rsi putting it all together

Rapid Sequence Rapid Sequence IntubationIntubation

Putting It All TogetherPutting It All Together

New HampshireNew HampshireDivision of Fire Standards & Training andDivision of Fire Standards & Training and

Emergency Medical ServicesEmergency Medical Services20112011

“One pound of knowledge takes ten pounds of common sense to apply it.”

“To Intubate or not to Intubate?” 6 questions to ask:

Can the patient maintain an airway? Can the patient protect this airway? Is the patient appropriately ventilating? Is the patient appropriately oxygenating? Is the patient’s condition likely to

deteriorate? Is the scene appropriate: safety, moving

the patient while apneic

Purpose of this Presentation: FAMILIARIZE

Medications used for RSI RSI Procedure

RECOGNIZE RSI: “When” and “When not” to perform

ANTICIPATE Back-up plan “Murphy’s Law”

What is “RSI” ? “RSI is the near-simultaneous administration of

neuromuscular blocking agents and sedative-hypnotic drugs in order to facilitate oral intubation of a patient with the least likelihood of trauma, aspiration, hypoxia and other physiologic complications.”

Why use RSI? Maximize probability of a successful intubation

RSI: 84.2-100% success rate

(US Air Medical Programs, Sand Diego CA (Ochs, Ann. Emerg. Med, 2002) and Washington state trial (Wayen & Friedland, Prehospital Emerg. Care, 1999)

Blind NTI: 72.2% success rate (medical) 66.7% success rate (trauma)

Minimize adverse physiologic effects

Indication “Immediate severe airway compromise in

the context of trauma, drug overdose, status epilepticus, etc. where respiratory arrest is imminent.”

Examples of RSI Indications Conditions requiring oxygenation/ventilation

control or positive pressure ventilation: Traumatic brain injury with ALOC Severe thoracic trauma (flail chest, pulmonary

contusions with hypoxemia) Clinical condition expected to deteriorate

Unconscious or ALOC with potential for or actual airway compromise or vomiting

And patient has…… A clenched jaw An active gag reflex

Contraindication “Extensive burns or crush injuries greater than

24 hours old.”

Other situations where RSI may not be the best choice:

Spontaneous breathing with adequate ventilation and oxygenation i.e. Ability to maintain an effective airway by less

invasive means Operator concern that both intubation and BVM

ventilation may not be successful due to: Major laryngeal trauma Upper airway obstruction Distorted facial or airway anatomy

Operator unfamiliarity with the medications used The patient is a candidate for CPAP

Complications Increased intracranial pressure Increased intraocular pressure Increased intragastric pressure Aspiration due to decreased gag reflex Malignant hyperthermia Dysrythmias Hypoxemia Airway trauma Failure to intubate / failure to ventilate DEATH

3 Major Assumptions of RSI1. The patient has a full stomach2. The operator can secure an airway

Failure = DEATH for the patientDO NOT take away what you cannot give back!

3. The operator can resuscitate the patientEquipment & Knowledge readily available

Preparation is the KEY for an organized, smooth intubation

Remember the 7 P’s!!

IFEndotracheal Intubation Endotracheal Intubation

fails, you must have a back-up plan...

RSI Procedure: The Seven P’s

1. Preparation2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care

1. Preparation A two-part process:

Assess the risks

Prepare the equipment

Assess the Risks

Difficult Airways - Assess the Risks“The difficult airway is something one anticipates;

the failed airway is something one experiences.”

-Walls 2002

How do you know if your patient is going to be difficult to intubate…

…and does it really matter?

Identifying a potentially difficult airway is essential to preparing and developing a strategy for successful ETI and also preparing an alternate plan in the event of a failed ETI.

Some Predictors of a Difficult Airway

C-spine immobilized trauma patient

Protruding tongue Short, thick neck Prominent upper

incisors (“buckteeth”) Receding mandible High, arched palate Beard or facial hair

Dentures Limited jaw opening Limited cervical mobility Upper airway conditions Face, neck, or oral trauma Laryngeal trauma Airway edema or

obstruction Morbidly obese

Additional Predictors:Medical History

Joint disease Acromegaly Thyroid or major neck

surgeries Tumors, known

abnormal structures Genetic anomalies Epiglottitis

Previous problems in surgery

Diabetes Pregnancy Obesity Pain issues

Objectives Identify 4 areas of airway difficulty

Difficult to ventilate with a BVM Difficult laryngoscopy Difficult to intubate

Predict a difficult airway using the following mnemonics: MOANS LEMONS DOA

Difficult to Bag (MOANS) Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff

Difficult Laryngoscopy & IntubationLEMONS

Look ExternallyEvaluate 3-3-2 Mallampati ScoreObstructionNeck MobilityScene and Situation

