The ABC of RSIThe ABC of RSI
Jason BoschinJason Boschin
Critical Care ParamedicCritical Care Paramedic
Advanced AirwayAdvanced Airway
Anatomic ConsiderationsAnatomic Considerations
Rapid Sequence inductionRapid Sequence induction
Neuromuscular BlockadeNeuromuscular Blockade
Induction AgentsInduction Agents
Intubation tricks & thoughtsIntubation tricks & thoughts
Indications for Definitive AirwayNeed for Airway ProtectionNeed for Airway Protection Need for VentilationNeed for Ventilation
UnconsciousUnconscious ApneaApnea
Neuromuscular ParalysisNeuromuscular Paralysis
UnconsciousUnconscious
Severe Maxillofacial fx’sSevere Maxillofacial fx’s Inadequate Respiratory Effort’Inadequate Respiratory Effort’
TachypnealTachypneal
HypoxiaHypoxia
HypercarbiaHypercarbia
CyanosisCyanosis
Risk for aspirationRisk for aspiration
BleedingBleeding
VomitingVomiting
Severe closed head injury with need Severe closed head injury with need for hyperventilationfor hyperventilation
Risk for obstructionRisk for obstruction
Neck hematomaNeck hematoma
Laryngeal, tracheal injury/burnLaryngeal, tracheal injury/burn
StridorStridor
Mouth:Mouth:– TongueTongue : :
variable in size (angioedema)variable in size (angioedema)
attached inferior to epiglottisattached inferior to epiglottis– MandibleMandible– UvulaUvula
PharynxPharynx– TonsilsTonsils– Merges with larynx anterior, esophagus Merges with larynx anterior, esophagus
posteriorposterior– Epiglottis high long flaccid and narrow in childEpiglottis high long flaccid and narrow in child
ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATIONFOR INTUBATION
The LarynxThe Larynx– High relative to mandible in childHigh relative to mandible in child– Cricoid smaller in child, narrow part of airwayCricoid smaller in child, narrow part of airway– vocal cord narrow part of adult airwayvocal cord narrow part of adult airway– arytenoid cartilagesarytenoid cartilages
ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)FOR INTUBATION (cont.)
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TracheaTrachea– 12-15 cm. Adult12-15 cm. Adult– 4 cm. Newborn4 cm. Newborn– right mainstem right mainstem
larger,shorter and larger,shorter and less angleless angle
ANATOMIC CONSIDERATIONS ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)FOR INTUBATION (cont.)
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– Tube Sizes (Kids)Tube Sizes (Kids) Fit through noseFit through nose
Age(years)/4 + 4Age(years)/4 + 4
Oral tube lengthOral tube length– Age(years)/2 + 12 cm.Age(years)/2 + 12 cm.– Nasal add 3 cm.Nasal add 3 cm.
No cuff under 6 to 8 yearsNo cuff under 6 to 8 years
OTHER CONSIDERATIONS FOR OTHER CONSIDERATIONS FOR INTUBATION (cont.)INTUBATION (cont.)
Difficult tubes Difficult tubes – Immobilized trauma patientImmobilized trauma patient– Combative patientCombative patient– Children, esp. InfantsChildren, esp. Infants– Short neckShort neck– Prominent upper incisorsProminent upper incisors– Receding mandibleReceding mandible– Limited jaw opening, limited Limited jaw opening, limited
cervical mobilitycervical mobility– Upper airway conditionsUpper airway conditions– Facial, laryngeal traumaFacial, laryngeal trauma
OTHER CONSIDERATIONS FOR OTHER CONSIDERATIONS FOR INTUBATION (cont.)INTUBATION (cont.)
Correct Placement for intubation (b)
Patient in correct position for intubation (sniffing position)
Incorrect airway position (hyperflexed)Incorrect airway position (hyperflexed)
Rapid Sequence InductionRapid Sequence Induction
IndicationsIndications– Ventilatory failure (eg’s)Ventilatory failure (eg’s)– Airway maintenance/protectionAirway maintenance/protection– Treatment and evaluationTreatment and evaluation
neuro resuscitation(hyperventilate)neuro resuscitation(hyperventilate)
shockshock
drug overdosedrug overdose
ContraindicationsContraindications– Cardiac arrestCardiac arrest– Adequate ventilationAdequate ventilation– Deeply comatose patient, absent toneDeeply comatose patient, absent tone– Airway Anatomy use LEMONAirway Anatomy use LEMON
Rapid Sequence InductionRapid Sequence Induction
Contraindications Contraindications (cont.)(cont.)– Intubation likely Intubation likely
unsuccessfulunsuccessfulPartially Partially obstructed airwayobstructed airway
Severe facial Severe facial abnormality(trauabnormality(trauma, etc.)ma, etc.)
