rsi sheet-2007

12/15/2007

1

Rapid Sequence Intubation (RSI)

in Emergency Room

Siriporn Pitimana-aree, MD

Dept. of Anesthesiology,

Faculty of Medicine Siriraj hospital.(The Royal College of Anesthesiologists of Thailand)

RSI in Emergency Department

• Indications for intubation• Considerations in Emergency intubation• Rapid Sequence Intubation (RSI) • The Failed Airway• Defining the Difficult Airway• Rescue Devices

Outline

Indications for ETT intubation

• Absent or inadequate respiration

• Impending airway obstruction

• Inability to protect airway

Emergency ETT intubation:

• Time pressure

• Unstable patient

• Possibly difficult situation

• Uncooperative / combative

• Not fasted• Difficult airway

Considerations

• Physiologic responses


Physiologic responses to intubation

•Gagging•Rise in ICP•Rise in BP•Tachycardia / Bradycardia•Dysrhythmias

• Incidence of difficult & failed intubation: 8%

• Frequency of esophageal intubation: 8% 40% of these - difficult intubation

almost all recognized by clinical criteria

but 3, decrease saturation detected by SpO2

• Incidence of pulmonary aspiration: 4%

• Hemodynamic consequences: 3% died during or within 30 min. of intubation

12/15/2007

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Definition

The virtually simultaneous administration of a potent sedative agent

& a neuromuscular blocking agent to induce unconsciousness

& motor paralysis for tracheal intubation.


Definition Incorporates:

• Every patient has a full stomach• Preoxygenation• No interposed ventilations• Sellick’s maneuver


Advantages of RSI

•Minimizes risk of aspiration•Facilitate intubation•Blunt untoward physiologic responses•Avoid awake intubation


Contraindications:

Anticipate of difficult airway& intubation

Staff inexperienced in RSI

Patients allergic or contraindication todrugs used in RSI


The Six Ps of RSI

Preparation

Preoxygenation

Paralysis with Sedation

Protection

Placement

Postintubation care

Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI)

………..Zero

The Sequence

the time of administration of Succinylcholine.

Preparation

Preoxygenation

10 min

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…10 minutes ---- Zero

Preparation

• Assess airway difficulty (LEMON)• Plan approach• Assemble drugs and equipments• Establish access• Establish monitoring


The Sequence


…5 minutes ---- ZeroThe Sequence

Preoxygenation

• 100% oxygen for five minutes• 8 vital capacity breaths• Provides essential apnea time• Apnea time varies


Zero!!

• Sedative / Induction agent IV push• Succinylcholine 1.5 mg/kg IV push

Entering the red zone...

The Sequence

Paralysis with Sedation


• Sellick’s Maneuver• Position patient• Do not bag unless SpO2 < 90%

Protection

…Zero + 30 secondsThe Sequence

Optimal ExternalLaryngeal Manipulation (Backwards, Upwards, Rightwards Position (BURP)

Sellick’s maneuver(Cricoid pressure)

12/15/2007

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“ Sniffing position ”

• Check mandible for flaccidity• Intubate, remove stylet• Confirm tube placement – EtCO2

• Release Sellick’s maneuver


…Zero + 60 secondsThe Sequence

Placement

ETCO2

Auscultation

Self inflating bulb

Trachlight

Experinced Inexperinced

100%

87%

100%

100%

84%

96% 98%

68%

Postintubation care


The Sequence

•Ongoing sedation and/or paralysis•Mechanical ventilation (if needed)•Further investigations (CXR, ABG)•Postintubation hypotension

What do you do?If you can not intubateafter RSI?

“Failed intubation”

• The first rescue from failed intubation is bagging.

• The first rescue from failed bagging is better bagging.

• Rescue devices

Rescue Maneuvers


“Failed intubation”

12/15/2007

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The “Failed” Airway

• Multiple Definitions…

– Number of failed attempts (e.g., three)

– Failure to ventilate with a BVM

– Failure to oxygenate

– Failure to visualize the larynx

Clinically, 2 types of “failed” airways:

1. Cannot intubate, but can oxygenate

2. Cannot intubate, and cannot

oxygenate

The “Failed” Airway

The DIFFICULT AIRWAY is something you PREDICT…

A FAILED AIRWAY is something you EXPERIENCE!!

