rsi - paramedic

Rapid Sequence Rapid Sequence InductionInduction

What is it?What is it?

It is a virtually simultaneous It is a virtually simultaneous administration of a potent administration of a potent sedative and a neuromuscular sedative and a neuromuscular blocking agent for the purpose of blocking agent for the purpose of intubationintubation

PurposePurpose

Routine: To introduce anesthesia Routine: To introduce anesthesia and neuromuscular blockade in and neuromuscular blockade in preparation for intubationpreparation for intubation

Emergency: To produce Emergency: To produce neuromuscular blockade to facilitate neuromuscular blockade to facilitate placement of an endotracheal tube placement of an endotracheal tube in those patients in which the airway in those patients in which the airway could not otherwise be managed.could not otherwise be managed.

Candidates for RSICandidates for RSI

Adults and childrenAdults and children Full or partially consciousFull or partially conscious Seizures resulting in status Seizures resulting in status

epilepticus unresponsive to epilepticus unresponsive to benzodiazepines.benzodiazepines.

Hypoxic and Combative, unable to Hypoxic and Combative, unable to intubate by regular meansintubate by regular means

Trauma with seizures or trismusTrauma with seizures or trismus

AdvantagesAdvantages

Easier intubationEasier intubation Reduces ICP associated with Reduces ICP associated with

intubationintubation Short-actingShort-acting

IndicationsIndications

Inadequate oxygenationInadequate oxygenation Inadequate ventilationInadequate ventilation Inability to maintain a patent airwayInability to maintain a patent airway Protection of the lower airwayProtection of the lower airway Treatment of elevated ICPTreatment of elevated ICP Impending airway collapse Impending airway collapse Control of the patientControl of the patient Head injuriesHead injuries Drug overdoseDrug overdose Status epilepticusStatus epilepticus

General Order of Rapid General Order of Rapid Sequence InductionSequence Induction

Brief HistoryBrief History Equipment PreparationEquipment Preparation PreoxygenationPreoxygenation PremedicationPremedication SedationSedation Cricoid PressureCricoid Pressure Muscle RelaxationMuscle Relaxation IntubationIntubation Verification of Tube PlacementVerification of Tube Placement Tube SecurityTube Security

Brief HistoryBrief History

ABC’s have been checked if a ABC’s have been checked if a decision to intubate has been decision to intubate has been mademade

History of present illness or injuryHistory of present illness or injury Inspection of head and airwayInspection of head and airway

– Difficult airway???Difficult airway??? Assessment of neck for possible Assessment of neck for possible

traumatrauma

Difficult Airways--Difficult Airways--MEDICTUBESMEDICTUBES MMouth, mandibleouth, mandible EExcessive weightxcessive weight DDeformityeformity IIncisorsncisors CC-spine-spine TThyromental distancehyromental distance UUvulavula BBurnsurns EEmesismesis SStridortridor

Mouth, MandibleMouth, Mandible

Measure the width of the mouth opening. Anything less than three (3) fingers width can complicate laryngoscopy. Mandible should be without deformity or dislocation.

Excessive WeightExcessive Weight

Overweight, pregnant or no-neck patients can also be very complicated. Complete repositioning of the patient may be required in order to visualize the airway

DeformityDeformity

IncisorsIncisors

C-Spine, TraumaC-Spine, Trauma

Patients with cervical immobilization in place have mis-aligned airway structures, landmarks and pathways.

These patients must remain immobile with cervical spine secured without manipulation when attempting intubation.

Thyromental DistanceThyromental Distance

Distance from chin to thyroid cartilage. Anything less than three (3) fingers width suggests difficult intubation.

UvulaUvula

Mallampati Signs. Ideally, you should be able to see the entire oropharynx, including the uvula. Any airways with a partial or complete concealment of this structure may prove difficult to intubate.