Disruption / Distortion Distortion

Surgeries Radiation Therapy Scarring Burns

Disruption / Distortion Disruption

Hanging Crush Injuries Penetrating Trauma Other Soft Tissue Trauma

Burns Laceration

Obstructions Hematoma Abscess Tumor

Tumors can also create distortions & extra bleeding

Access Issues Obesity Halo Short neck SC Emphysema Bushy beard Flexion deformity of the spine

So, give me some good news:The 3-3-2 Rule Bottom of Jaw/Chin to Neck >

3 fingers Jaw/Palate > 3 fingers wide Mouth opens > 2 fingers wide

Any single indicator has poor specificityAny single indicator has poor specificity

Mallampati Classification

Increased success/ease Decreased Increased success/ease Decreased success/easesuccess/ease

Cormack & Lehane Grading

Grade I = Grade I = success & ease success & ease of intubationof intubation

% listed = % listed = incidenceincidence

<1<1%%

<5%<5%

10-30%10-30%

Always have a back-up plan. Plans “A”, “B”, and “C” Know the answers before you begin

Plan “A”: (ALTERNATIVES) Different:

Size of blade Type of blade

Miller Macintosh Specialty

Position (patient & provider) Hockey stick bend in ETT or Directional tip ETT Gum Elastic Bougie or Flex-guide Endotracheal Tube

Introducer Remove the stylette as you pass through the cords “BURP” 2-person technique

“cowboy” or “skyhook” Have someone else try

The assistant should be able to identify and prepare the devices for the advanced provider, if asked.

“BURP” Backward, Upward,

Rightward Pressure: manipulation of the trachea

90% of the time the best view will be obtained by pressing over the thyroid cartilage

Differs from the Sellick Differs from the Sellick ManeuverManeuver

Plan “B”: (BVM and BACKUP AIRWAY Techniques )

Can you ventilate with a BVM? (Consider two NPA’s and an OPA, + Cricoid pressure w/

gentle ventilation) Gum Elastic Bougie Combitube KING – LT-D LMA?

Always expect the unexpected!


1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care

1. Preparation A two-part process:

Assess the risks

Prepare the equipment

Prepare the Equipment

Prepare the Equipment Adequate Ambu-mask/oxygen sources/suction 2 laryngoscope handles Assortment of blades Assortment of ET tubes, stylette, syringe Two assistants familiar with the procedure 1-2 secure IV lines All pharmaceutical agents needed for the

procedure Back-up plan and rescue airway devices Oximetry and capnography monitoring Bulb-style tube checker

Monitor the Patient Cardiac monitor

Monitor for dysrythmias bradycardia, tachycardia, ectopy

Blood Pressure monitoring (manual or NIBP) Monitor for hypo- or hypertension

Pulse oximetry Monitor for hypoxia

Capnography Monitor for hypo- or hypercarbia

2. Preoxygenation

Pre-oxygenate with 100% O2 via non-rebreather mask for at least 3-5 minutes Replaces the patient’s functional residual capacity (FRC)

of the lung with oxygen “Nitrogen Washout”

If done properly, this will permit as much as 3-4 minutes of apnea before hypoxia develops

In emergent cases, three mask breaths with 100% oxygen may have to suffice.

Assistant: Will most likely be responsible for the preoxygenation of your patient.

2. Preoxygenation

Resist the use of positive pressure ventilation (PPV). Use only if the patient is not ventilating adequately. PPV leads to gastric distention regurgitation

aspiration If PPV is necessary, utilize cricoid pressure Place NG/OG if prolonged use of BVM

Rapid Sequence Intubation

Medications

Note about Medications Medications are ONLY to be drawn,

prepared, and administered by paramedics.

The Basic or Intermediate Assistance cannot prepare RSI Medications, as they are not protocoled for their use.

3. Premedication These medications are given 2 minutes prior to

intubation to reduce/blunt the patient’s physiologic responses to the subsequent intubation

Possible physiologic responses include: Bradycardia Tachycardia Hypertension Hypoxia Increased intracranial and intraocular pressures Cough and gag reflexes

Lidocaine

Dose: 1.5 mg/kg IVP When: At least 2 minutes

prior to intubation Why: May prevent a rise in

ICP in TBI patients

Assistant: Will not see any major change in patient.

