Emergency RSI

Emergency Rapid Sequence Intubation:

A “How and When To” Guide

Pat Melanson, MD, FRCPCDepartment of Emergency

MedicineDivision of Critical Care Medicine

Royal Victoria Hospital

Emergency RSI

Rapid Sequence Intubation :Definition

• The near simultaneous administration of a sedative-hypnotic agent and a neuromuscular blocker in the presence of continuous cricoid pressure to facilitate endotracheal intubation and minimize risk of aspiration

• modifications are made depending upon the clinical scenario

Emergency RSI

A Brief History of Emergency RSI intubation of the newly/nearly dead

(prehistoric) techniques adapted from anesthetists in Case

Room and “crash” full-stomach induction's (exploration)

rapid dissemination of RSI teaching to emergency physicians (proselytism)

evidence-based research supporting safety and advantages of emergency RSI (enlightenment)

increasingly sophisticated techniques and methodology critically evaluated (postmodern)

Emergency RSI

Intubation Dilemmas:

• Intubate Awake or Asleep• Oral or Nasal• Laryngoscopy or Blind Intubation• To Paralyze or Not

Emergency RSI

Oral Intubation Without Drugs

• Reserved for the completely unconscious, unresponsive, pulseless and apneic

• Arrest situations only• The “ CRASH AIRWAY”

Emergency RSI

Oral Intubation with Sedation

• proponents argue use of BZ or opioids

–improves airway access

–decreases patient resistance

–avoids risks of NMB• Generally obtunds patient to point of loss of

protective reflexes and respiratory drive• lower success rate, higher complications

compared with RSI

Emergency RSI

Oral Intubation with Sedation

• “ In general, the technique of administering a potent sedative agent to obtund the patient’s responses and permit intubation in the absence of NMB is hazardous and to be discouraged… is not an appropriate alternative to properly conducted RSI and affords neither the success rate or the minimal complication rate of RSI.”

– RM Walls, page 4, Chapter 1, Rosen

Emergency RSI

Oral Intubation with Sedation

“ The avoidance of NMB actually creates a more hazardous situation for the patient and this practice should no longer be considered an appropriate method for emergency department ET intubation.”

RM Walls, page 8, Chapter 1, Rosen

Emergency RSI

Oral Intubation with Sedation:Use for the Anticipated Difficult Airway

• if time permits

–topical anesthesia

–careful titrated sedation

–avoid obtundation• ‘Awake” intubation technique

Emergency RSI

Blind Nasal Intubation

• success rates 65 - 80 % in most series• high complication rates

–epistaxis

–pharyngeal/ esophageal perforations

–increased incidence of O2 desats• Considered second line approach only• reserved for when RSI contraindicated• The “ DIFFICULT AIRWAY”

Emergency RSI

Approach to Airway Management: Algorithms

Is intubation indicated ?Is this a Crash Airway situation ?Is this a potentially Difficult Airway?

Difficult laryngoscopy ?Difficult Bag -Mask Ventilation?

Is RSI appropriate ?Is this a Failed Airway?

Emergency RSI

Emergency Airway Concerns

• “full” stomach• minimal respiratory reserve• hemodynamic instability• acute myocardial ischemia• increased intracranial pressure• C-spine injury• The “Difficult” Airway

Laryngoscopy bag-mask difficulty

Emergency RSI

Advantages of RSI facilitates and expedites endotracheal

intubation increased success rate decreased time to intubation

minimizes trauma during laryngoscopy minimizes hypoxia and hypercapnia minimizes risk of aspiration minimizes hemodynamic effects of

intubation

Emergency RSI

Disadvantages of RSI operator assumes complete

responsibility for oxygenation, ventilation and airway patency

irreversible commitment (burnt bridges)

adverse effects of medications ?? increases surgical airway rate

no evidence

Emergency RSI

Rapid Sequence Intubation: Principles

• Emergency intubation is indicated• The patient has a “full” stomach• Intubation is predicted to be successful• If intubation fails, ventilation is predicted

to be successful• Consists of a series of planned discrete

steps

Emergency RSI

Principles of RSI Competing demands:

Minimizing risk of aspiration vs. risk of hypoxia Preoxygenation:

ideally avoid BMV-PPV to minimize aspiration adequate N2 washout (5 min 100% O2 ) gives

oxygen reservoir providing several minutes of O2 supply despite apnea

4 assisted PPV breaths prior to paralysis pulse oximetry essential ANTICIPATE the O2 trend!

