Rapid Sequence Intubation:drugs and concepts
Decision to Intubate
• Failure to maintain/protect airway• Failure to ventilate/oxygenate• Condition present or therapy required that mandates
intubation
Once you have decided that the patient requires tracheal integration the primary goal is to secure the airway quickly and as
safely as possible to assure adequate oxygenation and ventilation
Rapid Sequence Intubation
Definition
The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness
and motor paralysis for tracheal intubation.
Rapid Sequence Intubation
Definition
The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness
and motor paralysis for tracheal intubation.
Rapid Sequence Intubation
Definition
The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness
and motor paralysis for tracheal intubation.
Rapid Sequence Intubation
Definition
The virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness
and motor paralysis for tracheal intubation.
Rapid Sequence Intubation
Definition Assumes:
• Patient has a full stomach• No interposed ventilation• Preoxygenation
Rapid Sequence Intubation
The Seven Ps of RSIPreparation
Preoxygenation
Pretreatment
Paralysis with induction
Protection
Placement
Post-Intubation Management
Rapid Sequence Intubation
The Sequence
Zero: the time of administration of
paralytic
Rapid Sequence IntubationThe Sequence
Zero - 10 minutes
Preparation
• Plan your approach ahead of time!!• Assemble drugs and equipment• Establish access, monitoring• CHECKLIST!!
PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
Rapid Sequence Intubation
Zero - 5 minutes
Preoxygenation• De-Nitrogenate patient’s lungs- 8 VC BREATHS or 3 minutes
• Provides essential apnea time• Apnea time varies • NO DESAT- 15L nasal cannula• 15L NRB• If sats <95% -> BVM with 15cmH20 PEEP
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
Rapid Sequence Intubation
Zero - 5 minutes
Preoxygenation• De-Nitrogenate patient’s lungs• Provides essential apnea time• Apnea time varies • NO DESAT-maintain airway open/HOB 30°• 15L nasal cannula• 15L NRB• If sats <95% -> BVM with 15cmH20 CPAP/PEEP
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
“Rule of 15s”
Rapid Sequence Intubation
Zero - 5 minutes
Preoxygenation• De-Nitrogenate patient’s lungs• Provides essential apnea time• Apnea time varies • NO DESAT• 15L nasal cannula• 15L NRB• If sats <95% -> BVM/PEEPval/CPAP @ 15cmH20
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
Rule of 15s
DSI: Delayed Sequence Intubation
The Basics:
“A procedural sedation, where the procedure is
pre-oxygenation”
* From EMCrit.org
Ph kills
• Pseudo- NIV with vent (not biPAP)- RR0• Give RSI meds• Give breaths (RR12) during apnea time for 1
minute –slow,controlled breaths with jaw thrust• Intubate, set vent to RR 30
Rapid Sequence Intubation
Zero - 3 minutes
Pretreatment• Fentanyl 5 mcg/kg• for high ICP/Vascular with elevated BP
• Scopolamine 0.4 mg• for amnesia in hypotensive patient intubation
•INOPRESSOR /IVFS- PDPS/Norepi gtt
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
Rapid Sequence Intubation
Zero!!
Paralysis with induction
• Induction agent• Ketamine 2 mg/kg• Etomidate 0.3 mg/kg• Propofol 1.5-3 mg/kg
• Paralytic agent• Rocuronium 1.2 mg/kg• Succinylcholine 1.5-2.0 mg/kg
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
Ketamine
Ketamine• Dissociative sedative and analgesic
• Dissociates the CNS from outside stimuli by “disconnecting” thalamocortical and limbic systems
• Produces trancelike cataleptic state
• Maintain protective airway reflexes• Very rapid onset - first pass effect• low dose gives analgesia 0.2 mg/kg• Moderate dose give analgesia and anxiolysis 0.5 mg/kg IV• High Doses give amnesia and disassociation IV dose 1.5-
2 mg/kg IV)
Ketamine- Cautions• Central adrenergic release, premedication with depressants (benzos) or
fentanyl will probably blunt this response.• MAP increased ~25 mmHg• Probably has neuroprotective effect by NDMA antagonism, so no issues
with elevated ICP patients-stroke and head injury• True laryngospasm is exceedingly rare, probably just tongue obstruction.
