indiana ena 2010 rsi and difficult intubation
DESCRIPTION
Review of ED RSI, Difficult and Failed IntubationTRANSCRIPT
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The Critical Airway:RSI & Failed Intubation
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Andrew J. Bowman
Acute Care Nurse PractitionerTrauma Nurse Specialist
Registered NurseParamedic
Emergency Department Emergency DepartmentWitham Health Services Clarian Arnett Hospital
KATS Transport Ambulance
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Disclaimer
I have no financial disclosures and I have no affiliation with any company to promote use of any drug or device described in this presentation.
Every Single Training Program
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AIRWAY COMES FIRST!!!!!
But…..
Not always as easy as it sounds!
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Attempts to Intubate
• <= 2 Attempts • > 2 Attempts
Overview
• What is RSI?
• RSI: The 10 “P’s”
• Failed Intubation
• Alternative airways and devices
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What is RSI?
• Rapid Sequence Intubation = RSI
• Cornerstone of emergency department (ED) airway management
• Timed delivery of medications to sedate and paralyze a patient to facilitate rapid placement of an endotracheal tube (ETT)
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Who Needs RSI?
• One or more of the following: Inability to maintain a patent airway Inability to protect against aspiration Compromised or impaired ventilation Failure to adequately oxygenate blood Anticipation of patient deterioration that will lead to
any/all of the above
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Why RSI?
• Results in rapid unconsciousness and chemical paralysis
• Most ED patients are not fasting
• Ideally, intubation without bag/mask ventilation
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When NOT to RSI
• Unconscious
• Apneic
• Need “Crash” airway
• Immediate BVM and ETT without pre-treatment
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When NOT to RSI
• Total upper airway obstruction
• Loss of facial or oropharyngeal landmarks
• Need surgical airway
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Cautious Use of RSI
• Suspected difficult airway or BVM
“LEMON”, “BONES”, “SHORT”
Mallampati Classification
3-3-2 Rule
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The 10 “P’s” of RSI
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The 10 “P’s” of RSI1. Preparation2. Pre-oxygenation3. Pre-treatment4. Put to sleep5. Paralyze6. Protect7. Position8. Placement9. Proof10.Post-Intubation management
Preparation
• Best defense against the chaos of achieving an emergent airway
• Why is it a dying patient only vomits when the suction has not been checked?????
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PreparationStart of shift preparation
Airway cart or CRASH cart is stocked and readyFunctioning equipment
Pre-arrival / arrival of patient preparationAdequate staffMedicationsAirway equipmentLength based resuscitation tape if pediatricsDetermine if potential for difficult airway or difficult BVM
Difficult ETT Prediction
• LEMON
• Mallampati Classification
• 3-3-2
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LEMON• Look externally
• Evaluate internally
• Mallampati
• Obstruction
• Neck mobility
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Look Externally
• Beard
• Small jaw, receding chin
• “Buck” teeth
• Craniofacial deformity or trauma
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Evaluate Internally
• 3-3-2
3 fingers of mouth opening
3 fingers mentum to hyoid
2 fingers hyoid to thyroid
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3-3-2
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Mallampati
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Obstruction
• Pre-glottic obstructions
Tongue enlargement
Airway edema
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Neck Mobility
• Trauma
• Anklosing spondylitis
• Arthritis
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Difficult BVM Prediction
• “BONES” Beard/mustache Obesity No teeth Elderly Snores
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Difficult Surgical Airway Prediction
• “SHORT” Surgery Hematoma of neck Obesity Radiation to neck Trauma
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Pre-Oxygenation
• AKA: Nitrogen Washout
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Pre-Oxygenation
• Best supplied by high flow non-rebreather mask for at least 5 minutes prior to RSI
• Creates a reservoir of oxygen in lungs, alveoli, blood and tissue
• Use positive pressure ventilation with BVM only when necessary (8 vital capacity breaths)
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Time to Desaturation
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Pre-Treatment
