basic rsi in the ed - collaboration. innovation. … · plan & prepare pre-oxygenate &...

H:reedflowcharts:airwayskills Dr. Duncan Reed, Director of Trauma Dec 2008 REVIEWED FEB 2012 & MAR 2013 1

BASIC RSI

IN THE ED

Dr D. Reed 2013


BASIC AIRWAY & RSI SKILLS

Golden Rules Basic Questions

1. BASIC PRINCIPLES Patients Specific Pitfalls

Paediatric Pearls

Suction 2. BASIC AIRWAY MAINTENANCE Manoeuvres

Devices Bag mask Plan & Prepare Pre-oxygenate & Position

3. RSI SEQUENCE Perform

Proof Post Intubation Predict (Can I?) Pillow Pre oxygenate Pull on mouth 4. TIPS / TRICKS / TECHNIQUES BURP

Blades Bougie Two person bag mask Laryngeal mask Laryngeal mask 5. RESCUE AIRWAYS Needle Cricothyroidectomy

Surgical Airway Difficult/Rescue airway - ‘inexperience’ - ‘poor preparation’ - rarely ‘truly difficult’


BASIC PRINCIPLES OF RSI

Golden Rules

Oxygenate and ventilate at all times (No ETT required!)

Inexperience makes any airway difficult

Experience teaches you to plan and prepare properly

Always have a back-up plan

When in doubt seek help

Basic Questions

Can I wait? (necessary? urgency? help available?)

Can I bag?

Can I tube? need 2 out of 3 to proceed

Can I rescue?

Patient Specific Pitfalls The following patient groups are particularly prone to either airway difficulty (A), rapid desaturation (B) or haemodynamic instability (C) during RSI and need to have strategies to optimise your intubation

‘Sick’ patients (B + C)

Trauma patients (A + B + C)

Elderly patients (B + C)

Obese patients (A + B)

Paediatric patients (B)

‘Sick’ and Elderly Patient Pearls

Anticipate rapid desaturation and haemodynamic instability

Optimise pre-oxygenation nb NP O2

Optimise fluid status with adequate pre-load plus bolus and inotropes available

Very low dose induction agent with maximal dose sux

Do not overventilate post intubation


Trauma Patient Pearls

Anticipate difficult tube, rapid desaturation and haemodynamic instability

Optimise pre-oxygenation

Prepare team for potential difficult intubation

Optimise fluid status if time allows

Very low dose induction agent with maximal dose sux


Obese Patient Pearls

Anticipate difficult tube, rapid desaturation and haemodynamic instability

Optimise pre-oxygenation

Prepare team for potential difficult intubation

Position sniffing, ramped up & bed up (nb tragus at level of sternum)

Optimise fluid status if time allows

Low dose induction agent (lean body weight) with maximal dose sux (total body weight)


Paediatric Pearls

Kids are easy to bag (if positioned properly) and kids are easy to tube

Stay in the midline

Always check equipment sizes and drug doses

Beware bradycardia

Beware rapid desaturation

Rescue with LMA (or needle cricothyrotomy)

Always place an NGT/OGT to decompress the stomach (nb hypotension or ventilation difficulty)

Always look at chest movements when ventilating with an uncuffed tube


AIRWAY MAINTENANCE

Suction

“Under the pillow”

Adequate

Simple Manoeuvres

Chin lift and head tilt

Jaw thrust

Combined spinal immobilisation with jaw thrust for trauma

Simple Devices

Guedels (incisor to angle of jaw - nb Madonna)

Nasopharyngeal (nares to tragus)

Bag and Mask

Correct sizes

Two person technique

Consider two person/four hand/two nasopharyngeal/guedels

Make the bag your friend

Bagging fills the stomach

Laryngeal mask = “advanced bagging”


RAPID SEQUENCE INTUBATION

Systematic Approach

Plan & Prepare

Pre-oxygenate & Position

Perform

Proof

Post intubation

Plan

Purpose - Necessity? - Urgency?

Predict Airway - Can I wait? (get help and optimise) - Can I bag? (Xmas/distortion) - Can I tube? (a lemon) - Can I rescue? (distortion)

Predict Breathing & Circulation - Rapid desaturation likely? - Difficult ventilation likely? - Haemodynamically unstable?

Plan A & B - Have a plan A - Communicate it! - Have a Plan B if things go wrong

The most important thing to do is to think about potential difficulties and prepare for them. This includes communicating your concerns and Plan B to your team.

It is sometimes better to wait for help or consider an alternative approach to RSI such as gaseous induction in OT.

