airway 1: rapid sequence intubation stuart swadron, md, frcpc, facep program director residency in...
TRANSCRIPT
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AIRWAY 1:RAPID
SEQUENCEINTUBATION
Stuart Swadron, MD, FRCPC, FACEPProgram Director
Residency in Emergency MedicineKeck-USC School of Medicine
LAC+USC Dept. of Emergency Medicine July 19, 2007
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DEFINITIONS
INDUCTION AGENT
PARALYTIC
UNCONSCIOUSNESS
MOTOR PARALYSIS
Rapid Sequence Intubation
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DEFINITIONS
INDUCTION AGENT
Pharmacologically Assisted Intubation
UNCONSCIOUSNESS
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DEFINITIONS
Geneva Convention Violation
PARALYTIC
MOTOR PARALYSIS
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RATIONALE – Principle
Increasedsuccess
Decreasedaspiration
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BetterC-spinecontrol
RATIONALE - Secondary
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Blunting↑ ICP / IOP
RATIONALE - Secondary
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Avoid airway trauma
RATIONALE - Secondary
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Avoid airway trauma
RATIONALE - Secondary
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↓ Pain↓ Discomfort ↓ Recall
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Prolongedintubation
HAZARDS
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Adverse Drug Events
HAZARDS
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May force crash airway scenario
HAZARDS
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INDICATIONS
Failure OR Imminent failure of :
1. oxygenation
2. ventilation
3. airway protection or maintenance
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CONTRAINDICATIONS
INDICATIONRISK
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RSI CAN ALSO BE…
UNNECESSARY
- OR –
INAPPROPRIATE
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PREPARATIONt – 10 minutes
1. EQUIPMENT PRESENT AND WORKING
MUST INCLUDE EQUIPMENT
FOR PLAN “B”
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PREPARATIONt – 10 minutes
2. ASK: CAN I…
BAG THE PATIENT
TUBE THE PATIENT
CRIC THE PATIENT
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L ook at general anatomyE valuate the 3-3-2 ruleM allampati scoreO bstructionN eck mobility
CAN I TUBE THIS PATIENT?
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CAN I BAG THIS PATIENT?
Maybe. Maybe Not.
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CAN I CRIC* THIS PATIENT?
* may include alternative airway techniques
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PREOXYGENATIONt – 5 minutes
1. “PRIMUM NO BAGER!”
(First, do not bag!)
2. If you do need to bag,
Remember TOM
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
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NITROGEN WASH-OUTOXYGEN WASH-IN
pO2LUNGS
pO2TISSUES
pO2BLOOD
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PREOXYGENATIONt – 5 minutes
1. Well-fitting mask
2. 8 vital capacity breaths
Nimmagadda et al. Anesthesiology 93 (3): 693-698, 2000Baraka et al. Anesthesiology 91 (3): 612, 1999
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PREOXYGENATIONt – 5 minutes
Normal adult
Obese adult
Normal child
Ill adult
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PRETREATMENTt – 3 minutes
L Lidocaine
O Opioids
A Atropine
D Defasciculating Medication
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PRETREATMENTt – 3 minutes
“LOAD”
may just be a
LOAD
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LIDOCAINETraditional Indications
Tight Brains
“There is currently no evidence to support the use of intravenous lidocaine as a pretreatment for RSI in patients with head injury and its use should only occur in clinical trials”
Robinson N, Clancy, M. Emergency Medicine Journal 18(6):453-7, 2001
Tight Lungs
“…no study has demonstrated a protective effect of [both intravenous and topical anesthetic agents] in preventing bronchospasm after intubation..”