BurnsBurns

EmesisEmesis

StridorStridor

Equipment and Equipment and MedicationMedication

SOAPMESOAPME SSuctionuction OOxygenxygen AAirway (laryngoscope, ET tubes, stylet, irway (laryngoscope, ET tubes, stylet,

BVM, tube holder)BVM, tube holder) PPharmacology (mix, draw-up and label)harmacology (mix, draw-up and label) MMonitoring onitoring EEquipment (ECG, SaO2, quipment (ECG, SaO2,

etCO2)etCO2)

PreoxygenationPreoxygenation

2- 5 minutes of 100% Oxygen 2- 5 minutes of 100% Oxygen before initiation of sedation and before initiation of sedation and neuromuscular blockadeneuromuscular blockade

BVM only if necessaryBVM only if necessary

PremedicationPremedication

Atropine * Atropine * in children onlyin children only

– Due to vagal stimulation causing Due to vagal stimulation causing bradycardiabradycardia

LidocaineLidocaine– Prevention of increased ICPPrevention of increased ICP

Defasciculating Agent Defasciculating Agent

AtropineAtropine

Bradycardia may be caused by hypoxia, Bradycardia may be caused by hypoxia, succinylcholine or vagal stimulation succinylcholine or vagal stimulation during laryngoscopy or vagal stimulationduring laryngoscopy or vagal stimulation

Atropine reduces vagal toneAtropine reduces vagal tone Atropine decreases secretionsAtropine decreases secretions *Atropine may be indicated before a *Atropine may be indicated before a

second dose of succinylcholine in second dose of succinylcholine in adolescents and adultsadolescents and adults

Adult: 0.6 – 0.8 mg IV, Pediatric: 0.02 Adult: 0.6 – 0.8 mg IV, Pediatric: 0.02 mg/kgmg/kg

LidocaineLidocaine

Is believed to blunt the increased Is believed to blunt the increased ICP response to intubationICP response to intubation

It is required in all cases of It is required in all cases of suspected head traumasuspected head trauma

Dosage: 1.5 mg/kg IVPDosage: 1.5 mg/kg IVP

SedationSedation

Administered to eliminate the sensation of paralysis and decrease sympathetic tone

Remember that paralytics do NOT alter consciousness. They do not work on the central nervous system. Your patient is aware of everything that is going on!

Sedation OptionsSedation Options

Sedative selection must be made on Sedative selection must be made on an individual patient basis with an individual patient basis with consideration of hypovolemia, consideration of hypovolemia, hypotension, increased ICP, age and hypotension, increased ICP, age and underlying medical conditionsunderlying medical conditions

Sedatives should never be withheld Sedatives should never be withheld from the patient about to undergo from the patient about to undergo paralysis! There are ethical paralysis! There are ethical considerations as well.considerations as well.

SedativesSedatives

While benzodiazepines are mostly given While benzodiazepines are mostly given in the field, you may also need to be in the field, you may also need to be familiar with these other sedatives:familiar with these other sedatives:

Thiopental (Pentothal)Thiopental (Pentothal) Midazolam (Versed)Midazolam (Versed) Lorazepam (Ativan)Lorazepam (Ativan) Fentanyl (Sublimaze)Fentanyl (Sublimaze) Ketamine (Ketalar)Ketamine (Ketalar) Etomidate (Amidate)Etomidate (Amidate) Propofol (Diprivan)Propofol (Diprivan)

Thiopental (Pentothal)Thiopental (Pentothal) Short-acting barbiturateShort-acting barbiturate Produces rapid, deep sedation but Produces rapid, deep sedation but

not analgesianot analgesia Excellent choice for sedation of Excellent choice for sedation of

patients with head injury because:patients with head injury because:– attenuates the ICP response to intubationattenuates the ICP response to intubation– reduces the cerebral metabolic rate and reduces the cerebral metabolic rate and

oxygen consumptionoxygen consumption– acts as a free radical scavenger to decrease acts as a free radical scavenger to decrease

brain damage by toxic metabolites in the brain damage by toxic metabolites in the injured braininjured brain

Thiopental (Pentothal) Thiopental (Pentothal) cont’dcont’d Adverse Effects:Adverse Effects:

– respiratory depression and apnearespiratory depression and apnea– decreased cardiac outputdecreased cardiac output– hypotensionhypotension– anaphylaxisanaphylaxis– bronchospasmbronchospasm

Midazolam (Versed)Midazolam (Versed)