Emergency RSI

Principles of RSI (cont) Minimizing gastric distention

avoidance of BMV-PPV cricoid pressure

–caudal to thyroid cartilage–complete ring esophageal occlusion– release if vomiting occurs–maintain until ETT position confirmed

minimize peak pressures if BMV-PPV immediate ID of esophageal intubation

Emergency RSI

Typical Emergency RSI: Time Course

time 0:00

2:002:15

3:003:20

5:00

100% O2, iv access, monitor, oximetry assemble equipment, meds and team thiopental 3mg/kg iv succinylcholine 1.5mg/kg iv cricoid pressure with LOC; no bagging laryngoscopy after fasciculations tube position confirmed and secured positive pressure ventilation begins To CT/lavage/OR/etc. O2 sat 100% throughout

Emergency RSI

Drugs used for RSI: Overview

Essential:ParalyticSedative/ Induction agent

Optional:DefasciculantModulators of

hemodynamics/ICP/etc.

Emergency RSI

Emergency RSI: Selecting the PatientIs RSI contraindicated?

Absolute: Cardiopulmonary arrest

present/imminent Operator inexperience

Relative: Anticipated technical difficulties with

laryngoscopy and/or intubation Anticipated difficulty with BVM

Emergency RSI

Emergency RSI: Selecting the Paralytic

Neuromuscular blocking agents

Depolarizing:Succinylcholine

Non-depolarizing:VecuroniumRocuronium

Emergency RSI

Emergency RSI: Selecting the Paralytic

Is succinylcholine contraindicated? NO: choose succinylcholine YES: choose rocuronium (or vecuronium)

If using SUX, is atropine needed?atropine 0.02mg/kg (.15mg-.5mg) 2min before

If using SUX, is a defasciculant desired?

10% dose of non-depolarizing agent 2 min prior

Emergency RSI

Succinylcholine ( Anectine) dose: 1.5 mg/kg onset : 45 - 60 seconds duration : 6 to 10 min (3 to 15) disadvantages :

ACh analog - bradycardia fasciculations hyperkalemia ( K+ release) malignant hyperthermia

Emergency RSI

Succinylcholine : Contraindications

• Hyperkalemia - renal failure• Active neuromuscular disease with

functional denervation

• ( 6 days to 6 months)• Extensive burns, crush injuries• Malignant hyperthermia• Pseudocholinesterase deficiency• Organophosphate poisoning

Emergency RSI

Succinylcholine : Complications

• Inability to secure airway• Increased vagal tone ( second dose )• Histamine release ( rare )• Increased ICP/ IOP/ gastric pressure• Myalgias• Hyperkalemia with burns, NM disease• Malignant hyperthermia

Emergency RSI

Vecuronium ( Norcuron )

• dose : 0.1 - 0.2 mg/kg• action : 120 secs to 60 minutes• “prime” with 1/10 dose 2 min prior

• onset in 90 secs• advantages :

• non-depolarizing• neutral hemodynamics• hepatic clearance

Emergency RSI

Rocuronium ( Zemuron )

• dose : 0.6 - 1.2 mg/kg• onset : 60 -90 secs• advantages :

• almost as rapid as SUX• disadvantages

• less rapid in elderly• long duration

Emergency RSI

Emergency RSI: Selecting the Sedative

Thiopental

Ketamine

MidazolamPropofol

Etomidate(nothing)

????

??

??