The Difficult Airway

Identification of the Difficult Airway3 Key Attributes

• Difficult Bag/Mask Ventilation• Difficult Intubation

• Difficult Cricothyrotomy


Mask seal

ObesityAged (>55)

No teeth

Stiff lungs

Difficult Bag Mask Ventilation


Difficult Cricothyrotomy

Surgery scar

HematomaObesity

Radiation

Tumor


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Difficult Intubation

Identification of the Difficult Airway

• BMV as important as intubation• Mouth opening/access

• Neck extension at AOJ

• Neck flexion at CTJ• Mentum-Hyoid-Thyroid distance

• Presence/Risk of obstruction

Predicting of difficult airway

• A short bull neck• Prominent incisors• A receding chin• Limited mouth opening• Chin to hyoid distance

< 6 cm (3FB)• Potential C-spine injury • Facial deformity• Morbid obesity

Development of a consistent approach:

The LEMON law



© National Emergency Airway Management Course

L ook externallyE valuate 3-3-2

M allampati

O bstruction?N eck mobility

The LEMON law

© National Emergency Airway Management Course



L ook externally

- Difficult BMV (MOANS)- Difficult Cricothyrotomy (SHORT)

- Intubator Gestalt



E valuate 3-3-2

Or some other thyromental distance equivalent



12/15/2007

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M allampati O bstruction?





N eck mobility • Need a consistent approach• Awake techniques by default

• Need definition of and preplanned

approach to failed airway• No “one trick pony” approach

• Alternative devices

Management of the Difficult Airway


• Alternative/Rescue devices?– Supraglottic: LMA, Combitube

– Stylet, Gum elastic bougie; GEB

– Lighted stylets: Trachlight, Lightwand

– Fiberoptic devices: flexible, rigid, hand-held

– Surgical: open, transtracheal

Management of the Difficult Airway


12/15/2007

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L

M

A

I

n

s

e

r

t

i

o

nCombitube I n s e r t i o n

Needle

Cricothyrotomy


Team members & their roles

Time Airway doctor/nurse Doctor / Nurse

Preparation(drugs/equipments)

Assess airwayPlan approach

Preoxygenation

ETT placement

IV access

Assist with preparation& drugs admin.

Cricoid pressure

Nurse (Scribe)

Document All events

Assist withMonitor &preparation

Confirmation of ETT placement

The commonly used drugs

Emergency ETT intubation (RSI)

Drug

Induction agents:

Thiopental

Propofol

Etomidate

Ketamine

3-5

1-2

0.2-0.6

1-2

10-15

10-15

10-15

30-45

Hypotension/ Porphyria

Hypotension/Age< 2 yrs.

Adrenal insufficiency/

ICP / Head injury

Precaution/ContraindicationDose; mg/kgOnset(Sec)



Drug

Sedation/Analgesia:Midazolam

Fentanyl (mcg/kg)

Morphine

Pretreatment:Lidoocaine

0.1-0.3

1-2

0.1-0.2

1-1.5

60-90

30-45

10-15

3-5 min.

Long onset / no

Chest wall rigidity / no

Long onset / no

Bradycardia / no

Precaution/ContraindicationDose; mg/kgOnset(Sec)

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Drug

Muscle relaxants:

Succinylcholine

Rocuronium

1-2

0.6-0.9

60

45-60

N-M disease /

Severe burn, Hyperkalemia

Intra-ocular injury

Precaution/Contraindication

Dose (mg/kg)

Onset(sec)

Duration(min)

5-10

45-60



Drug

Emergency drugs:

Atropine

Adrenaline

Levophed

Metaraminol

0.02 Pediatric intubation

Standard resuscitation

cart in hand (emergency intubation)

ConsiderationsDose; mg/kg

Incrementaldose

to targetBP

• Emergency airway management is different

• Emergency Airway Algorithm necessity

• Prediction tools have limitations:• LEMON criteria cannot be universally applied• Consistent use will predict most of the difficult

The Emergency Difficult Airway Algorithm

Can’t intubate Seek HELP

? Can ventilate

Maintain Sellick’sReposition head

Use oral/nasal airway

Maintain oxygenationBy BVM

Reattempt intubationby rescue devices

Maintain oxygenationBy BVM

LMA / Combitube

Maintain oxygenationIntubation through

LMAAwait expert help

LMA / Combitube

CricothyrotomyJet ventilation

Ventilation effective

Unable to ventilate

Unable to ventilateEmergency

Airway Algorithm

“ True success is notin the learning,

But in it’s applicationto the mankind �

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rsi sheet-2007

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