Maslow et al. Anesthesiology, 93(5): 1198-1204, 2000
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OPIOIDS (Fentanyl)
Traditional Indications
1. Blunt hemodynamic response
2. Decrease pain
Adachi et al. Anesthesia & Analgesia. 95(1):233-7, 2002
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FENTANYL DOSE
Dose = 3µg/kg* IV slow push
*Beware of hypotension and apnea
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ATROPINEStandard practiceGive atropine to:
1. all children less than 8 years old2. prior to second dose of succinylcholine
Dose = 0.01-0.02 mg/kg IVP
Evidence is mounting that questions routine use of atropine
Fastle et al. Pediatr Emerg Care;20(10):651-5, 2004McAuliffe et al. Can J Anaesth; 43(7) 754-5,1996Fleming et al. CJEM. 2005;7(2):114-7
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DEFASCICULATING DOSEOne tenth the RSI dose
Traditional Indications
1. Blunt rise in ICP
2. Decrease risk of aspiration
3. Prevent muscular pain
Clancy et al. Emergency Medicine Journal. 18(5):373-5, 2001
Questionable value
“no definitive evidence that SCh caused a rise in ICP”“no studies that investigated the issue of pretreatment with defasciculating doses and their effect on ICP”
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And what’s more…
DEFASCICULATING DOSEcan be downright dangerous*
* it may cause premature apnea
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PRETREATMENTt – 3 minutes
If you’re going to give these drugs:
…at least give them some time to circulate (3 minutes)
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Summary of LOADPRETREATMENT
L idocaine optional
O piates optional
A tropine still mandatory for kids < 8
D efasciculating optional dose
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PARALYSIS WITH INDUCTION
Time “0”INDUCTION AGENTS
Etomidate
Thiopental
Ketamine
Propafol
Midazolam
PARALYTIC AGENTS
DEPOLARIZING
Succinylcholine
NON-DEPOLARIZING
Vecuronium Rocuronium
+
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SUX IS STILL KING
…but nondepolarizing agents are gaining ground
Perry et al. Academic Emergency Medicine 9(8): 813-23, 2002
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SUX versus ROC
45 seconds ONSET 1 minute
9 minutes DURATION 45 minutes
1 mg/kg1-2.5 mg/kg
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When Sux Really “Sucks”CONTRAINDICATIONS
1. HYPERKALEMIARENAL FAILURERHABDOMYOLYSIS
2. RECEPTOR UPREGULATIONSUBACUTE BURNS (>1 day)SUBACUTE DENERVATING DISORDERHISTORY OF MALIGNANT HYPERTHERMIA
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Advent of the Non-Depolarizing Agents
Pancuronium
Vecuronium
Rocuronium
Rapacuronium –oops!
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Making non-depolarizing agents FASTER
1. Large Doses
2. Priming Doses
3. Better Induction Agents
}Increase duration
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The Choice of Induction Agent
ETOMIDATE – the agent of choice
THIOPENTAL – hypotension
– not the greatest intubating conditions
PROPAFOL – hypotension
– storage, allergy concerns
KETAMINE – not the greatest intubating conditions
– some like it for asthma
– good for penetrating neck trauma
MIDAZOLAM – effective induction doses cause hypotension
– usually underdosed (requires 0.3mg/kg)
– better for conscious sedation
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PROTECTION AND POSITIONING t + 20 seconds
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C Spine Precautions
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PLACEMENT AND PROOF t + 45 seconds
Over here,
Socrates !!!
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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POST-INTUBATION MANAGEMENT t + 90 seconds
THE “APRÈS INTUBATION”
CONFIRM INTUBATION
SECURE TUBE
CHECK CHEST X-RAY, ABG’S
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CONFIRMING INTUBATION
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SECURING TUBE
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THE 7 P’s OF RSIPREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PUTTING IT ALL TOGETHER
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TRAUMA WITH HEAD INJURY
PREPARATIONPREOXYGENATION WITH 100% O2 (t -5min)PRETREATMENT (t -3min)
Lidocaine 1.5 mg/kg IVP (Optional - if time allows)Vecuronium 0.01 mg/kg IVP (Optional - if time / resp status allows)Fentanyl 3 μg/kg IVP (Optional - if time / BP allows)
PARALYSIS WITH INDUCTION (t = 0)Etomidate 0.3 mg/kgSuccinylcholine 1.5 mg/kg
PROTECTION AND POSITIONING
PLACEMENT AND PROOF (t +45 sec)
with in-line C-spine stabilization POST-INTUBATION MANAGEMENT
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STATUS ASTHMATICUS
PREPARATIONPREOXYGENATION WITH 100% O2 (t -5min)PRETREATMENT (t -3min)
Lidocaine 1.5 mg/kg IVP (Optional - if time allows)
PARALYSIS WITH INDUCTION (t = 0)Ketamine 1.5 mg/kg IVP Succinylcholine 1.5 mg/kg
PROTECTION AND POSITIONING
PLACEMENT AND PROOF (t +45 sec)
POST-INTUBATION MANAGEMENT
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ONE SIZE FITS ALL!
PREPARATION
PREOXYGENATION WITH 100% O2 (t -5min)
PARALYSIS WITH INDUCTION (t = 0)Etomidate 0.3 mg/kgSuccinylcholine 1.5 mg/kg OR Rocuronium 1mg/kg
PROTECTION AND POSITIONING
PLACEMENT AND PROOF (t +45 sec)
POST-INTUBATION MANAGEMENT
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INTUBATION HURTS!!!
And it keeps on hurting once the tube is in.
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Thank you!