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#5Intro to EM Airway Management-

RSI Pharmacology

Andrew Brainard

#5 RSI Medications on a Dialysis Pt• Learning Objectives:

• Prep team/plan/room/equipment• Mask Seal, BVM, adjuncts, suction, • Pre & apnoeic oxygenation• Positioning

– Airway assessment and plan• MOANS/LEMON• Briefing for Plans A, B, C, & D• Completes airway checklist

– Call and response– <1 min

– Dose, timing, advantages/disadvantages of RSI sedatives• Etomidate• Propofol• Ketamine• Thiopental

– Dose, timing, and of RSI paralytics• Rocuronium• Suxamethonium

• R40: 50y/o M unresponsive– Unresponsive for >24 hours – Has missed last several dialysis appointments– GCS 7, RR 6, SaO2 95%, pulse 50, BP 80/60. – ECG shows wide complex bradycardia

• On arrival:– Same vitals – Pt being bagged well by Ambos

• 2-hands, 2 people w/ OPA + NPA

– Obvious dialysis shunt– LEMON shows:

• Beard , 2-1-1 (small mouth, no neck, small jaw), no obstruction, no neck

• Very difficult airway: – harder than you feel comfortable with

– MOANS• Easy to ventilate/oxygenate with BVM

• Consultant suggests RSI– Pt will gradually desaturate unless:

• Bagged, positioned, and preoxygenated

– Prepare for sedation w/ minimal thio or etomidate or ketamine

– Prepare for paralytic w/ rocuronium – Run through checklist– Be prepared for intubation but…– Wait for help

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Sedatives for RSI

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Sedatives• Etomidate (0.3mg/kg TBW)– Minimal hemodynamic effects– Minimal respiratory depression– Controversial in sepsis– Myoclonus

• Fentanyl (5-10mcg/kg)– Familiar agent for paeds– Minimal Sedation

• Ketamine (0.5-2mg/kg IBW)– Minimal hemodynamic effects– Minimal respiratory depression– Bronchodilator– Increased secretions– Laryngeal spasm (very rare)

• Propofol (0.5-3mg/kg TBW)– Familiar agent– Respiratory depression– Hypotension

• Thiopental (0.25-3mg/kg TBW)– Antiepileptic– Respiratory depression– Hypotension– Histamine release

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Paralytics for RSI

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Paralytics

• Rocuronium (1.2mg/kg IBW)

– Identical intubationing conditions

– Few contraindications– Longer duration

• Avoid in status• Difficulty canceling cases

• Suxamethonium (1.5-2mg/kg TBW)

– Familiar and fast– 10 minute duration– Bradycardia– Short duration

• Poor relaxation• Can lead to redosing

– Contraindications• Hyperkalemia

– Renal failure, rhabdo, crush injuries

• Upregulated aCh receptors – Old burns, old strokes, old

paralysis• Malignant Hyperthermia

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Drug Controversies

• Access– IV/IO

• Equal

– IM • Double dose

ketamine/sux

• When are drugs needed?– Type– Dose

• Pushing RSI Drugs– Sedative

• Flush (for thio)

– Paralytic– Fluid/presser

• RSI– Rapid push of Sedative and Paralytic

• Non-RSI regimens– Awake Intubation

• Cooperative patient• Topical airway anesthesia• DL/VL or FiberOptic intubation

– Delayed Sequence Intubation (DSI)• Sedation for agitation and pre-oxygenation then RSI for ETT

– Rapid Sequence Airway (RSA)• Sedation/Paralysis to SGA• ETT after pt optimized via SGA

– Premeditations?• Oxygen, sedation, analgesia, neuroprotection?

– Sedation only intubation• Give sedative (+/- topical anesthesia)• DL/VL/FOI

– Non-rapid RSI• Small doses of analgesia and sedation then paralysis

– No Drug Intubation• Almost all pts require sedation and paralysis for optimal conditions

• ACEP Practice Management- Focus on Rapid Sequent Intubation: http://www.acep.org/Clinical---Practice-Management/Focus-On--Rapid-Sequence-Intubation-Pharmacology/ (Accessed 21/03/2013)

• Walls RM. Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF. (Eds), Lippincott Williams and Wilkins, Philadelphia 2012

• Morris et al Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009 May;64(5):532-9.