Rapid Sequence InductionRapid Sequence Induction
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Maintain adequate oxygenationMaintain adequate oxygenation
Airway protection Airway protection – Prevent regurgitation, aspirationPrevent regurgitation, aspiration
Obtund adverse cardiovascular and Obtund adverse cardiovascular and ICP response to intubationICP response to intubation
Better early than lateBetter early than late
Hypoxemia and acidosis effectsHypoxemia and acidosis effects
Rapid Sequence InductionRapid Sequence Induction
Treatment Algorithm (6 P’s)Treatment Algorithm (6 P’s)– Preparation T-10”Preparation T-10”– Pre-oxygenation( functional reserve capacity) Pre-oxygenation( functional reserve capacity)
T-5”T-5”– Pre-medication T-3”Pre-medication T-3”– Paralysis T-0Paralysis T-0– Placement of Tube T+45Placement of Tube T+45– Post Management T+2”Post Management T+2”
Rapid Sequence InductionRapid Sequence Induction
DO NO HARM!DO NO HARM!
TAKE AWAY NOTHING TAKE AWAY NOTHING FROM THE PATIENT YOU FROM THE PATIENT YOU
CANNOT REPLACECANNOT REPLACE
Anticipate the difficultiesAnticipate the difficulties– Identify Identify in advancein advance the patient who may the patient who may
require RSIrequire RSI– Identify the patient with anatomic Identify the patient with anatomic
difficultydifficulty– Have sufficient skill and training : Have sufficient skill and training : – TRAINING NOT DONE ON SCENE..NO TRAINING NOT DONE ON SCENE..NO
EGO’S!!!EGO’S!!!– Have aHave a preformulated preformulated planplan for potential for potential
disasterdisaster
Rapid Sequence InductionRapid Sequence Induction
Airway EvaluationAirway Evaluation
Problem Airway
epiglottis Vocal cords
Be prepared:Be prepared:– Competence with all Competence with all
equipmentequipment– Working equipmentWorking equipment– Be prepared for surgical Be prepared for surgical
managementmanagement– Master the art of baggingMaster the art of bagging– Have at least one, if not two, Have at least one, if not two,
working IV linesworking IV lines– STAY ONE STEP AHEAD!!STAY ONE STEP AHEAD!!
Rapid Sequence InductionRapid Sequence Induction
Equipment:Equipment:– Suction, OxygenSuction, Oxygen– Laryngoscope, ET Tubes, StyletLaryngoscope, ET Tubes, Stylet– BVMRBVMR– Pharmacologic agents, mixed and Pharmacologic agents, mixed and
readyready– Monitoring equipmentMonitoring equipment
Continuous cardiac monitoringContinuous cardiac monitoring
Pulse oximeter (continuous)Pulse oximeter (continuous)
NIBP (ideal)NIBP (ideal)
CO2 device (ET confirmation device)CO2 device (ET confirmation device)
Rapid Sequence InductionRapid Sequence Induction
Pre-oxygenation:Pre-oxygenation:– Functional residual capacityFunctional residual capacity– Oxygen 6-10 l/min via snug maskOxygen 6-10 l/min via snug mask– Three minutes ideal, if spontaneous Three minutes ideal, if spontaneous
breathing assist only.breathing assist only.– BEWARE BVM while spontaneously BEWARE BVM while spontaneously
breathing..Gastric insufflation is real!! breathing..Gastric insufflation is real!! – Avoid BVMR if Spo2 >90% if Avoid BVMR if Spo2 >90% if
breathing….breathing….