“Talk to Team”

“Trauma Airway = Difficult Airway”


“Difficult to Bag” - Old - Fat - Bearded - No teeth - Distorted

“Difficult to Tube” - Inexperience - Inadequate preparations - Previous attempts - “A LEMON”

“Difficult to Rescue” - Burns - Trauma - Distortion

“A LEMON”

A - “Anaesthetic history”

- Allergy - Alert bracelet

L - “Look” - Teeth and tongue Guide only - Beard and chin - Trauma Misses up to 50%

E - “Evaluate” 3/3/2 - Mouth open 3 fingers - Mentum to hyoid 3 fingers Enough time ? - Thyroid to floor mouth 2 fingers

M - “Mallampati” - Uvula visibility

O - “Obstruction / obesity”

- Blood / abscess/ foreign body/ fat

N - “Neck mobility”

“Father Xmas”

“A LEMON”

“Trauma Airway = Difficult Airway”


Prepare

Always “S.P.E.N.D.” time preparing !

Staff - Allocate roles

- Check familiarity

- Intubator

- Drugs and fluids

- Equipment

- Cricoid/BURP/ELM/angle of mouth

- C-spine

Patient - Patient specific problem (pregnancy/ paeds/ obesity/ elderly/hypotensive)

- Position (sniff pillow if c-spine ok)

- Protect (C-spine)

- Pre-oxygenate (nb NRB / BVM / NP / BIPAP)

Equipment - NRB O2 and bag mask

- Guedels and sucker

- Laryngoscopes x 2 with different size blades

- ETT checked/lubed/introduced and bougie

- Ties and bite block and pillow

- Post-intubation (NG/ OG/ ETCO2 /syringe)

- Rescue/difficult/failed tray

Non Invasive - O2/ ETCO2 Monitoring - HR/BP

Drugs and - KISS 02/ Thio/ Sux Fluids N Saline Aramine (?) Post-intubation drugs (vec/m&m)

Cricoid / BURP / Mouth

Cricoid - passive regurgitation - improve view

‘Pre-oxygentate” ‘Position’

Always use an introducer

Consider video laryngoscope

Always consider a bougie


Pre-oxygenate

Pre-oxygenate on 15L/min O2 via NRB for at least 5 minutes or 8 maximal breaths

Consider high flow NP O2 at 15L/min for all patients for additional passive oxygenation

Consider BIPAP for some patients to maximise pre-O2

Pre-oxygenation de-nitrogenates the lungs and gives a reservoir of 100% O2 for passive diffusion while

you intubate

Time to de-saturate will vary according to patient variables (see diagram). Most Emergency Department

patients will de-saturate rapidly compared to elective anaesthesia

Pre-oxygenation will buy you a little time but that is usually enough

Most patients can be easily bagged up again before another try, but remember to allow sufficient time to

adequately re-oxygenate

Position

The vast majority of ‘difficult’ intubations can be made easy by positioning the patient properly

Remember ‘THE PILLOW IS YOUR FRIEND”

Most adults simply require a pillow to optimise the alignment of oral, pharyngeal and laryngeal axes

Note that the intubators head has to be sufficiently low down so that their line of sight parallels the

‘axis of intubation’ ’look from low down’

Perform

- Position (nb pillow) - Pre-oxygenate (5 mins / 8 maximal breaths) - Drugs with flush - Cricoid - Do not bag - Fasciculation - Laryngoscope (lift not lever) - Look from low down - Place tube - Remove introducer - Bag - Inflate cuff - Remove cricoid only when position checked

If second attempt required then it is crucial to approach this systematically and consider getting help or changing the intubator or changing something. As long as the patient can be oxygenated and ventilated there is time

Pre-oxygenate

Position

Lift not lever Look from lowdown


Options for a second attempt include waking the patient up, changing the intubator or changing something about the technique used.

The most useful things to do prior to a second attempt - if not done previously: - get help - position with a pillow - use an introducer - change the blade size or type - use BURP/ELM (nb move assistants hand yourself) - use a bougie - prepare Plan B (laryngeal mask/surgical airway)

Proof

Visual (through the chords)

Fogging

Chest movement

Listen in axilla

ETCO2 (disposable >> sidestream)

Aspiration of ETT with 50ml Toomey (variant of oesophageal bulb)

Sa O2 (late)

CXR (depth only)

ABG (ventilation)

Flexible bronchoscope if skilled & available

Post-Intubation

Document

Drugs - Morphine - Midazolam - Vecuronium

NG/ OG

Bite block – Guedels

Basic ventilation - PEEP 5-10 - TV 5-7ml/kg - RATE 12-14 - 100% O2 - Check ABG - Check pressure

Get help Change something


TIPS/TRICKS/TECHNIQUES

Can I bag / tube / rescue / wait?

