Rapid Sequence Intubation

Guardian EMS

Introduction

•The most important task in patient care is providing proper support and not further endangering the patient

•Airway management can be critical in the survival of the patient

Introduction

•Must have the proper (and working) equipment

•If intubation is initiated, it must be rapid and effective

Objectives

•Philosophy

•Rapid Sequence Intubation

•Drugs

•Rescue and alternatives

•Verification of placement

•Current literature

Philosophy

•First, “Do no harm”

•RSI should only be done if absolutely necessary

•The paramedic must choose the therapeutic option that offers the most benefit for the least risk

Philosophy

•The first priority in patient care is the Airway (ABC)

•Rapid airway intervention is critical in certain circumstances, but field RSI has been shown in some large randomized studies to increase mortality of the patient

Philosophy

•If transport times are short (<15 minutes), there are extremely few patients that should be intubated in the field -- use BVM and drive quickly

•In long transport times, there may be a need to intubate the patient

•Proper training and maintaining skills are essential

The 5 P Philosophy

•Proper Preparation Prevents Poor Performance

Philosophy

•No equipment, no matter how advanced, is error proof

•Be prepared for failure

•Know your equipment and know what you will do when your equipment (or you) fails

Patient Protection•Protect the patient from intubation that

could be harmful

•Protect the cervical spine (minimize motion)

•Protect from aspiration

•Aspiration mortality is 30%-62%

•Unwatched, obtunded and intoxicated patients can more easily aspirate

Scenario

•Asthmatic patient with severe respiratory distress not responding to nebulizer treatments. The transport time is 30 minutes. The patient is still awake but is becoming confused and tiring.

Scenario

•25 year-old intoxicated (EtOH) trauma patient on a back board and C-collar. He is deeply sedated with a questionable history of head trauma (starred windshield, patient does not remember accident but is so drunk he can hardly talk at all).

Rapid Sequence Intubation

•Administration of a sedative and a paralytic to facilitate the rapid placement of an endotracheal tube.

•RSI can help to diminish risk of aspiration

EMS RSI Indications

•Very few

•Prolonged transport times with high potential for loss of airway or respiratory failure

RSI Technique

•Pre-oxygenate (careful not to bag a conscious or spontaneously breathing patient -- you can inflate the stomach and increase the risk of vomiting)

•Prepare equipment

•Pre-medicate

•Put the patient down (sedate)

•Paralyze

•Place tube

RSI EquipmentSuction

Oxygen

BVM

LMA

Working laryngoscope

Tubes and stylets

Gum Elastic Bougie

Bite blocks

Tape

ETCO2 detectors

RSI Timing

•T-3 min: Ready all equipment, pre-oxygentate

•T-2 min: Insure IV access

•T-15 sec: Sedation with etomidate 0.5 mg/kg IVP

•T-0 sec: Paralyze with succinylcholine 200 mg IVP (1.5 mg/kg)

RSI Timing

•T+10 sec: Sellick’s maneuver

•T+45 sec: Place tube and verify placement

•T+5 min: Medications may ware off, add sedation and paralysis as needed

Be Prepared

•Have all of your primary equipment ready and ensure that it works

•Know what you are going to do with your intubation attempt fails -- have your backup ready to go

Pre-medication

•Lidocaine

•Used to blunt increases in intracranial and intraoccular pressure for patients with head or eye injuries

•Dose: 1.5 mg/kg IV over 30-60 seconds

Pre-medication

•Atropine

•Can help blunt bradycardia in pediatric patients

•Can help limit secretions

•Dose: 0.01 mg/kg IVP

Sedation

•Midazolam (Versed)

•Benzodiazepine with short duration of action

•May cause hypotension and respiratory suppression

•Dose for induction: 0.2 mg/kg IVP

•Dose for maintenance: 0.1 mg/kg IVP

Midazolam

•Most people (including physicians) underdose the midazolam with RSI

•Use 0.2 mg/kg IVP

•70 kg man = 14 mg IVP midazolam

Etomidate

•The best medication for the job

•Use 0.5 mg/kg IVP

•Typical dose is 20-40 mg IVP

Paralysis

•Cricoid pressure prior to paralysis and continue until tube is in place

•Defense against aspiration

•BURP - Backwards, Upwards, Right Pressure

Paralysis

•Succinylcholine

•Depolarizing neuromuscular blocker

•Onset of 30-60 seconds

•Dose: 200 mg IVP (1.5 mg/kg) -- no danger in “over paralyzing”, but can be hard to intubate if too little is given

•Precautions: Neuromuscular disease, hyperkalemia, glaucoma, increased gastic pressure

RSI

•If you are going to do it, do it decisively and carefully

•Be smart about the decision realizing that most data point to increased mortality with field intubations -- egos should never interfere with patient care