Rapid Sequence InductionRapid Sequence Induction
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Downloaded from: Rosen's Emergency Medicine (on 6 August 2006 02:03 PM)
© 2005 Elsevier
Pre-medication:Pre-medication:– AtropineAtropine
All children under 12 yearsAll children under 12 years
Adults with heart rate 100 or less ***Adults with heart rate 100 or less ***
Second dose of SuccinylcholineSecond dose of Succinylcholine
Dosage: 0.5 to 1.0 mg adultDosage: 0.5 to 1.0 mg adult
Dosage 0.01 to 0.02 mg child (1 mg max)Dosage 0.01 to 0.02 mg child (1 mg max)
Give ideally 2-3 minutes prior to intubationGive ideally 2-3 minutes prior to intubation
Rapid Sequence InductionRapid Sequence Induction
Sedation AgentsSedation AgentsGoal is to blunt the pt’s physiologic responses to intubation Goal is to blunt the pt’s physiologic responses to intubation ie: minimizes bradycardia, hypoxemia, gag/cough & increases ie: minimizes bradycardia, hypoxemia, gag/cough & increases in ICP/IOP/IGPin ICP/IOP/IGP
– Selection of agent(s)Selection of agent(s)perfusion stateperfusion state
presence of head injurypresence of head injury
clinical diagnosisclinical diagnosis
Rapid Sequence InductionRapid Sequence Induction
Paralytics Have No Sedative or Analgesic Qualities!!!
Selection of Sedative (cont.)Selection of Sedative (cont.)– BenzodiazepinesBenzodiazepines
Amnestic and at high dose, anestheticAmnestic and at high dose, anesthetic
Little cardiovascular depression if titratedLittle cardiovascular depression if titrated
MidazolamMidazolam– Rapid onsetRapid onset– Potent amnesticPotent amnestic– Moderate decrease in ICPModerate decrease in ICP– 1-5 mg IV (adult) as per CPG1-5 mg IV (adult) as per CPG– 0.1 mg/Kg titrated in kids0.1 mg/Kg titrated in kids
Rapid Sequence InductionRapid Sequence Induction
Selection of Sedative (cont.)Selection of Sedative (cont.)– NarcoticsNarcotics
Potent analgesics/sedativesPotent analgesics/sedatives
Rapid onset w/ brief durationRapid onset w/ brief duration
Effect can be reversed!Effect can be reversed!FentanylFentanyl– Rapid acting (<1min), duration of 30minRapid acting (<1min), duration of 30min– No histamine releaseNo histamine release– May decrease tachycardia and hypertension May decrease tachycardia and hypertension
associated with intubationassociated with intubation
Rapid Sequence InductionRapid Sequence Induction
Induction AgentsInduction Agents
ACh binds to post ACh binds to post synaptic receptors synaptic receptors causing depolarization causing depolarization … … Contraction of Contraction of musclemuscle
ACh removed by ACh removed by acetylcholinesterase acetylcholinesterase and by diffusion …. and by diffusion …. Relaxation of Relaxation of musclemuscle
Neuromuscular Junction
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Mechanism of action:Mechanism of action:– NondepolarizersNondepolarizers
CompetitiveCompetitive
Block ACh receptors … paralysisBlock ACh receptors … paralysis
– DepolarizersDepolarizersNoncompetitiveNoncompetitive
Persistent stimulation …fasciculationsPersistent stimulation …fasciculations
Unresponsiveness to ACh….ParalysisUnresponsiveness to ACh….Paralysis
Induction AgentsInduction Agents
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DepolarizingDepolarizing– SuccinylcholineSuccinylcholine
Vagal effectsVagal effects– Excessive bronchial secretions (blunted by Excessive bronchial secretions (blunted by
Atropine?)Atropine?)
Negative inotropic and chronotropic, esp. Negative inotropic and chronotropic, esp. with repeated dose and in children with repeated dose and in children (Bradycardia..Atropine)(Bradycardia..Atropine)
Fasciculations (amelioration)Fasciculations (amelioration)
Malignant hyperthermia?Malignant hyperthermia?
