Rapid Sequence ion

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Rapid Sequence Intubation

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RSI Definition

The administration of a potent inductionagent followed immediately by a rapid actingneuromuscular blocker (NMB) to renderunconsciousness and motor paralysis fortracheal intubation

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Indications for Tracheal Intubation

failure to maintainairway failure of airway protection

Failure of ventilation or oxygenation Anticipated airway obstruction or special

situations

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RSI Contraindications

Tracheal / laryngeal injury / disruption S/P Laryngectomy

Massive facial trauma Anticipated difficult airway

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RSIThe 7 Ps

Preparation Preoxygenation

Pretreatment Paralysis with induction Protection with positioning Placement with proof Post-intubation management

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RSI Timeline

Time ActionZero - 10 min PreparationZero - 5 min PreoxygenationZero - 3 min PretreatmentZero Paralysis with inductionZero + 20-30 sec Protection with positioningZero + 45-60 sec Placement with proof Zero + 60-90 sec Post-intubation management

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Preparation

Patient airway assessment, IV access Positioning

Equipment Airway, monitoring, failed airway Blade type and size, ETT size

placement confirmation device Cuff integrity and stylet, laryngoscope functioning

Personnel

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Airway Assessment (LEMON)

Look externally Evaluate 3-3-2

Mallampati or Obstruction Neck

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Look Externally

Morbid obesity Abnormalities of the face

Facial or neck trauma Protruding tongue Receding mandible Facial hair

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Evaluate(3-3-2 Rule)

3 finger breadths between upper lower teeth(mouth opening)

3 finger breadths between tip of the chin andhyoid bone

2 finger breadths between thyroid cartilage andfloor of the mouth

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Mallampati Classification

I Tonsillar pillars and fauces visibleII Upper portion of pillars and uvula visibleIII Base of uvula / soft palate visibleIV Only tongue and hard palate visible

Patients mouth open, tongue sticking out

Correlates with laryngoscopy classification, but notas sensitive in grades 3 and 4

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Mallampati classification for grading airways

Class I visualization of the soft palate, fauces, uvula, and anterior andposterior pillars;class II visualization of the soft palate, fauces, and uvula;class III visualization of the soft palate and the base of the uvula; andclass IV soft palate is not visible at all.www.chestjournal.org CHEST


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Laryngoscopic Classification Grade I Entire glottis visible Grade II Arytenoid cartilage and

posterior glottis visible Grade III Epiglottis only visible Grade IV Tongue or soft palate visible

Grade III and IV are considered difficultintubations (about 5% of OR cases)

Visualization predicts intubation success

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Obstruction

Angioedema Epiglottis

Foreign bodies tonsil Airway Trauma Tumor

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Neck

Possible cervical spine injury Preexisting disease

Rheumatoid arthritis Ankylosing spondylitis

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ETT Size and Depth

Size Females 7.5-8; Males 8-8.5 Broslow tape, little finger diameter 4 + age/4

Depth Females - 21 cm; Males - 23 cm Broslow tape, markings on ETT ETT size x 3 (cm); age + 10

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Preoxygenation

Establish an O2 reservoir in the lungs & body Essential to no bagging principle of RSI Function residual capacity is primary reservoir Permits several minutes of apnea without

desaturation 100% O2 via nonrebreather for 5 minutes

OR8 VC breaths with 100% O2 via bag/mask

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Pretreatment (LOAD) Mitigate adverse effects of laryngoscopy Lidocaine 1.5 mg/kg

Airway bronchospasm / cough reflex Increased ICP

Opiates (Fentanyl 3-6 mcg/kg) Increased ICP, aortic dissection, ruptured aortic or

IC aneurysm, ischemic heart disease Blunts reflex sympathetic response to

laryngoscopy Not recommended under age 1

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Pretreatment (LOAD)

Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg) Children


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Paralysis with Induction

Rapid IV administration of sedation followedimmediately by rapid administration of aneuromuscular blocking agent

Iv induction agent (etomidate, propofol,thiopentone or ketamine)

Iv suxamethonium (immediately afterinduction agent)

Fluid bolus

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Protection and Positioning

Sellicks maneuver Cricoid pressure Maintain until placement confirmation and cuff

inflation Positioning

Patient in supine position

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Placement with Proof

Test for jaw flaccidity Extend head on neck Gentle controlled technique Blade entry on right, sweep tongue to left Lift handle up and away Suction prn Insert into esophagus, then slowly withdraw Visualize vocal cords Watch ETT pass through vocal cords Check ETT depth Never let go of the tube! Inflate cuff Auscultation

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Placement with Proof

Confirm tracheal placement Direct visualization plus either EtCO2 detector or Esophageal detector

Preferred in cardiopulmonary arrest

Confirm depth (cords > bronchus) Auscultation CXR

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Post-Intubation Management

Secure ETT Reassess VS PCXR for depth of placement

Bradycardia / Hypoxia -> Nontracheal tubeplacement until proven otherwise

Hypertension->inadequate sedation/analgesia Hypotension

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Post-intubation Management(Hypotension)

Tension PTX High PIP, hard to bag, decreased BS, hypoxia Immediate thoracostomy

Decreased venous return High PIPs 2ndary to high intrathoracic pressure Fluids, bronchodilators, Increase expiratory time, decrease TV

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Post-intubation Management(Hypotension)

Induction agent Other causes excluded Fluid bolus, consider reversal agent, expectant

Cardiogenic Usually a compromised pt Check EKG, exclude other causes Fluid bolus (caution), pressors

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Medications

Pretreatment drugs (LOAD) Lidocaine Opiates Atropine Defasiculation

Sedation Paralysis

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Sedation

Midazolam Etomidate

Methohexital / Thiopental Ketamine Propofol

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Neuromuscular Blocking Agents Noncompetitive depolarizer

Succinylcholine (Anectine) Competitive nondepolarizer

Benzylisoquinolinium group Atracurium (Tracrium), cisatracurium (Nimbex),

mivacurium (Mivacron)

Aminosteroid group Pancuronium (Pavulon), vecuronium (Norcuron),

rocuronium (Zemuron)

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Succinylcholine (SCh) (Anectine)

Rapid onset (45 seconds) and short durationof action (


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SCh Adverse Effects

Malignant hyperthermia Masseter spasm Hyperkalemia Increased ICP / Increased IOP

Fasciculations Bradycardia (peds) Prolonged NMB Hypotension (histamine release, (-) inotrope)

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SCh Contraindications Personal or FH of malignant hyperthermia

Known or suspected hyperkalemia

> 24 hours post-burn (>10% BSA, 1-2 yrs) > 1 week post crush injury (60-90 days) > 1 week post SCI or CVA (6 months)

Neuromuscular disease (indefinite) MS, ALS, muscular dystrophy

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Competitive, Nondepolarizing NMB

Most commonly utilized post-intubation No CIs other than the difficult airway Disadvantage is longer onset and duration Metabolism variable Higher dose reduces time to paralysis but

prolongs time to recovery

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Aminosteroid group dose not cause histaminerelease

Reversible with AChesterase inhibitor Requires 40% spontaneous recovery

Consider administering sedation shortly afteradministering vecuronium or pancuronium forRSI

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Rapacurium off the market Rocuronium (0.6-1.2 mg/kg) Mivacurium (0.15 mg/kg) Vecuronium (0.3 mg/kg) Pancuronium (0.1 mg/kg)

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Rapid Sequence ion

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