Rescue and Alternatives

•Ventilate & retry

•Gum Elastic Bougie

•LMA -- limited protection of airway in patient with vomiting

•Cricothyrotomy

Verification

•You must verify correct tube placement using both clinical exam and mechanical testing

Clinical Verification•Visualize placement of tube through

cords

•Lung auscultation (bilateral breath sounds)

•Abdomen auscultation (no gastric sounds with bagging)

•Clinical improvement

•Tube condensation (not reliable)

Mechanical Verification

•Pulse oximetry

•End tidal CO2 detection

•Esophageal detector device

Summary

•Patient safety and care is top priority

•Be prepared

•Minimize aspiration risks

•Always confirm proper tube placement

Literature

•Avoid thinking that the studies apply to other, less trained medics

•The medics in many of the studies are well trained and experienced

INCIDENCE OF TRANSIENT HYPOXIA AND PULSE RATE REACTIVITY DURING PARAMEDIC RAPID SEQUENCE INTUBATION

Dunford, J.V., et al, Ann Emerg Med 42(6):721, December 2003

BACKGROUND: Cerebral injury is exacerbated by hypotension and hypoxia. Outcome studies of prehospital rapid sequence intubation (RSI) in patients with significant head injuries have yielded conflicting results.

METHODS: The authors examined data from a subset of 54 adults with closed head injuries who participated in a larger study of paramedic RSI, to identify episodes of desaturation and pulse rate reactivity during RSI. The larger study was performed within the San Diego EMS System and was terminated after it was found that RSI was associated with worse outcomes. The RSI protocol called for preoxygenation for at least 60 seconds, use of midazolam for sedation if systolic pressure was at least 120mm Hg, weight- based dosing of succinylcholine to achieve neuromuscular blockade, and a maximum of three 30-second intubation attempts.

RESULTS: Oxygen desaturation during RSI (to levels below 90%, or any decrease in patients having an initial O2 saturation below 90%) was documented in 57% of the patients, most of whom (84%) had initial SPO2 values of at least 90% before administration of RSI medications. The median decrease in SPO2 during desaturation was 22% and the median duration of the episodes was 160 seconds. Most of the patients had a 20-beat increase (61%) or decrease (29%) in pulse rate during desaturation, and 36% developed significant bradycardia (heart rate below 50). The intubation was considered by paramedics to be "easy" in 26 of the 31 RSI episodes associated with oxygen desaturation.

CONCLUSIONS: This study demonstrated a substantial rate of oxygen desaturation during RSI by paramedics in patients with serious closed head injury

EFFECT OF OUT-OF-HOSPITAL PEDIATRIC ENDOTRACHEAL INTUBATION ON SURVIVAL AND NEUROLOGIC OUTCOME: A CONTROLLED CLINICAL TRIAL

Gausche, M., et al, JAMA 283(6):783, February 9, 2000

METHODS: In this extraordinary controlled clinical trial, from Harbor-UCLA Medical Center in Torrance, CA, outcomes were compared in 410 children below the age of twelve who received bag-valve-mask (BVM) ventilatory support in the prehospital setting and 420 similar children who were assigned to receive endotracheal intubation (ETI). Indications for airway management included traumatic or nontraumatic cardiopulmonary or respiratory arrest respiratory failure, airway obstruction, head trauma with nonpurposeful response, or a perceived need for assisted ventilation. All participating paramedics underwent an initial six-hour training course in pediatric airway management. RESULTS Rates of survival to hospital discharge were similar in the ETI and BVM groups (26% and 30%, respectively), as were rates of discharge with good neurologic outcome (20% and 23%). Survival and/or good neurologic outcome were statistically more likely in the BVM group in subgroups having diagnoses of child abuse, respiratory arrest and foreign body aspiration. Overall, ETI was successful in 57 of children in whom it was attempted. Complications specific to ETI included esophageal intubation (2%), recognized or unrecognized dislodgment of the ET tube (14%), mainstem bronchus intubation (18%), and incorrect tube size (24%). Median scene time and total prehospital time were longer (by 2-3 minutes) in the ETI group

BACKGROUND: Although pediatric endotracheal intubation is taught in 97% of paramedic training programs and is widely used in the out-of-hospital setting, findings in this landmark study suggest that (in an urban environment) it is no better than, and may be worse than, pre-hospital use of BVM only.