Complete paralysis w/in 30-45 sec. Complete paralysis w/in 30-45 sec. Lasting 4-6 minLasting 4-6 min
– 1.5-2 mg/kg IV1.5-2 mg/kg IV
Induction AgentsInduction Agents
– Succinylcholine (cont.)Succinylcholine (cont.)Metabolized via CholinesteraseMetabolized via Cholinesterase
– 0.3% defective enzyme0.3% defective enzyme
ContraindicationsContraindications– Absolute - noneAbsolute - none– HyperkalemiaHyperkalemia
Renal failureRenal failure
Crush injury Crush injury
Burns Burns
MyotoniaMyotonia
ParaplegiaParaplegia
Induction AgentsInduction Agents
•Non-depolarizing
–Rocuronium•Minimal cardiovascular effect•Long duration of action (may exceed 45 mins)•Shorter onset than Pancuronium/Vecuronium: 1-3 min•0.6-1.2 mg/kg
Induction AgentsInduction Agents
Airway ManagementAirway Management
Airway ManagementAirway Management
Airway ManagementAirway Management
Digital Digital Tactile Tactile IntubationIntubationRetrogradeRetrograde
Airtraq Airtraq
FiberscopeFiberscope
BURPBURP
Intubation TricksIntubation Tricks
SURGICAL AIRWAYSSURGICAL AIRWAYS•Cricothyrotomy
–Indications (Identified need for intubation)•Maxillofacial trauma•Oropharyngeal obstruction
–Edema–FBAO–Mass Lesion–Cancer
•Unsuccessful oral/nasal tracheal•Difficult anatomy•Massive hemorrhage/regurgitation
SURGICAL AIRWAYSSURGICAL AIRWAYS•Cricothyrotomy (cont..)
–Contraindications:–Age <10-12–Laryngeal crush injury–Laryngeal tumor/stricture–Tracheal transsection–subglottic stenosis–Expanding hematoma–Coagulopathy–Unfamiliar w/ procedure
SURGICAL AIRWAYSSURGICAL AIRWAYS
Anatomy:Anatomy:– Thyroid cartilageThyroid cartilage– Cricoid ringCricoid ring– Cricoid cartilageCricoid cartilage– Thyroid glandThyroid gland– TracheaTrachea– Major vesselsMajor vessels
SURGICAL AIRWAYSSURGICAL AIRWAYS
Netter; Atlas of Human Anatomy
SURGICAL AIRWAYSSURGICAL AIRWAYS
Procedure:Procedure:– Identify thyroid cartilageIdentify thyroid cartilage
Cricothyroid membraneCricothyroid membrane
– Vertical incision through skinVertical incision through skinPrep priorPrep prior
Incise membraneIncise membrane
– Open incisionOpen incisionDilator/tracheal hookDilator/tracheal hook
– Insert ETT/Trach tubeInsert ETT/Trach tubeVentilate patientVentilate patient
SURGICAL AIRWAYSSURGICAL AIRWAYS
Complications:Complications:– Incorrect placementIncorrect placement– Long execution timeLong execution time– HemorrhageHemorrhage– Passage sub QPassage sub Q– Plugging Plugging – PneumomediastinumPneumomediastinum– AspirationAspiration– etc.etc.
SURGICAL AIRWAYSSURGICAL AIRWAYSA
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SURGICAL AIRWAYSSURGICAL AIRWAYS
Retrograde Tracheal Intubation Retrograde Tracheal Intubation (RTI):(RTI):– IndicationsIndications
Abnormal anatomyAbnormal anatomy– Pt. W/ epiglottitisPt. W/ epiglottitis– Severe kyphosisSevere kyphosis– Cervical spondylosisCervical spondylosis
TraumaTrauma
Reasonable alternative to Surg and Reasonable alternative to Surg and Needle CrikeNeedle Crike
SURGICAL AIRWAYSSURGICAL AIRWAYS
RTI (cont...):RTI (cont...):– ContraindicationsContraindications
Trismus (w/o paralytic)Trismus (w/o paralytic)
CoagulopathyCoagulopathy
Enlarged thyroidEnlarged thyroid
– Procedure:Procedure:Supplemental OSupplemental O22
Catheter over needle into CTMCatheter over needle into CTM
Insert guidewire through catheterInsert guidewire through catheter
Visualize guidewire and pass tubeVisualize guidewire and pass tube
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QUESTIONS ??QUESTIONS ??
Defasiculating Doses (priming Defasiculating Doses (priming with 10% NDNMB)with 10% NDNMB)
KetamineKetamine
Braeslow system for KidsBraeslow system for Kids