Lidocaine

Lidocaine for head injuries, non-traumatic head bleeds and asthma patients (Tight head, tight chest)

Takes 3 minutes to work, so may not be worthwhile if time is critical……..

Use your judgment

Atropine Dose: 0.5 mg IVP When: Prior to intubation

for bradycardic adults Why: Given to prevent

worsening bradycardia From Succs, vagal

stimulation during direct visualization, and hypoxia

Assistant: Will not see any major change in patient.

4. Paralyze

A three step process: Induction Cricoid Pressure Paralytic

Induction with Etomidate Hypnotic induction agent

No analgesic properties Dose: 0.3 mg/kg IV Onset: 30-60 seconds Duration: 3-5 minutes Should always be given prior to paralytic

Assistant: Will see the patient become less responsive; more relaxed.

Cricoid Pressure Also known as “Sellick’s Maneuver” Should be automatic

Begin just as Etomidate is administered Maintained until ETT placement is confirmed and tube is

secure (cuff inflated) Used to occlude the esophagus and prevent passive

regurgitation common with Succs If patient starts to actively vomit – RELEASE!

and suction oropharnyx. Otherwise, can lead to esophageal rupture

Assistant: This an important role for you!

Cricoid Pressure

Use thumb and forefinger to apply pressure directly backward/posterior over the cricoid cartilage.

Cricoid Pressure The patient MAY become apneic shortly

after receiving Etomidate, and will be completely paralyzed 30-60 seconds after Succinylcholine

An assistant MUST perform cricoid pressure at the first sign of sedation and continue until the airway is secure

Anectine (Succinylcholine)SCh or “Succs” The only depolarizing paralytic in clinical

use Benefits:

Rapid onset Short duration

Will cause “fasciculations”

Fasciculations Muscular twitching involving the

simultaneous contraction of contiguous groups of muscle fibers

Merriam-Webster Dictionary

Succinylcholine Dose: 1.5mg/kg IV When: Immediately after

Etomidate Onset: rapid, usually 30-90

secs Duration: short acting, 3-5 mins

Assistant: You will likely see the patient go through a brief period of fasciculations followed by complete flaccidity,as the patient become paralyzed.

Contraindications Severe burns

> 24 hours old Massive crush injuries

>8 hours old Spinal cord injury

>3 days old Penetrating eye injuries Narrow angle glaucoma

Hx of malignant hyperthermia patient or family

Pseudocholinesterase deficiency

Neuromuscular disease patient or family

Hyperkalemia May precipitate fatal

hyperkalemia!

Complications Cardiovascular Effects

Minimal in adults Muscle Pain

From the fasciculations Hyperkalemia

Not a significant issue in the acute period Should be considered in patients with known

hyperkalemia, acute renal failure

Complications Increased intraocular pressure

May be a concern for those with penetrating globe injuries – theoretically can lead to expulsion of intraocular contents

No documented cases found Defasciculating dose of a non-depolarizing

neuromuscular blocker and lidocaine pretreatment may abolish this complication

Complications Increased intracranial pressure

Controversial May be a concern for those with suspected

traumatic brain injury Lidocaine administration is thought to blunt the

ICP spike

Complications Increased intragastric pressure

Passive regurgitation from fasciculations Importance of Cricoid Pressure / Sellick’s

maneuver

Complications Malignant Hyperthermia

Very rare condition – 1:15,000 Patient experiences a rapid increase of

temperature, metabolic acidosis, rhabdomyolysis, and DIC

Treatment includes administration of Dantrolene and external means of temp. reduction

Complications Prolonged paralysis

In patients with: A deficiency of pseudocholinesterase Certain meds: magnesium, lithium, quinidine Cocaine

Masseter muscle rigidity

5. Pass the Tube Intubation is performed when there is full

relaxation of the airway muscles About 90 seconds after Succs

If intubation fails, maintain cricoid pressure and ventilate with BVM

After patient is reoxygenated, reattempt or move to a different airway adjunct

Assistant: You are still performing the cricoid pressure at this point.

Direct Visualization…

Hold manual in-line axial stabilization (MIAS)

Suspected Cervical Injury?

Pass the Tube

COMPLICATIONS: If you miss or are unable to intubate after 30

seconds…… Ventilate with BVM / high flow O2 with cricoid

pressure maintained Make ONE more attempt to intubate If still unsuccessful – continue BVM / Cricoid pressure Secure Airway with backup device (CombiTube, LMA

or King-LT-D)

Assistant: The advanced provider may ask you to perform the “BURP” maneuver to better visualize the cord.

