1
#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
3
Sedatives for RSI
4
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
5
Paralytics for RSI
6
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
7
8
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.