depolarizing • succinylcholine
Competitive (nondepolarizing)
• Aminosteroids• Benzylisoquinolines
Rapid Sequence Intubation
Succinylcholine
• Still the ED NMB of choice• Rapid effect• Short duration• Generally well tolerated• A few important side effects
THE AIRWAY COURSE
National Emergency Airway Management 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)
THE AIRWAY COURSE
National Emergency Airway Management Course
NEUROMUSCULAR BLOCKADE
Aminosteroids Benzylisoquinolines
• atracurium• cisatracurium• mivacurium• metocurine • DTC
• rocuronium• pancuronium• vecuronium• rapacuronium
THE AIRWAY COURSE
National Emergency Airway Management Course
NEUROMUSCULAR BLOCKADE
Summary
• SCh for RSI• Competitive for pre-treatment• Rocuronium for competitive RSI
Rapid Sequence Intubation
Zero + 30 seconds
Protection
• Sellick’s Maneuver• Position patient• Do not bag unless S O < 90%p 2
The Sequence
Rapid Sequence Intubation
Zero + 45 seconds
Placement
The Sequence
• Check mandible for flaccidity• Intubate, remove stylet• Confirm tube placement - E CO• Release Sellick’s maneuver• Long acting agents/ventilator
t 2
Rapid Sequence Intubation
Failed Attempt
• Plan in advance• Systematic approach essential• Equipment• Training
…remember “Skydiving!!”
Rescue Maneuvers
Rapid Sequence Intubation
• The first rescue from failed intubation is bagging.
• The first rescue from failed bagging is better bagging.
• Rescue devices
Failed Attempt
Rescue Maneuvers
How do we know that RSI really works?
Rapid Sequence Intubation
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.
6294 ED Intubations from the second report of the ongoing National Emergency Airway
Registry Study (NEAR II)
NEAR
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.
6294 Intubations from the National Emergency Airway Registry
Personnel Performing ED Intubations
Emergency MedicineInternal Med.OtherSurgeryPeds EM??Critical CarePedsFPEMT
6294 Intubations from the National Emergency Airway Registry
Demographics of Cases:
Indication Cases Female Male Unknown
Trauma 1605 (22%) 349 (22%) 1059 (65%) 97 (3%)
Medical 4286 (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%)
6294 Intubations from the National Emergency Airway Registry
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 16Oral awake with topical 21 Unknown 5 TOTAL 6294
1st Course Success Rates:
Medical TraumaOral 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/AOther 50.0% 100%Surgical cricothyrotomy 60.0% 68.7%Unknown 50.0% N/ATOTAL 94.7% 96.2%
6294 Intubations from the National Emergency Airway Registry
6294 Intubations from the National Emergency Airway Registry
Success Rates by Intubator:
First pass OverallEM 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%
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.
• 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
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)
Air Medical Research Collaborative (AMTC)
Success Failure Total Success 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%)
Air Medical Research Collaborative (AMTC)
The Future:• Standardize the jargon• What is an intubation attempt?• Immediate vs. long-term complications
• Difficult airway assessments• Rapid and predictive• Universally applied
The “Science” of Airway Management
The “Science” of Airway Management
The Future:• Unbiased reporting systems• Large-scale data collection (web)• Standardized reporting tools• NEAR III and IV
• Data analysis• Trends and outcomes• New devices/technologies
Emergency medicine…
…the specialty that…
…ALWAYS…
…has customers!!
The End…