BenzodiazepineBenzodiazepine Provides sedation, amnesia and Provides sedation, amnesia and

anticonvulsant propertiesanticonvulsant properties No analgesiaNo analgesia Advantages over other Advantages over other

benzodiazepinesbenzodiazepines– faster onset than Ativan or Valiumfaster onset than Ativan or Valium– shorter duration than Ativan or Valiumshorter duration than Ativan or Valium

Midazolam (Versed) Midazolam (Versed) cont’dcont’d Adverse effects:Adverse effects:

– cardiovascular depressioncardiovascular depression– respiratory depressionrespiratory depression– broad dosing range and need for broad dosing range and need for

titrationtitration

Fentanyl (Sublimaze)Fentanyl (Sublimaze)

Short-acting narcoticShort-acting narcotic Often used in combination with a Often used in combination with a

benzodiazepinebenzodiazepine The dose for induction is variable The dose for induction is variable

and much higher than for and much higher than for premedicationpremedication

Fentanyl (Sublimaze) Fentanyl (Sublimaze) cont’dcont’d Adverse Effects:Adverse Effects:

– cardiovascular depression at high cardiovascular depression at high dosesdoses

– skeletal and thoracic muscle rigidityskeletal and thoracic muscle rigidity

Ketamine (Ketalar)Ketamine (Ketalar)

A dissociative anesthetic agentA dissociative anesthetic agent Also a phencyclidine derivativeAlso a phencyclidine derivative Causes analgesia, amnesia, Causes analgesia, amnesia,

dissociation from the dissociation from the environment, maintenance of environment, maintenance of reflexes, cardiorespiratory reflexes, cardiorespiratory stabilitystability

Ketamine (Ketalar) Ketamine (Ketalar) cont’dcont’d Adverse Effects:Adverse Effects:

– increases ICPincreases ICP– increases blood pressureincreases blood pressure– increases airway secretionsincreases airway secretions– increases intraocular pressureincreases intraocular pressure– increases intragastric pressureincreases intragastric pressure– causes hallucinations known as causes hallucinations known as

emergence reactionsemergence reactions

Etomidate (Amidate)Etomidate (Amidate)

Rapid-onsetRapid-onset Short-actingShort-acting Sedative-hypnotic agentSedative-hypnotic agent Not approved for children under 10 Not approved for children under 10

yearsyears Reduces cardiorespiratory depressionReduces cardiorespiratory depression Minimizes increased ICP during Minimizes increased ICP during

intubationintubation

Etomidate (Amidate) Etomidate (Amidate) cont’dcont’d Adverse Effects:Adverse Effects:

– transient reduction in plasma transient reduction in plasma cortisol levelscortisol levels

– transient reduction in aldosterone transient reduction in aldosterone levelslevels

Propofol (Diprivan)Propofol (Diprivan)

Relatively new anesthetic Relatively new anesthetic induction and sedative agentinduction and sedative agent

Rapid onsetRapid onset Short duration of actionShort duration of action Cerebroprotective effects similar to Cerebroprotective effects similar to

thiopentalthiopental Recommended for ages 3 and overRecommended for ages 3 and over

Propofol (Diprivan) Propofol (Diprivan) cont’dcont’d Adverse Effects:Adverse Effects:

– can decrease mean arterial pressurecan decrease mean arterial pressure

Prehospital ChoicePrehospital Choice

There is literature that demonstrates There is literature that demonstrates that approximately 30% of prehospital that approximately 30% of prehospital RSI could be avoided by using “High-RSI could be avoided by using “High-dose Versed”dose Versed”

Dose 0.1 mg/kg (max dose is 10 mg)Dose 0.1 mg/kg (max dose is 10 mg) Often, the patient will sedate enough to Often, the patient will sedate enough to

be intubated without requiring RSI.be intubated without requiring RSI. If unsuccessful, proceed to paralytics.If unsuccessful, proceed to paralytics.