If Unable

If unable to intubate, unable to secure the airway with backup device, and unable to maintain an SpO2 of >90% with a BVM

Contact Med Control

6. Proof of Placement OBJECTIVE

Direct visualization BEST

CXR (in hospital) Pulse oximetry Capnography CO2 detectors

Easy Cap - colormetric Self-inflating bulb

SUBJECTIVE Absence of abdominal

sounds while ambu- bagged

Mist in the tube Bilateral breath sounds Rise/fall in chest

Confirm placement using at least 3 methods, including capnography waveform.

Assistant: Be familiar with the set-up and/or assembly of the various confirmation devices as you will likely be called upon to connect them.

SpO2 (Pulse Oximetry) Provides quick

estimate of PaO2 Often referred to as

an additional vital sign

Non-invasive

Waveform Capnometry Number of important applications

Monitor & Confirm ETT placement Useful to document adequacy of ventilation

during mechanical ventilation Limitations:

For patients with impaired pulmonary function or hemodynamic instability

Assistant: Become familiar with the appropriate waveform for a properly ventilated patient.

The Capnogram Represents the

Respiratory Cycle Exhalation

A to D Inhalation

D to E

Waveform Capnometry Prerequisite

Requirement Becoming a

standard of care Easy to Use Good measure of

Pulmonary Perfusion

Relates well to PaCO2

Does have limitations

After confirming placement: Secure airway device Immobilize the head Verify correct placement each time the

patient is moved Document appropriately

Assistant: Again, be familiar with these steps and be able to perform.

7. Post Intubation Care Medicate:

Sedation midazolam (0.05-0.1 mg/kg IVP) or lorazepam (1-2 mg IV) fentanyl (25-100 mcg may be considered prn)

Paralysis (with online medical control) vecuronium (0.1 mg/kg IVP) or rocuronium (1 mg/kg IVP)

Consider wrist restraints

Midazolam & Lorazepam Benzodiazepines Provide sedation, amnesia, and

anticonvulsant properties No analgesia

Midazolam: Faster onset, shorter duration than lorazepamLorazepam: may be the preferred agent due to its longer action duration

Pay close attention to the patient’s level of consciousness. Should the patient at anytime show any signs/symptoms of discomfort (movement, increase heart rate, increased blood pressure) consider further sedation.

Sedation Assessment Sign/symptoms

Movement Increase in heart rate Increase in blood pressure Decrease in SpO2 Changes in muscle tone Facial muscle tension

Midazolam (Versed)

Dose: 0.05-0.1 mg/kg IVP Rapid onset – 1-2 minutes Single dose duration: 15-20 minutes

Midazolam Duration: 1-4 hours Hepatic clearance Decreased dose needed (longer half life)

Obese Geriatric CHF Hepatic or renal insufficiency

Lorazepam (Ativan)

Post-RSI sedation: Lorazepam 1-2 mg IV push q 5 min prn

Titrate to keep patient sedated and SBP >90 Onset: 5 minutes Duration: 6-8 hours, dose dependant

Fentanyl Class

Anesthetic Induction / Maintenance

Narcotic 25-100 mcg may be

considered prn

http://www.drmarkmoore.com/Medications/fentanyl_citrate_lg.htm

Fentanyl Opioid agonist Dampens sympathetic (catecholamine)

response Does not release histamine May cause stiff chest in doses >500mcg Caution in hypotension / hypovolemia

Vecuronium & Rocuronium Non-Depolarizing

Paralytics Provide paralysis, but

NO sedation, amnesia, or analgesia properties

Vecuronium (Norcuron) Considered safe without

many contraindications May be used in most

patients including cardiovascular, pulmonary, and neurological emergencies

Must be reconstituted from powdered form

Vecuronium

Dose: 0.1mg/kg IVP Repeat/maintenance dose: 0.01 mg/kg Onset: 2-3 minutes Duration: approx. 20-30 minutes

Vecuronium Metabolized by the liver and kidneys Use with caution in patients with liver

failure May have 2x the recovery time

Patients with renal or hepatic failure will need less medication to maintain paralysis

Does not cause hypotension or tachycardia

Rocuronium (Zemuron) Very similar properties to

Vecuronium Does not need to be mixed,

can be stored at room temp for 60 days

Less vagolytic properties

Rocuronium Onset: 30-60 seconds

Fastest onset of all non-depolarizing NMBs Dose related

Dose: 1 mg/kg IVP Duration: 20-75 minutes Repeat/maintenance dose is the same as

the initial dose

Review:Sequence of Administration

Time -5 minutes Preoxygenation Time -2 minutes Premedication Time -0 minutes Sellick Maneuver,