Emergency RSI

Thiopental ( Pentothal ) dose : 1- 5 mg/kg action : 20 sec to 5 minutes advantages

ultrafast, short duration neuroprotective, anticonvulsant familiar

disadvantages hypotension ( myocardial depression, vd) ultrashort duration ( 3 - 5 minutes ) demyelination in porphyria chemical endarteritis, thrombosis

Emergency RSI

Midazolam ( Versed ) dose : 0.1 - 0.4 mg/kg action : 2 min to 120 minutes advantages:

wide therapeutic index amnesia

disadvantages variable dose response slower onset suboptimal effect at lower doses negative inotrope, vasodilation

Emergency RSI

Ketamine ( Ketalar ) dose : 1 - 2 mg/kg action : 30 secs to 15 minutes advantages :

bronchodilation supports BP

disadvantages : increases ICP and IOP salivation emergence reactions

Emergency RSI

Propofol ( Diprivan ) dose : 0.5 - 2.5 mg/kg (20-40mg q10 s) action : 20 sec to 5 minutes advantages :

ultrarapid neuroprotective

disadvantages hypotension, bradycardia ultrashort duration

Emergency RSI

Etomidate ( Amidate ) dose ; 0.3 mg/kg action : 1 minute to 10 minutes advantages :

hemodynamically neutral neuroprotective

disadvantages : unfamiliar vomiting cortisol suppression

Emergency RSI

Emergency RSI: Selecting the Sedative

Identify Primary Concern:

Hemodynamics: fentanyl, ketamine, etomidate

Neuroprotection: thiopental, propofol (midazolam)

Bronchodilation: ketamine Speed: thiopental, propofol

(ketamine)

Emergency RSI

Emergency RSI: Selecting the Sedative

Identify any Secondary Concerns:

Hemodynamics: beware thiopental, propofol (midazolam)

Neuroprotection: avoid ketamine (??) Speed: beware midazolam Patient given naloxone: avoid fentanyl Specific contraindications (e.g. porphyria):

avoid drug

Emergency RSI

The “Intubation Reflex “

• Catecholamine release in response to laryngeal manipulation

• Tachycardia, hypertension, raised ICP• Attenuated by beta-blockers, fentanyl• ICP rise possibly attenuated by lidocaine• Midazolam and thiopental have no effect

Emergency RSI

Emergency RSI: Selecting optional medications

Increased ICP: Lidocaine Bronchospasm : Lidocaine Tachycardia harmful: fentanyl

(esmolol) 3 min before atropine if child receiving Sux defasciculant “priming” dose of neuromuscular

blocking agent topical/regional anesthetics

Emergency RSI

Emergency RSI Checklist: Flight planning

Move patient to resuscitation suite Assemble personnel 100% O2 Patient too unstable for RSI => intubate ASAP Inadequate ventilation/sat <90% => BMV Select drugs and doses, delegate “Drug Nurse” Cardiac monitor, BP cuff, O2 sat continuously IV running in limb contralateral to BP cuff Cleared to taxi

Emergency RSI

Emergency RSI Checklist: Taxiing

C-Spine? OK: pillow/folded sheet under head?: designate assistant in-line stabilization

Check ETT and lubricate (+/- stylet) Check laryngoscope (and other airway device prn) Yankauer suction on and under mattress (to right) Final neuro assessment (AVPU, posturing, pupils) Baseline HR, BP, O2 sat Review drugs, doses and sequence with Drug Nurse Cleared for take-off

Emergency RSI

Emergency RSI Checklist: Take-off

0:003:00

3:15

4:00

4:30

5:00-15:00

administer optional drugs administer sedative administer paralytic cricoid pressure with loss of ciliary reflex BMV if hypercapnia deleterious/sat <90% laryngoscopy once fully relaxed BURP to visualize larynx Confirm ETT placement and secure Ventilator settings Treat fluctuations in VS as indicated CXR

time (mm:ss)

Emergency RSI

Rapid Sequence Intubation :Procedure

• Pre-intubation assessment• Pre-oxygenate• Prepare• Premedicate• Paralyze with Induction• Pressure on cricoid• Place the tube• Post intubation assessment

Emergency RSI

Pre-oxygenate ( Time - 5 Minutes)