Cricoid PressureCricoid Pressure

Selleck’s Maneuver prevents passive Selleck’s Maneuver prevents passive regurgitation during intubationregurgitation during intubation

Place digital pressure over the cricoid Place digital pressure over the cricoid cartilage to occlude the esophaguscartilage to occlude the esophagus

Cricoid pressure is released after the Cricoid pressure is released after the patient has been successfully patient has been successfully intubatedintubated

Muscle RelaxationMuscle Relaxation

Neuromuscular Blockade allows Neuromuscular Blockade allows for easier intubation and for easier intubation and ventilationventilation

A muscle relaxant is given in A muscle relaxant is given in rapid sequence with a sedative rapid sequence with a sedative before intubation is attemptedbefore intubation is attempted

Categories of Categories of Neuromuscular Neuromuscular Blocking AgentsBlocking Agents DepolarizingDepolarizing

– (noncompetitive and nonreversible)(noncompetitive and nonreversible)– produces a brief period of excitation produces a brief period of excitation

resulting in fasciculations followed by a resulting in fasciculations followed by a brief period of neuromuscular blockadebrief period of neuromuscular blockade

Nondepolarizing Nondepolarizing – (competitive and reversible)(competitive and reversible)– slower onset than depolarizing agentslower onset than depolarizing agent– no fasciculationsno fasciculations

Neuromuscular Neuromuscular BlockadeBlockade Using neuromuscular blockadeUsing neuromuscular blockade How neuromuscular blocking How neuromuscular blocking

agents workagents work

Before ParalysisBefore Paralysis

Clinical endpoint should be Clinical endpoint should be established at the startestablished at the start

Know exactly why the patient is Know exactly why the patient is being paralyzedbeing paralyzed

How will we know when we have How will we know when we have met goals of care?met goals of care?

Indications for Indications for ParalysisParalysis To facilitate intubation To facilitate intubation Agitation so severe that patient is at Agitation so severe that patient is at

risk of injury despite appropriate risk of injury despite appropriate sedationsedation

Severe hypoxemia, to reduce oxygen Severe hypoxemia, to reduce oxygen consumption by muscle movementconsumption by muscle movement

Increased ICPIncreased ICP Seizures, trismusSeizures, trismus

Indications for Indications for ParalysisParalysis To facilitate To facilitate

procedures and procedures and diagnostic tests diagnostic tests such as CT scans such as CT scans and MRIs, when and MRIs, when patients must patients must remain stillremain still

Indications for Indications for ParalysisParalysis

When patients When patients with seizures are with seizures are paralyzed, it is paralyzed, it is critical to critical to remember that remember that just because you just because you can’t see motor can’t see motor activity, it doesn’t activity, it doesn’t mean the seizures mean the seizures are stopped in the are stopped in the brain!brain!

How Muscles ContractHow Muscles Contract

Muscle receives Muscle receives impulse from impulse from nerve or nerve nerve or nerve groupgroup

Muscle and nerve Muscle and nerve do not touchdo not touch

Synapse at the Synapse at the neuromuscular or neuromuscular or myoneural myoneural junctionjunction


Axon contains Axon contains neurotransmitterneurotransmitter

Muscle has Muscle has special receptorsspecial receptors

Between nerve Between nerve and muscle, and muscle, neurotransmitter neurotransmitter is acetylcholineis acetylcholine


Acetylcholine Acetylcholine triggers triggers cholinergic cholinergic receptors on receptors on muscle cellsmuscle cells

Muscle contractsMuscle contracts AcetylcholinesterAcetylcholinester

ase removes ase removes neurotransmitterneurotransmitter

Classifying NMBsClassifying NMBs

DepolarizingDepolarizing– mimic mimic

acetylcholineacetylcholine– sustained sustained

depolarization depolarization at synapseat synapse

– prevents prevents repolarizationrepolarization

– muscle fiber muscle fiber refractoryrefractory

NondepolarizingNondepolarizing– block block

cholinergic cholinergic transmission at transmission at synapsesynapse

– binds to binds to acetylcholine acetylcholine receptors on receptors on musclemuscle


DepolarizingDepolarizing– succinylcholinesuccinylcholine

NondepolarizingNondepolarizing– atracuriumatracurium– doxacuriumdoxacurium– mivacuriummivacurium– pancuroniumpancuronium– rocuroniumrocuronium– VecuroniumVecuronium– rapacuroniumrapacuronium


Short & Short & IntermediateIntermediate– rapacuroniumrapacuronium– atracuriumatracurium– mivacuriummivacurium– rocuroniumrocuronium– vecuroniumvecuronium