Induction Agent, Paralytic

Time +1 minutes Intubation

Medication Sequence Oxygen Lidocaine and/or Atropine if indicated Etomidate Cricoid Pressure Succinylcholine INTUBATION Lorazepam / Fentanyl prn Rocuronium or Vecuronium prn

IMPORTANT REMINDERS!! Always remember (and suggest) the use

of sedatives before giving paralytics, and allow them to take effect

Sedatives and paralytics do not have any analgesic properties, evaluate patient response and possible need for analgesia vital signs, skin signs

R a p id S e qu en ce In tu b a tion

L o ra zep a m IV F e n tan yl IV

IN T U B A T E !

S u cc in ylch o line

S e llic ks M a n e u ver - B U R P

E to m id a te IV

L id oca ine IV if in d ica ted

P re -o xyg e na te p a tie n t1 0 0% O 2 fo r 5 m inu tes

N R M a sk o r B V M

“Failed Airway”Worst case scenario:

Know Your Options!!!& Don’t hesitate to use them!

Failed AirwayUnable to intubate

(including blind devices) and unable to ventilate with a BVM and maintain an Sp02 > 90 %.

Rescue Airway Management Have a back-up plan Algorithmic approach

BVM Gum Elastic Bougie Laryngeal Mask Airway (LMA) Esophageal Tracheal Combitube King-LT-D

Assistant: Be familiar with the set-up and/or assembly of the various backup devices as you will likely be called upon to assist with them.

BVM Can you obtain a good mask seal? Adequate chest rise & fall? Adequate oxygenation & ventilation?

Assistant: You will most likely be performing this skill.

Gum Elastic Bougie (GEB) or Flex-guide (FG) Endotracheal Tube Introducer First introduced in 1949 Useful in failed intubation with Grade III or Grade IV

laryngoscopic view Might be helpful in the immobilized trauma patient Has been found to reduce the incidence of failed intubation

96% success rate On average, use if an FG instead of a stylet only requires

10 seconds longer to perform intubation Providers must receive training in the use if the FG

LMA Good temporizing

measure Multiple sizes Aspiration likely if

vomiting occurs Pre-Hospital use

unproven/unpublished Risk of aspiration

CombitubeEspecially suited for…

Patients with difficult anatomy Reduced access spaces Reduced illumination (bright light)

King-LT-D

Failed Airway Management

Final Thoughts on the“Failed Airway” In all cases of a failed airway, the

operator must continually assess the adequacy of oxygenation and ventilation

7% of all trauma patients will require intubation

Additional Documentation Items Why was the decision made to RSI Pre & Post O2 and CO2 levels Airway Grading/scales Unsuccessful Attempts

Case Studies

Case 1 67 y/o female “code blue” – in asystole.

PLAN?

Case 2 72 y/o female with Hx fever, productive

cough and progressive dyspnea. Lethargic, perioral cyanosis. RR 34 and labored, HR 114, BP 117/76. Lung sounds equal with scattered rhonchi. PLAN?

Case 3 41 y/o female with c/o “asthma attacks”

x20 minutes. Severe respiratory distress. RR 32, HR 127, BP 160/92. Bilateral I/E wheezes. Within 10 minutes, she becomes lethargic and her RR slows. PLAN?

Case 4 46 y/o male with a Hx of EtOH and drug abuse.

Presents with “had a seizure” per bystanders. Pt is responsive to pain, but does not follow commands or answer questions. RR 18, HR 109, BP 120/80. Within minutes, he has 2 episodes of vomiting and “gurgling respirations”. PLAN?

Case 5 25 y/o male with GSW to abdomen. Pt is

intoxicated, decreased LOC, minimal gag reflex. RR 8-10, HR 120, BP 100/80. PLAN?

Case 6 87 y/o male MVC, high-speed, unrestrained.

Patient gasping for air, able to talk, c/o right side CP. RR 32, HR 120, BP 186/92. Multiple deformities to face and chin. Ecchymosis and swelling to neck and anterior chest. Large flail segment to ant/lat chest. Decreased BS on the right. No stridor, but some gurgling in throat. PLAN?

References Marx: Rosen's Emergency Medicine:

Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.

Miller: Miller's Anesthesia, 6th ed., Copyright © 2005 Elsevier

Roberts: Clinical Procedures in Emergency Medicine, 4th ed., Copyright © 2004 Elsevier

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