Rapid sequence intubation
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Transcript of Rapid sequence intubation
Paleerat Jariyakanjana, MDEmergency Physician
Naresuan University Hospital
Rapid Sequence Intubation
Decision to Intubate
1) Failure to maintain or protect the airway
2) failure of ventilation or oxygenation3) the patient’s anticipated clinical
course and likelihood of deterioration
Administration of a potent sedative (induction) agent and an NMBA without interposed assisted ventilation
positive-pressure ventilation
air to pass into the stomach
gastric distention
risk of regurgitation & aspiration
Requires preoxygenation phasepermits pharmacologic control of the
physiologic responses to laryngoscopy and intubation, mitigating potential adverse effects Increase ICP sympathetic discharge
Preparation
assessed for intubation difficultydetermining dosages and sequence
of drugs, tube size, and laryngoscope type, blade and size
continuous cardiac monitoring and pulse oximetry
≥1 good-quality IV linesRedundancy is always desirable in
case of equipment or IV access failure.
Preparation
Preoxygenation
100% oxygen for 3 minutes of normal, tidal volume breathing
normal, healthy adult establishes an adequate oxygen reservoir to permit 8 minutes of apnea before oxygen desaturation to less than 90% occurs
“no bagging”time is insufficient
8 vital capacity breaths using high-flow oxygen
Pretreatment
drugs are before administration of the succinylcholine & induction agent
mitigate the effects of laryngoscopy and intubation on the patient’s presenting or comorbid conditions
Intubation sympathetic discharge elevation of ICP reactive bronchospasm Bradycardia: children
Pretreatment
Paralysis with Induction
rapid IV pushimmediately followed by rapid
administration of intubating dose of NMBA
wait 45 s from the time the succinylcholine is given to allow sufficient paralysis to occur
Paralysis with Induction
Tintinalli's Emergency Medicine, 7e
Paralysis with Induction
Tintinalli's Emergency Medicine, 7e
Paralysis with Induction
Tintinalli's Emergency Medicine, 7e
Positioning
The patient should be positioned for intubation as consciousness is lost.
Sniffing position: head extension, neck flexion
Positioning
Sellick’s maneuver application of firm backward-directed pressure
over the cricoid cartilage minimize the risk of passive regurgitation and,
hence, aspirationafter administration of the induction
agent and NMBA BMV should not be initiated unless O2 sat ≤ 90%
Placement of Tube
assessed most easily by moving the mandible to test for absence of muscle tone
O2 sat is approaching 90%, the pt may be ventilated
When BMV is performed, Sellick’s maneuver is advisable
As soon as the ETT is placed, the cuff should be inflated and its position confirmed
Postintubation Management
CXRuse of long-acting NMBAs (e.g.,
pancuronium, vecuronium) toward optimal management using opioid analgesics and sedative agents to facilitate mechanical ventilation
ANY QUESTIONS?