• Use of medications to blunt or decrease adverse physiologic responses to laryngoscopy and intubation
• “LOAD”
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“LOAD”
• Lidocaine
• Opiates
• Atropine
• Defasciculating agents
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Lidocaine
• 1.5mg/kg IV - Given 3 minutes prior to ETT
• Suppresses cough and gag reflex
• MAY decrease rises in ICP
• No good studies that prove benefit
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Lidocaine
• May decrease or diminish reflex bronchospasm in patients with reactive airway disease
Asthma
COPD
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Lidocaine
• Topical lidocaine may deliver a more consistent blunting of responses to intubation
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Opiates
• Fentanyl 1-3mcg/kg IVP – Given 2 - 3 minutes prior to ETT
• Decreases sympathetic response to intubation
• Possible benefit with increased ICP, aortic dissection, ICH, ischemic heart disease
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Atropine
• 0.02 mg/kg IV to maximum 1mg (minimum 0.1mg)
• Historically used in pediatrics being treated with succinylcholine to prevent reflexive bradycardia
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Atropine
• No longer recommended
• Eliminates a step that has no clear benefit
• Bradycardia, especially in pediatrics, is a hallmark of hypoxemia and should not be masked by medications
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Defasciculating Agents
• Use of a competitive neuromuscular blocker (NMB) 3 minutes before succinylcholine to decrease fasciculations
• Decrease increases in ICP
• Shown to have little, if any benefit and again eliminates a step
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Pre-Treatment Summary
• Lidocaine Reactive airway disease (good evidence) Increased ICP (conflicting evidence)
• Opiates Increased ICP Cardiovascular disease
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Pre-Treatment Summary
• Atropine No longer recommended
• Defasciculating Agents No longer recommended
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Pre-Treatment Summary
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Put to Sleep
• Administer rapid acting induction (sedation) drug to promote prompt loss of consciousness
• Dose selected to provide rapid unconsciousness
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Induction Agents
• Etomidate
• Ketamine
• Propofol
• Midazolam
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Etomidate
• 0.3 mg/kg IVP
• Rapid onset with short duration
• Little change in hemodynamics
• May be cerebroprotective
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Etomidate
• Concern for adrenal suppression in patients with prior known adrenal dysfunction or in patients with sepsis
• May prefer alternative agent in these scenarios
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Ketamine
• 1-2 mg/kg IVP
• Dissociative state with some analgesic properties
• Bronchodilation
• May increase ICP (Recent conflicting data)
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Ketamine
• Consider for use in asthmatics or in anaphylaxis
• ???Avoid use with increased ICP???
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Propofol
• 2 mg/kg IVP
• Rapid onset and short duration
• Cerebral protection
• Myocardial depressant and decreases systemic vascular resistance
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Midazolam
• 0.3 mg/kg IVP
• Slow onset (minutes) and long duration (hours)
• Hypotension common
• Rarely recommended
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Paralyze
• Provides neuromuscular blockade and is given immediately after induction agent
• Does not provide sedation, analgesia or amnesia
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Paralyze
• Depolarizing Agent Succinylcholine
• Non-Depolarizing Agents Rocuronium Vecuronium
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Succinylcholine
• 1.5 – 2 mg/kg IVP
• Rapid onset (45 – 60 seconds)
• Shortest duration (8 -10 minutes)
• Cautious use in hyperkalemia, muscular disorders, open globe injuries
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Rocuronium
• Good 2nd line agent after succinylcholine Does not worsen hyperkalemia
• 1 mg/kg IVP
• At this dose has rapid onset similar to succinylcholine but MUCH longer duration of action (30 – 60 minutes)
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Vecuronium
• Good 3rd line agent
• 0.15 mg/kg IVP
• Onset 75 -90 seconds, duration 60 -75 minutes
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Drug & Weight Considerations• Dose based on TRUE body weight
Succinylcholine Etomidate Midazolam
• Dose based on IDEAL body weight Propofol Rocuronium
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Positioning
• If concern for trauma Manual immobilization of head/neck by experienced
assistant C-collar is NOT adequate!!!!