Long ActingLong Acting– doxacuriumdoxacurium– pancuroniumpancuronium

Patient Care Patient Care ResponsibilitiesResponsibilities

All patients All patients receiving receiving paralytic drugs paralytic drugs must also must also receive receive sedationsedation

Succinylcholine Succinylcholine (Anectine)(Anectine) Depolarizing agentDepolarizing agent Rapid onsetRapid onset Short durationShort duration

Succinylcholine Succinylcholine (Anectine) cont’d(Anectine) cont’d Adverse Effects:Adverse Effects:

– increased ICPincreased ICP– increased intraocular pressureincreased intraocular pressure– increased intragastric pressureincreased intragastric pressure– hyperthermiahyperthermia– muscarinic stimulation of the SA node muscarinic stimulation of the SA node

causing bradycardia especially in causing bradycardia especially in childrenchildren

– release of potassiumrelease of potassium

Succinylcholine Succinylcholine (Anectine) cont’d(Anectine) cont’d Contraindications:Contraindications:

– patients with burns more that 24 hours patients with burns more that 24 hours oldold

– massive muscle injurymassive muscle injury– patients with upper motor neuron patients with upper motor neuron

diseases such as Muscular Dystrophydiseases such as Muscular Dystrophy– penetrating globe injurypenetrating globe injury– history of malignant hyperthermiahistory of malignant hyperthermia– other agents are preferable in childrenother agents are preferable in children

Rocuronium (Zemuron)Rocuronium (Zemuron)

Nondepolarizing agentNondepolarizing agent Relatively new agentRelatively new agent Rapid onsetRapid onset Vagolytic propertiesVagolytic properties Studies with Succinylcholine have Studies with Succinylcholine have

shown no difference in time to actionshown no difference in time to action No fasiculations at onset of paralysisNo fasiculations at onset of paralysis

Rocuronium (Zemuron) Rocuronium (Zemuron) cont’dcont’d Longer duration than Longer duration than

SuccinylcholineSuccinylcholine

Vecuronium Vecuronium (Norcuron)(Norcuron) Nondepolarizing agentNondepolarizing agent Slower onsetSlower onset Longer durationLonger duration Minimal cardiovascular effectsMinimal cardiovascular effects Produces no histamine releaseProduces no histamine release

Vecuronium Vecuronium (Norcuron) cont’d(Norcuron) cont’d Longer duration than Longer duration than

Succinylcholine - 90 - 120 Succinylcholine - 90 - 120 minutesminutes

Reversing Reversing Nondepolarizing Nondepolarizing AgentsAgents NeostigmineNeostigmine PyridostigminePyridostigmine EdrophoniumEdrophonium Administer Atropine before Administer Atropine before

reversing a nondepolarizing agent reversing a nondepolarizing agent to abort the muscarinic effectsto abort the muscarinic effects

IntubationIntubation

Visualization with direct Visualization with direct laryngoscopylaryngoscopy

Introduction of the appropriate Introduction of the appropriate sized ET tubesized ET tube

Verification of Verification of PlacementPlacement Auscultation of bilateral breath Auscultation of bilateral breath

soundssounds Equal chest rise, misting in tubeEqual chest rise, misting in tube Absence of epigastric air movementAbsence of epigastric air movement Use one other method besides Use one other method besides

auscultationauscultation– End-Tidal COEnd-Tidal CO22 monitoring monitoring– Esophageal Detector DeviceEsophageal Detector Device

Security of ET TubeSecurity of ET Tube

Chart the depth of the ET tube at the Chart the depth of the ET tube at the patient’s lippatient’s lip

Use tape or an approved ET tube Use tape or an approved ET tube holder to secure the ET tube at the holder to secure the ET tube at the correct depthcorrect depth

Re-evaluate tube placement by Re-evaluate tube placement by checking the depth of the ET tube and checking the depth of the ET tube and auscultating breath sounds at regular auscultating breath sounds at regular intervalsintervals

SummarySummary

Be preparedBe prepared Re-assess frequentlyRe-assess frequently Be vigilantBe vigilant

rsi - paramedic

Documents