THE EFFECT OF PARAMEDIC RAPID SEQUENCE INTUBATION ON OUTCOME IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY

Davis, D.P., et al, J Trauma 54:444 March 2003

METHODS: This prospective study, from the University of California, San Diego, investigated the effect of rapid sequence intubation (RSI) on outcomes in adults with severe traumatic brain injury. Paramedics underwent eight hours of training in RSI, GCS scoring and Combitube (CT insertion. Patients were enrolled if they had a suspected head injury with a GCS of 3-8, an estimated transport time of more than 10 minutes, and could not be intubated without RSI. CT insertion was mandated if RSI was unsuccessful. Each of the 209 study patients was matched to three nonintubated historical controls matched for age, gender, trauma center mechanism of injury and abbreviated injury score (AIS) (total controls 627).

RESULTS: When compared with controls, the RSI group had a lower rate of "good outcomes," defined as discharge to home, jail rehabilitation, a psychiatric facility or leaving against medical advice (45.5% vs. 57.9%, p<0.01) and a higher mortality rate (33% vs. 24.2 p<0.05). The RSI group also had longer scene times (mean, 22.8 vs. 16.4 minutes, p<0.0001) and more frequent inadvertent hyperventilation (15.4 vs. 8.0%, p=0.014). Although the measured mean pO2 on arrival at the ED was higher in the RSI group (315 vs. 216mm Hg in controls, p<0.001 transient hypoxia occurred in more than 50% of the intubated patients in whom pulse oximetry was recorded.

CONCLUSIONS: In these patients with severe traumatic brain injury, rapid sequence intubation by paramedics was associated with worse outcomes than those documented in unintubated control patients. Since patients were excluded if intubation was unsuccessful, the detrimental effect of RSI might have been underestimated.

COMPARISON OF DIFFERENT AIRWAY MANAGEMENT STRATEGIES TO VENTILATE APNEIC NONPREOXYGENATED PATIENTS

Dorges, V., et al, Crit Care Med 31(3):800, 2003

BACKGROUND: Although endotracheal intubation is considered the gold standard for emergency airway management, adjunctive techniques can sometimes be necessary.

METHODS: This German study evaluated alternative strategies for emergency ventilation in an apneic patient. Forty-eight ASA I/II non-preoxygenated adults undergoing general anesthesia for a routine surgical procedure were randomized to use of one of four airway devices (bag-valve-mask [BVM], laryngeal mask airway [LMA], cuffed oropharyngeal airway [COPA] or Combitube [CT]). The devices were inserted by an experienced paramedic, and patients were ventilated with 100% oxygen for three minutes, using a self-inflating pediatric bag.

RESULTS: The study was terminated due to a decrease in oxygen saturation below 90% during insertion in 3/12 patients in the COPA group, 2/12 in the LMA group and 1/12 CT patients; this complication did not occur in the BVM group Achievement of adequate tidal volumes was also accomplished more rapidly in the BVM group (20 vs. 33-43 seconds). Oxygen saturation decreased statistically during insertion of the CT and LMA, but not with the BVM or COPA. In all patients, however, O2 saturation increased to greater than 98% after one minute of ventilation with 100% oxygen.

CONCLUSIONS: Bag valve-mask ventilation with a pediatric self-inflating bag and 100% oxygen appeared to be the most simple and effective of four airway strategies in this series of non-preoxygenated apneic adults ventilated in the operating room by paramedics.

COMPARISON OF DIFFERENT AIRWAY MANAGEMENT STRATEGIES TO VENTILATE APNEIC NONPREOXYGENATED PATIENTS

Dorges, V., et al, Crit Care Med 31(3):800, 2003

BACKGROUND: Although endotracheal intubation is considered the gold standard for emergency airway management, adjunctive techniques can sometimes be necessary.

METHODS: This German study evaluated alternative strategies for emergency ventilation in an apneic patient. Forty-eight ASA I/II non-preoxygenated adults undergoing general anesthesia for a routine surgical procedure were randomized to use of one of four airway devices (bag-valve-mask [BVM], laryngeal mask airway [LMA], cuffed oropharyngeal airway [COPA] or Combitube [CT]). The devices were inserted by an experienced paramedic, and patients were ventilated with 100% oxygen for three minutes, using a self-inflating pediatric bag.

RESULTS: The study was terminated due to a decrease in oxygen saturation below 90% during insertion in 3/12 patients in the COPA group, 2/12 in the LMA group and 1/12 CT patients; this complication did not occur in the BVM group Achievement of adequate tidal volumes was also accomplished more rapidly in the BVM group (20 vs. 33-43 seconds). Oxygen saturation decreased statistically during insertion of the CT and LMA, but not with the BVM or COPA. In all patients, however, O2 saturation increased to greater than 98% after one minute of ventilation with 100% oxygen.

CONCLUSIONS: Bag valve-mask ventilation with a pediatric self-inflating bag and 100% oxygen appeared to be the most simple and effective of four airway strategies in this series of non-preoxygenated apneic adults ventilated in the operating room by paramedics.