Pre-oxygenate

Position with pillow

Pull on angle mouth

BURP (nb move the assistants hand yourself)

BLADE (consider video laryngoscope as alternative blade)

BOUGIE

Two person bag mask

Laryngeal mask

RESCUE AIRWAY

Laryngeal mask

Needle cricothyroidotomy

Surgical cricothyroidotomy

‘Inexperience’ and ‘poor preparation’ more common than ‘truly difficult’

TEAMS / TEAMWORK

Training and equipment familiarity

Talk to the Team:

- planning (especially plan B) - prepare roles and check familiarity - especially check familiarity with cricoid / BURP/bougie

Team Leader ideally should not intubate (focus inattention)


PRE OXYGENATE !

NOTE :

The following groups desaturate rapidly

KIDS

PREGNANT

OBESE

ELDERLY

CROOK


MALLAMPATI SCORE

NOTE:

ORIGINALLY SITTING UP AND TONGUE OUT

PRACTICALLY ASK - CAN YOU SEE THE TIP OF UVULA ?


POSITION WITH PILLOW AND LOOK FROM

LOWDOWN DUE TO THE LINES OF SIGHT


LIFT NOT LEVER & ANGLE OF MOUTH

CORMACK & LEHANE VIEW


SURGICAL AIRWAY TECHNIQUES

Needle Cricothyroidotomy

Equipment

High flow wall oxygen 50 RSI

Oxygen tubing

Side hole in tubing or 3 way tap to allow ventilation

Cannula connection

14g cannula

10ml syringe

5ml NS

Technique

Identify cricothyroid membrane

Prepare skin

Stand on patients left

Stabilise neck with left hand from below

Place re-inforced 14g cannula on 10ml syringe with 5ml NS

Insert cannula through cricothyroid membrane

Direct cannula 45° caudally aspirating as you go

Stop when aspirate air

Secure cannula with left hand

Remove needle and syringe with right hand while advancing cannula with left hand

Recheck that air can be aspirated

Connect oxygen tubing

Ventilate at 15L/min at 50 PSI (or 1L/min/year of age)

On for 1 second off for 4 seconds

Confirm chest movement usually

Allow passive exhalation via upper airway


Surgical Cricothyroidotomy

Equipment

Self inflating bag

Oxygen tubing

ETT or tracheostomy tube sizes 5 & 6

Scalpel

Artery forceps

Tracheal hooks (optional)

Tracheal spreader (optional)

Technique


Prepare skin

Stand on patients right

Secure thyroid cartilage with left hand from above

Vertical skin incision in midline over cricothyroid membrane

Spread skin with left hand

Transverse incision through cricothyroid membrane with scalpel

Remove scalpel and place index finger left hand into incision

Place artery forceps into incision and dilate incision with right hand

Stabilise artery forceps in left hand

Insert ETT or tracheostomy tube with right hand

Inflate cuff

Check adequacy of ventilation

Secure tube


Modified Cook/Melker Seldinger Technique

Equipment

Cook/Melker Set

Needle cricothyroidotomy jet ventilation set

Technique


Prepare skin

Stand on patients left

Stabilise neck with left hand from below

Insert re-inforced 14g cannula through cricothyroid membrane

Direct 45° caudally aspirating as you go

Stop when aspirate air

Secure cannula with left hand

Remove needle and syringe with right hand while advancing cannula with left hand

Recheck air aspiration

Connect for ventilation to oxygenate before proceeding to insert Cook/Melker airway

Insert wire through cannula

Remove cannula

Make caudal stab adjacent to wire with scalpel

Pass Melker airway and dilator over wire (size 5-0)

Advance dilator inside trachea

Then advance Melker airway over dilator into trachea

Remove wire and dilator

Inflate cuff

Ventilate with self inflicting bag


Modifications to Cricothyroidotomy Techniques

Scalpel Bougie

As per surgical cricothyroidotomy but:

Horizontal stab incision through cricothyroid membrane

Rotate scalpel through 90° and enlarge incision caudally

Transfer scalpel to left hand

Introduce bougie with right hand

Remove scalpel

Consider jet ventilation via bougie

Feed size 6 ETT over bougie (with connector removed)

Remove bougie and secure ETT

Ventilate

Potential advantage of still having instrument in incision hole at all times and less steps

Scalpel Finger Needle for Fat Necks/No Anatomy

As per surgical cricothyroidotomy but:

Generous vertical midline incision of skin and fat

Blunt dissect neck with fingers including strap muscles


Secure with left hand

Insert re-inforced 14g needle with right hand as per needle techniques

Jet ventilate

Convert with Melker Set

Potential advantage when cannot recognise anatomy. Allows for early oxygenation.

DR D Reed June 2011


NB: CONFIRMING ETT POSITION

- ETCO2 (disposable/sidestream/ABG) - Visual; fogging; chest movement - Listen axillae and stomach - Toomeys syringe/oesophageal detection device - SaO2 (late) CXR (depth) ABG (ventilation)

- Flexible bronchoscope if experienced

basic rsi in the ed - collaboration. innovation. … · plan & prepare pre-oxygenate &...

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