• 100 % oxygen for 5 minutes• 4 conscious deep breaths of 100 % O2• Fill FRC with reservoir of 100 % O2• Allows 3 to 5 minutes of apnea• Essential to allow avoidance of bagging• If necessary bag with cricoid pressure

Emergency RSI

Preparation ( Time - 5 Minutes )

• ETT, stylet, blades, suction, BVM• Cardiac monitor, pulse oximeter, ETCO2• One ( preferably two ) iv lines• Drugs• Difficult airway kit including cric kit• Patient positioning

Emergency RSI

Pre-treatment/ Prime ( Time - 2 Minutes )

• Lidocaine 1.5 mg/kg iv• Defasciculating dose of non-

depolarizing NMB• Fentanyl 3- 5 mcg/kg• Atropine 0.02 mg/kg• ( The above agents are optional and given if there is a

specific indication and time permits)

Emergency RSI

Induction agent

–Thiopental 3 - 5 mg/kg

–Midazolam 0.1 - 0.4mg/kg

–Ketamine 1.5 - 2.0 mg/kg

–Propafol 0.5 - 2.0 mg/kg

–Etomidate 0.2 - 0.3 mg/kg

Emergency RSI

Paralyze ( Time Zero )• Succinylcholine 1.5 mg/kg iv• Allow 45 - 60 seconds for complete

muscle relaxation• Alternatives

–Vecuromium 0.1 - 0.2 mg/kg

–Rocuronium 0.6 - 1.2 mg/kg

Emergency RSI

Pressure

• Sellick maneuver• initiate upon loss of

consciousness• continue until ETT balloon

inflation• release if active vomiting

Emergency RSI

Place the Tube ( Time Zero + 45 Secs )

• Wait for optimal paralysis

• Confirm tube placement with ETCO2

Emergency RSI

Post-intubation Hypotension

• Loss of sympathetic drive• Myocardial infarction• Tension pneumothorax• Auto-peep

Emergency RSI

Difficult Airway Kit

• Multiple blades and ETTs• ETT guides ( stylets, bougé, light wand)• Emergency nonsurgical ventilation

( LMA, Combitube, TTJV )• Emergency surgical airway access

( cricothyroidotomy kit, cricotomes ) • ETT placement verification• Fiberoptic and retrograde intubation

Emergency RSI

Amitriptyline tripper

27 year old overdose benzos + TCAs 1 hour PTA.

Decreasing LOC (?ciliary reflex). HR 140 wide-complex regular, BP 90/50, RR 24,

O2 sat 99% on O2.

Emergency RSI

Walking at the scene

22 yr old multiple abdominal stab wounds 6” knife.

Evisceration, agitation and uncooperative.

HR 140, BP 90/50, RR 22, O2 sat 99% on O2.

Emergency RSI

Status asthmaticus severus

50 yr old asthmatic x years, never admitted O/N. SOB x 2d despite prednisone, antibiotics, and salbutamol q1h. Despite continuous salbutamol, epi s/c x 2, and SoluMedrol iv, begins to fatigue.

pH 7.22, pCO2 70, pO2 140.

Emergency RSI

Collapse at bank

38 year old male, standing in line at bank, complained of sudden severe HA and collapsed.

On arrival, HR 55 BP 170/100 RR 12 decorticate posturing.

Emergency RSI

NOT renal colic

68 year old male, hypertensive, no past history of urolithiasis, presents with R flank pain and hematuria. While you are booking the spiral CT, he complains of increasing back pain, then vomits. HR 140 BP 85/palp diaphoretic ++.

And then he gets worse.

Emergency RSI

Overdue for dialysis

68 yr old hemodialysis-dependent pt in florid pulmonary edema and decreasing LOC.

HR 120 reg, BP 220/120, O2 sat 85% on non-rebreather

15L/min.

Emergency RSI

Too much Nintendo

14 year old known epileptic on multiple meds, still seizing after diazepam, phenobarb and over 30 minutes in the ED.

160 100/50 37.2 99% sat. Small jaw.

Emergency RSI

“ I would especially commend the physician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.”

Hippocrates