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Rapid Sequence Intubation
Erik D. Barton, MD, MS, MBA University of Utah Affiliated Emergency
Medicine Residency Program
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The Decision to Intubate
Four Reasons for Intubation
• Establish, maintain or protect airway• Failure to ventilate• Failure to oxygenate• Anticipated clinical course
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Sagarin, Barton, et al, Ann Emer Med, 2005
First Provider Intubations
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Sagarin, Barton, et al, Ann Emer Med, 2005
Rescue Intubations
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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.
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Just like Skydiving….
Skydiving is lethal unless one deploys a parachute…
RSI is lethal unless you rescue the airway!
Rapid Sequence Intubation
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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
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Rapid Sequence Intubation
Definition Incorporates:
• Every patient has a full stomach• Preoxygenation• No interposed ventilations• Sellick’s maneuver
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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
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Rapid Sequence Intubation
The Six Ps of RSI
PreparationPreoxygenationPretreatmentParalysis with SedationProtectionPlacement
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Rapid Sequence Intubation
The Sequence
Zero:
the time of administration of succinylcholine.
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Rapid Sequence IntubationThe Sequence
Zero - 10 minutes
Preparation
• Assess airway difficulty (LEMON)• Plan approach• Assemble drugs and equipment• Establish access• Establish monitoring
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Rapid Sequence IntubationThe Difficult Airway Rule
L ook externallyE valuate 3-3-2M allampatiO bstruction?N eck mobility
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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
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Rapid Sequence IntubationTime to Desaturation
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Rapid Sequence Intubation
Zero - 3 minutes
Pretreatment• Lidocaine• Opioid• Atropine• Defasciculation
“LOAD the patient before intubation.”
The Sequence
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THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
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THE AIRWAY COURSE
National Emergency Airway Management Course
• L idocaine• O pioid• A tropine• D efasciculation
Give 3 minutes before SCh
PRETREATMENT AGENTS
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THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
1.5 mg/kg
• Increased intracranial pressure• Bronchospasm
LIDOCAINE
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THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
OPIOID
Fentanyl 3 g/kg
• Cardiovascular disease• Intracranial hypertension
Caution: sympathetic drive
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THE AIRWAY COURSE
National Emergency Airway Management Course
PRETREATMENT AGENTS
ATROPINE
0.01 mg/kg
• Children < 10 years who receive Sch
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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
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THE AIRWAY COURSE
National Emergency Airway Management Course
INDUCTION AGENTS
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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
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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
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THE AIRWAY COURSE
National Emergency Airway Management Course
INDUCTION AGENTS
FOR SPECIFIC CONDITIONS
Reactive airways ketamineICP etomidate, pentothalHypotensive ketamineOperator preference
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Rapid Sequence Intubation
Zero!!
Paralysis with sedation
• Induction agent IV push • Succinylcholine 1.5 mg/kg IVP
Entering the red zone...
The Sequence
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THE AIRWAY COURSE
National Emergency Airway Management Course
NEUROMUSCULAR BLOCKADE
Depolarizing • succinylcholine
Competitive (nondepolarizing)
• Aminosteroids• Benzylisoquinolines
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Rapid Sequence Intubation
Succinylcholine
• Still the ED NMB of choice• Rapid effect• Short duration• Generally well tolerated• A few important side effects
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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)
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THE AIRWAY COURSE
National Emergency Airway Management Course
NEUROMUSCULAR BLOCKADE
Aminosteroids Benzylisoquinolines
• atracurium• cisatracurium• mivacurium• metocurine • DTC
• rocuronium• pancuronium• vecuronium• rapacuronium
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THE AIRWAY COURSE
National Emergency Airway Management Course
NEUROMUSCULAR BLOCKADE
Summary
• SCh for RSI• Competitive for pre-treatment• Rocuronium for competitive RSI
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Rapid Sequence Intubation
Zero + 30 seconds
Protection
• Sellick’s Maneuver• Position patient• Do not bag unless S O < 90%p 2
The Sequence
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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
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Rapid Sequence Intubation
Failed Attempt
• Plan in advance• Systematic approach essential• Equipment• Training
…remember “Skydiving!!”
Rescue Maneuvers
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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
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How do we know that RSI really works?
Rapid Sequence Intubation
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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.
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6294 ED Intubations from the second report of the ongoing National Emergency Airway
Registry Study (NEAR II)
NEAR
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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
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Personnel Performing ED Intubations
Emergency MedicineInternal Med.OtherSurgeryPeds EM??Critical CarePedsFPEMT
6294 Intubations from the National Emergency Airway Registry
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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
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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
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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
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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%
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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.
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• 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)
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• 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)
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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)
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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
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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
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Emergency medicine…
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…the specialty that…
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…ALWAYS…
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…has customers!!
The End…