Inevitably resolves with airway positioning.• The intraocular pressure increase has only been reported in animals• Avoid in hyperthyroid states due to catecholamine release
Etomidate• ultra–short-acting nonbarbiturate hypnotic• No analgesic effect• Dose: 0.2-0.3 mg/kg IV
– Onset: > 1min– Duration: 3-5 mins
Etomidate
• it causes adrenal suppression which may be linked to increased mortality in septic patients (though many argue that etomidate is safe)
• it is unreliable as an induction agent in reduced doses (even in shocked patients)
• Good hemodynamic profile
Propofol
• potent, ultra–short-acting sedation and anesthesia• It is a phenolic compound, and its mechanism of
action is unknown, but it is thought to mediate GABA activity
• Propofol has no analgesic properties• It is associated with rapid deepening of a
sedation level to that of general anesthesia
Propofol
• Dose 0.5-1 mg/kg IV loading dose ; repeat 0.5 mg/kg q3-5 mins until desired depth of sedation
• Onset: < 1 min• Duration 3-10 mins
Adverse effects
• Hypoventilation/apnea- preO2!!, ETCO2!!• Cardiovascular collapse/hypotension
– Exacerbated in patients who are volume depleted• Give IVFs up front
Ketofol• Best of both worlds !
Deep sedation of propofol (HR BP)
+Dissociation, analgesia, maintenance of airway reflexes
and sympathomimetic effects of ketamine
= Hemodynamically balanced sedation agent
TBW
IBW
IBW
TBW
TBW
Rapid Sequence Intubation
Zero + 30 seconds
Protection
• Position patient- ear to sternal notch, face parallel
• Do not bag unless SpO2 < 90%
The SequencePreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
Rapid Sequence Intubation
Zero + 45 seconds
Placement
The Sequence
• Intubate, remove stylet• Confirm tube placement - ETCO2
PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
Rapid Sequence Intubation
Zero + 90 seconds
Post-intubation Management
The Sequence
• Secure tube• Fentanyl push then drip OR• Dilaudid pushes• Sedation if necessary- propofol, ketamine or midazolam• Establish ventilator parameters
PreparationPreoxygenationPretreatmentParalysisProtectionPlacementPost-Intubation
NEUROMUSCULAR BLOCKING AGENTS
NEUROMUSCULAR BLOCKING AGENTS
• Depolarizing - succinylcholine • Competitive (nondepolarizing)
• eg rocuronium, vecuronium
•Succinylcholine is a universally safe drug.
•No-one is too sick to get succinylcholine………
Succinylcholine has one very, very lethal side effect…
Fatal Hyperkalemia
SuccinylcholineHyperkalemia
• Motor endplate proliferation burns, crush injuries stroke spinal cord injury MS, ALS, other denervations
• Myopathies Muscular dystrophy
Mortality 11%
Mortality 30%
Does Sux SUCK ?
or
Does Roc ROCK?
Sux vs Roc• Succinylcholine
– Used in 82% ED RSI– Faster onset to ETI
conditions?– Onset = 60 sec– Duration = 3-15 min– Benefit:Stat
epilepticus;ICH/stroke evals
– Adverse effects• K- do we know pts at risk?• rhabdo• ICP and IOP• Masseter spasm• Malignant hyperthermia
• Rocuronium– Onset = 45-60 sec (at 1.2
mg/kg)– Duration 30-90 min– Longer duration of safe apnea
vs. sux (preox!)– Reversal in 2mins with
Suggamadex?– Adverse effects
• None• Prolonged paralysis?• What if I can’t intubate?• What if I can’t ventilate?
Rapid Sequence Intubation
The Seven Ps of RSI
PreparationPreoxygenationPretreatmentParalysis with inductionProtectionPlacementPost-Intubation Management
Summary
Review…….
•Plan Ahead•Use checklist
Denitrogenate
Preoxygenate
Apneic oxygenation
pretreat
Dose smart
QUESTIONS??
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