rsi sheet-2007
TRANSCRIPT
12/15/2007
1
Rapid Sequence Intubation (RSI)
in Emergency Room
Siriporn Pitimana-aree, MD
Dept. of Anesthesiology,
Faculty of Medicine Siriraj hospital.(The Royal College of Anesthesiologists of Thailand)
RSI in Emergency Department
• Indications for intubation• Considerations in Emergency intubation• Rapid Sequence Intubation (RSI) • The Failed Airway• Defining the Difficult Airway• Rescue Devices
Outline
Indications for ETT intubation
• Absent or inadequate respiration
• Impending airway obstruction
• Inability to protect airway
Emergency ETT intubation:
• Time pressure
• Unstable patient
• Possibly difficult situation
• Uncooperative / combative
• Not fasted• Difficult airway
Considerations
• Physiologic responses
Emergency ETT intubation:
Physiologic responses to intubation
•Gagging•Rise in ICP•Rise in BP•Tachycardia / Bradycardia•Dysrhythmias
• Incidence of difficult & failed intubation: 8%
• Frequency of esophageal intubation: 8% 40% of these - difficult intubation
almost all recognized by clinical criteria
but 3, decrease saturation detected by SpO2
• Incidence of pulmonary aspiration: 4%
• Hemodynamic consequences: 3% died during or within 30 min. of intubation
12/15/2007
2
Definition
The virtually simultaneous administration of a potent sedative agent
& a neuromuscular blocking agent to induce unconsciousness
& motor paralysis for tracheal intubation.
Rapid Sequence Intubation (RSI)
Definition Incorporates:
• Every patient has a full stomach• Preoxygenation• No interposed ventilations• Sellick’s maneuver
Rapid Sequence Intubation (RSI)
Advantages of RSI
•Minimizes risk of aspiration•Facilitate intubation•Blunt untoward physiologic responses•Avoid awake intubation
Rapid Sequence Intubation (RSI)
Contraindications:
Anticipate of difficult airway& intubation
Staff inexperienced in RSI
Patients allergic or contraindication todrugs used in RSI
Rapid Sequence Intubation (RSI)
The Six Ps of RSI
Preparation
Preoxygenation
Paralysis with Sedation
Protection
Placement
Postintubation care
Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI)
………..Zero
The Sequence
the time of administration of Succinylcholine.
Preparation
Preoxygenation
10 min
12/15/2007
3
…10 minutes ---- Zero
Preparation
• Assess airway difficulty (LEMON)• Plan approach• Assemble drugs and equipments• Establish access• Establish monitoring
Rapid Sequence Intubation (RSI)
The Sequence
Rapid Sequence Intubation (RSI)
…5 minutes ---- ZeroThe Sequence
Preoxygenation
• 100% oxygen for five minutes• 8 vital capacity breaths• Provides essential apnea time• Apnea time varies
Rapid Sequence Intubation (RSI)
Zero!!
• Sedative / Induction agent IV push• Succinylcholine 1.5 mg/kg IV push
Entering the red zone...
The Sequence
Paralysis with Sedation
Rapid Sequence Intubation (RSI)
• Sellick’s Maneuver• Position patient• Do not bag unless SpO2 < 90%
Protection
…Zero + 30 secondsThe Sequence
Optimal ExternalLaryngeal Manipulation (Backwards, Upwards, Rightwards Position (BURP)
Sellick’s maneuver(Cricoid pressure)
12/15/2007
4
“ Sniffing position ”
• Check mandible for flaccidity• Intubate, remove stylet• Confirm tube placement – EtCO2
• Release Sellick’s maneuver
Rapid Sequence Intubation (RSI)
…Zero + 60 secondsThe Sequence
Placement
ETCO2
Auscultation
Self inflating bulb
Trachlight
Experinced Inexperinced
100%
87%
100%
100%
84%
96% 98%
68%
Postintubation care
Rapid Sequence Intubation (RSI)
The Sequence
•Ongoing sedation and/or paralysis•Mechanical ventilation (if needed)•Further investigations (CXR, ABG)•Postintubation hypotension
What do you do?If you can not intubateafter RSI?
“Failed intubation”
• The first rescue from failed intubation is bagging.
• The first rescue from failed bagging is better bagging.
• Rescue devices
Rescue Maneuvers
Rapid Sequence Intubation (RSI)
“Failed intubation”
12/15/2007
5
The “Failed” Airway
• Multiple Definitions…
– Number of failed attempts (e.g., three)
– Failure to ventilate with a BVM
– Failure to oxygenate
– Failure to visualize the larynx
Clinically, 2 types of “failed” airways:
1. Cannot intubate, but can oxygenate
2. Cannot intubate, and cannot
oxygenate
The “Failed” Airway
The DIFFICULT AIRWAY is something you PREDICT…
A FAILED AIRWAY is something you EXPERIENCE!!