• If NO concern for trauma Intubator positions head and airway to facilitate
visualization for intubation
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Trauma
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Trauma
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No Trauma
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Protection
• Application of Sellick maneuver (cricoid pressure) to prevent aspiration
• Applied with delivery of induction/paralytic medications
• “BURP”
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Protection
• Recent studies show little evidence that aspiration is effectively reduced
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Position & Protection
• Bimanual laryngoscopy
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Placement
• The intubator places the ETT into the trachea Direct laryngoscopy with conventional laryngoscope Direct laryngoscopy with video laryngoscope Laryngoscopy with bougie device Combination of above
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Proof
• Primary Methods
• Secondary Methods
• NO SINGLE METHOD PROVIDES 100% RELIABILITY THAT ETT IS IN THE TRACHEA!
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Primary Methods
• Intubator sees tube go through cords
• Symmetrical rise and fall of chest
• Absence of air sounds over epigastrium
• Presence of bilateral breath sounds
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Secondary Methods
• Presence of exhaled CO2 Colorimetric Capnography
• Aspiration of air from ETT EDD
• Chest X-Ray Assures proper height above carina
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End Tidal CO2 (EtCO2)
• Colorimetric
• Capnography
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Aspiration of Air
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Chest X-Ray
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Post-Intubation Management
• Secure ETT and record depth of insertion
• Initiate mechanical ventilation
• Administer ordered analgesics, sedation agents and possibly prolonged paralysis as required by clinical situation
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Post-Intubation Management
• Hypotension is COMMON!
• Often related to: Decreased venous return with positive pressure
ventilation Induction agent side effect Cardiogenic Pneumothorax Auto-PEEP
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Failed Intubation
Failed Intubation
• Cannot Intubate – Can Ventilate
• Cannot Intubate – Cannot Ventilate
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Can Ventilate
• Call for assistance
• Oxygenation and Ventilation is being maintained with BVM
• Alternative Airway
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Alternative Airway• Fiberoptic Method
• Video Laryngoscopy
• Extra-Glottic Device
• Bougie
• Surgical (Cricothyrotomy)
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Cannot Ventilate
• Call for assistance
• Simultaneous preparation for cricothyrotomy while MAYBE, BRIEFLY attempting alternative airway
• Cricothyrotomy will usually be THE method of CHOICE in cannot intubate, cannot ventilate scenario!!!
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Rescue Airway Devices and Alternative Methods for Intubation or Airway Acquisition
Alternative Airways• Fiberoptic
• Video Laryngoscopy
• Extra-Glottic Device
• Bougie
• Surgical
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Fiberoptic
• Flexible fiberoptic
• Fiberoptic stylets and guides
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Flexible Fiberoptic
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Fiberoptic Stylets & Guides
• Shikani Optical Stylet
• Levitan/FPS Scope
• Airway RIFL
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Shikani
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Levitan
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Airway RIFL
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Video Laryngoscopy• Glidescope
• C-MAC Video Laryngoscope
• McGrath Video Laryngoscope
• Pentax Airway Scope
• Res-Q-Scope II
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Glidescope
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C-MAC Video Laryngoscope
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McGrath Video Laryngoscope
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Pentax Airway Scope
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Res-Q-Scope II
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Extra-Glottic Devices
• Combitube
• King LT Airway
• Laryngeal Mask Airway (LMA)
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Combitube
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Combitube
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King LT Airway
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LMA
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LMA
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Bougie
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Bougie
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? Best in Trauma ?
• Glidescope + Bougie
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Surgical Airway
• Cricothyrotomy
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Summary
• To simplify RSI, think INDUCTION (etomidate) and PARALYSIS (succinylcholine)
• In trauma, maintain MANUAL c-spine immobilization during intubation
• Adequate pre-oxygenation is paramount to success, best delivered by high flow mask
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• Anticipate post-intubation hypotension as it is COMMON
• Anticipate difficult intubation, BVM, surgical airway by “LEMON”, “BONES” & “SHORT”
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• Know what methods/devices you have available in case of failed intubation (AND where they are!!!!!)
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QUESTIONS?
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Thank You!