rsi putting it all together
TRANSCRIPT
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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
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“One pound of knowledge takes ten pounds of common sense to apply it.”
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“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
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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”
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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.”
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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
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Indication “Immediate severe airway compromise in
the context of trauma, drug overdose, status epilepticus, etc. where respiratory arrest is imminent.”
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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
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Contraindication “Extensive burns or crush injuries greater than
24 hours old.”
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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
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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
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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
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Preparation is the KEY for an organized, smooth intubation
Remember the 7 P’s!!
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IFEndotracheal Intubation Endotracheal Intubation
fails, you must have a back-up plan...
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RSI Procedure: The Seven P’s
1. Preparation2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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1. Preparation A two-part process:
Assess the risks
Prepare the equipment
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Assess the Risks
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Difficult Airways - Assess the Risks“The difficult airway is something one anticipates;
the failed airway is something one experiences.”
-Walls 2002
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How do you know if your patient is going to be difficult to intubate…
…and does it really matter?
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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.
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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
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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
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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
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Difficult to Bag (MOANS) Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff
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Difficult Laryngoscopy & IntubationLEMONS
Look ExternallyEvaluate 3-3-2 Mallampati ScoreObstructionNeck MobilityScene and Situation
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Disruption / Distortion Distortion
Surgeries Radiation Therapy Scarring Burns
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Disruption / Distortion Disruption
Hanging Crush Injuries Penetrating Trauma Other Soft Tissue Trauma
Burns Laceration
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Obstructions Hematoma Abscess Tumor
Tumors can also create distortions & extra bleeding
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Access Issues Obesity Halo Short neck SC Emphysema Bushy beard Flexion deformity of the spine
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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
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Mallampati Classification
Increased success/ease Decreased Increased success/ease Decreased success/easesuccess/ease
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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%
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Always have a back-up plan. Plans “A”, “B”, and “C” Know the answers before you begin
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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.
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“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
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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?
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Always expect the unexpected!
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RSI Procedure: The Seven P’s
1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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1. Preparation A two-part process:
Assess the risks
Prepare the equipment
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Prepare the Equipment
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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
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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
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RSI Procedure: The Seven P’s
1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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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.
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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
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Rapid Sequence Intubation
Medications
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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.
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RSI Procedure: The Seven P’s
1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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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
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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.
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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
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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.
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RSI Procedure: The Seven P’s
1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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4. Paralyze
A three step process: Induction Cricoid Pressure Paralytic
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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.
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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!
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Cricoid Pressure
Use thumb and forefinger to apply pressure directly backward/posterior over the cricoid cartilage.
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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
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Anectine (Succinylcholine)SCh or “Succs” The only depolarizing paralytic in clinical
use Benefits:
Rapid onset Short duration
Will cause “fasciculations”
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Fasciculations Muscular twitching involving the
simultaneous contraction of contiguous groups of muscle fibers
Merriam-Webster Dictionary
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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.
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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!
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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
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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
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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
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Complications Increased intragastric pressure
Passive regurgitation from fasciculations Importance of Cricoid Pressure / Sellick’s
maneuver
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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
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Complications Prolonged paralysis
In patients with: A deficiency of pseudocholinesterase Certain meds: magnesium, lithium, quinidine Cocaine
Masseter muscle rigidity
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RSI Procedure: The Seven P’s
1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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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.
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Direct Visualization…
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Hold manual in-line axial stabilization (MIAS)
Suspected Cervical Injury?
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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.
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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
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RSI Procedure: The Seven P’s
1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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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.
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SpO2 (Pulse Oximetry) Provides quick
estimate of PaO2 Often referred to as
an additional vital sign
Non-invasive
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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.
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The Capnogram Represents the
Respiratory Cycle Exhalation
A to D Inhalation
D to E
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Waveform Capnometry Prerequisite
Requirement Becoming a
standard of care Easy to Use Good measure of
Pulmonary Perfusion
Relates well to PaCO2
Does have limitations
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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.
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RSI Procedure: The Seven P’s
1. Preparation - CONTINUED2. Preoxygenation3. Premedication4. Paralyze 5. Pass the tube6. Proof of placement7. Post intubation care
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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
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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.
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Sedation Assessment Sign/symptoms
Movement Increase in heart rate Increase in blood pressure Decrease in SpO2 Changes in muscle tone Facial muscle tension
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Midazolam (Versed)
Dose: 0.05-0.1 mg/kg IVP Rapid onset – 1-2 minutes Single dose duration: 15-20 minutes
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Midazolam Duration: 1-4 hours Hepatic clearance Decreased dose needed (longer half life)
Obese Geriatric CHF Hepatic or renal insufficiency
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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
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Fentanyl Class
Anesthetic Induction / Maintenance
Narcotic 25-100 mcg may be
considered prn
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Fentanyl Opioid agonist Dampens sympathetic (catecholamine)
response Does not release histamine May cause stiff chest in doses >500mcg Caution in hypotension / hypovolemia
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Vecuronium & Rocuronium Non-Depolarizing
Paralytics Provide paralysis, but
NO sedation, amnesia, or analgesia properties
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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
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Vecuronium
Dose: 0.1mg/kg IVP Repeat/maintenance dose: 0.01 mg/kg Onset: 2-3 minutes Duration: approx. 20-30 minutes
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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
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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
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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
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Review:Sequence of Administration
Time -5 minutes Preoxygenation Time -2 minutes Premedication Time -0 minutes Sellick Maneuver,
Induction Agent, Paralytic
Time +1 minutes Intubation
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Medication Sequence Oxygen Lidocaine and/or Atropine if indicated Etomidate Cricoid Pressure Succinylcholine INTUBATION Lorazepam / Fentanyl prn Rocuronium or Vecuronium prn
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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
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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
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“Failed Airway”Worst case scenario:
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Know Your Options!!!& Don’t hesitate to use them!
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Failed AirwayUnable to intubate
(including blind devices) and unable to ventilate with a BVM and maintain an Sp02 > 90 %.
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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.
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BVM Can you obtain a good mask seal? Adequate chest rise & fall? Adequate oxygenation & ventilation?
Assistant: You will most likely be performing this skill.
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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
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LMA Good temporizing
measure Multiple sizes Aspiration likely if
vomiting occurs Pre-Hospital use
unproven/unpublished Risk of aspiration
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CombitubeEspecially suited for…
Patients with difficult anatomy Reduced access spaces Reduced illumination (bright light)
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King-LT-D
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Failed Airway Management
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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
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Additional Documentation Items Why was the decision made to RSI Pre & Post O2 and CO2 levels Airway Grading/scales Unsuccessful Attempts
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Case Studies
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Case 1 67 y/o female “code blue” – in asystole.
PLAN?
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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?
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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?
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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?
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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?
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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?
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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