The Difficult Airway
Identification of the Difficult Airway3 Key Attributes
• Difficult Bag/Mask Ventilation• Difficult Intubation
• Difficult Cricothyrotomy
The Difficult Airway
Mask seal
ObesityAged (>55)
No teeth
Stiff lungs
Difficult Bag Mask Ventilation
The Difficult Airway
Difficult Cricothyrotomy
Surgery scar
HematomaObesity
Radiation
Tumor
The Difficult Airway
12/15/2007
6
Difficult Intubation
Identification of the Difficult Airway
• BMV as important as intubation• Mouth opening/access
• Neck extension at AOJ
• Neck flexion at CTJ• Mentum-Hyoid-Thyroid distance
• Presence/Risk of obstruction
Predicting of difficult airway
• A short bull neck• Prominent incisors• A receding chin• Limited mouth opening• Chin to hyoid distance
< 6 cm (3FB)• Potential C-spine injury • Facial deformity• Morbid obesity
Development of a consistent approach:
The LEMON law
Difficult Intubation
Identification of the Difficult Airway
© National Emergency Airway Management Course
L ook externallyE valuate 3-3-2
M allampati
O bstruction?N eck mobility
The LEMON law
© National Emergency Airway Management Course
Difficult Intubation
Identification of the Difficult Airway
L ook externally
- Difficult BMV (MOANS)- Difficult Cricothyrotomy (SHORT)
- Intubator Gestalt
Difficult Intubation
Identification of the Difficult Airway
E valuate 3-3-2
Or some other thyromental distance equivalent
Difficult Intubation
Identification of the Difficult Airway
12/15/2007
7
Difficult Intubation
Identification of the Difficult Airway
M allampati O bstruction?
Difficult Intubation
Identification of the Difficult Airway
Difficult Intubation
Identification of the Difficult Airway
N eck mobility • Need a consistent approach• Awake techniques by default
• Need definition of and preplanned
approach to failed airway• No “one trick pony” approach
• Alternative devices
Management of the Difficult Airway
Difficult Intubation
• Alternative/Rescue devices?– Supraglottic: LMA, Combitube
– Stylet, Gum elastic bougie; GEB
– Lighted stylets: Trachlight, Lightwand
– Fiberoptic devices: flexible, rigid, hand-held
– Surgical: open, transtracheal
Management of the Difficult Airway
Difficult Intubation
12/15/2007
8
L
M
A
I
n
s
e
r
t
i
o
nCombitube I n s e r t i o n
Needle
Cricothyrotomy
Emergency ETT intubation:
Team members & their roles
Time Airway doctor/nurse Doctor / Nurse
Preparation(drugs/equipments)
Assess airwayPlan approach
Preoxygenation
ETT placement
IV access
Assist with preparation& drugs admin.
Cricoid pressure
Nurse (Scribe)
Document All events
Assist withMonitor &preparation
Confirmation of ETT placement
The commonly used drugs
Emergency ETT intubation (RSI)
Drug
Induction agents:
Thiopental
Propofol
Etomidate
Ketamine
3-5
1-2
0.2-0.6
1-2
10-15
10-15
10-15
30-45
Hypotension/ Porphyria
Hypotension/Age< 2 yrs.
Adrenal insufficiency/
ICP / Head injury
Precaution/ContraindicationDose; mg/kgOnset(Sec)
The commonly used drugs
Emergency ETT intubation (RSI)
Drug
Sedation/Analgesia:Midazolam
Fentanyl (mcg/kg)
Morphine
Pretreatment:Lidoocaine
0.1-0.3
1-2
0.1-0.2
1-1.5
60-90
30-45
10-15
3-5 min.
Long onset / no
Chest wall rigidity / no
Long onset / no
Bradycardia / no
Precaution/ContraindicationDose; mg/kgOnset(Sec)
12/15/2007
9
The commonly used drugs
Emergency ETT intubation (RSI)
Drug
Muscle relaxants:
Succinylcholine
Rocuronium
1-2
0.6-0.9
60
45-60
N-M disease /
Severe burn, Hyperkalemia
Intra-ocular injury
Precaution/Contraindication
Dose (mg/kg)
Onset(sec)
Duration(min)
5-10
45-60
The commonly used drugs
Emergency ETT intubation (RSI)
Drug
Emergency drugs:
Atropine
Adrenaline
Levophed
Metaraminol
0.02 Pediatric intubation
Standard resuscitation
cart in hand (emergency intubation)
ConsiderationsDose; mg/kg
Incrementaldose
to targetBP
• Emergency airway management is different
• Emergency Airway Algorithm necessity
• Prediction tools have limitations:• LEMON criteria cannot be universally applied• Consistent use will predict most of the difficult
The Emergency Difficult Airway Algorithm
Can’t intubate Seek HELP
? Can ventilate
Maintain Sellick’sReposition head
Use oral/nasal airway
Maintain oxygenationBy BVM
Reattempt intubationby rescue devices
Maintain oxygenationBy BVM
LMA / Combitube
Maintain oxygenationIntubation through
LMAAwait expert help
LMA / Combitube
CricothyrotomyJet ventilation
Ventilation effective
Unable to ventilate
Unable to ventilateEmergency
Airway Algorithm
“ True success is notin the learning,
But in it’s applicationto the mankind �
� ����������� ������ ����������� ����������� ��������� ����������� ������ !���"�����#$����� �