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Rapid Sequence Intubation

Rapid Sequence Intubation. In the Emergency Department. Rapid Sequence Intubation. RSI The use of medication to facilitate passing the endotracheal tube Analgesics Sedatives Paralytics CONTROLLED procedure Will take several minutes to accomplish Requires a team effort

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Rapid Sequence Intubation

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  1. Rapid Sequence Intubation In the Emergency Department

  2. Rapid Sequence Intubation • RSI • The use of medication to facilitate passing the endotracheal tube • Analgesics • Sedatives • Paralytics • CONTROLLED procedure • Will take several minutes to accomplish • Requires a team effort • The ultimate goal is to secure an airway without having the patient vomit and aspirate.

  3. Indications for RSI • Impending airway obstruction • Facial fractures…no excessive oral bleeding • Facial burns…inhalation injury • Expanding retropharyngeal hematoma • Excessive work of breathing • Example…the exhausted asthmatic • Shock • GCS <8 • Persistent hypoxia (<90%)

  4. 6 P's of RSI • Preparation • Preoxygenation • Pretreatment • Paralysis (with induction) • Placement of the tube • Post intubation management

  5. Oxygen Source Suction Equipment Endotracheal tubes Bag-valve-mask device Glidescope Cardiac Monitor Pulse oximeter End-tidal CO² monitor Temperature probe (LONG TERM) Alternative airway equipment-laryngeal mask airway or jet ventilator or crich tray Preparation

  6. Preparation • Assign roles and responsibilities • Leader • Intubationist • Cricoid pressure • Monitoring • Medications • Documentation

  7. 2. Preoxygenate • 3-5 minutes with 100% O2 bag mask to ensure adequate oxygen reservoir in lungs during apnea • Assure age appropriate fitting mask

  8. 3. Pre-treatment • Laryngoscopy causes stimulation of afferent receptors in the posterior pharynx, hypopharynx and larynx. • Reflexes can cause: – Increased intracranial pressure (ICP) – Stimulation of upper & lower respiratory tract increasing airway resistance. – Stimulation of autonomic nervous system, with increase heart rate and BP (vagal stimulation cause decrease in pediatric!)

  9. Pre-treatment • Attenuate (weaken) normal physiologic & pathophysiological reflex responses caused by airway manipulation during laryngoscope and insertion of an endotracheal tube. - Lidocaine - Atropine - Defasiculating agent

  10. Pre-treatment meds • Atropine – Treats brady response to SUX, and in young children. • Lidocaine – Helps decrease ICP associated with intubation. • Vecuronium (defasiculationg dose)- keeps muscles from fasiculating (twitching) when using “Succs”

  11. 4. Paralysis (with induction) • Check patency of line first! • Make sure everyone is ready • Give IV pushes rapidly and flush • Anesthesia before paralysis! • *Induction agent is followed immediately by the paralytic without waiting to see if ventilation can be maintained • Hallmark of RSI

  12. Anesthesia • Etomidate • Short acting sedative hypnotic • Dose=0.3 mg/kg • Induction time= 5-10 min. • *Myoclonus

  13. IM or IV Dissociative anesthesia Dose = 1-2 mg/kg (IV)/ 4-10mg/kg IM Lasts approx. 30” Glazed eyes & nystagmus Watch for agitated recovery *Increased BP, HR,tonic/clonic,N/V, hypersalivation Ketamine

  14. Anesthesia • Versed • Benzodiazepine, • Sedative • 1-2 mg IV • Onset 1.5 min. to 2H • *Hypotension

  15. Anesthesia • Fentanyl • Narcotic analgesic • 50-100 mcg/kg • Lasts 30 min. • *Resp. depression

  16. Propofol (Diprivan) • Induction agent • Standard dose: 2 mg/kg • Rapid onset, short duration • Considerations: *Hypotension,apnea

  17. Paralytic (Neuromuscular block) • VECURONIUM • Skeletal Muscle Relaxer • 0.1 MG/KG IV(PARALYZING DOSE) • Lasts 25 to 45 min.

  18. SUCCINYLCHOLINE Neuromuscular blocking agent Dose: 1 mg/kg Duration: 5 min. Side effects: Fasciculations, muscle pain,rhabdo, hyper K, brady, vent. Dysthythmias Malignant Hyperthermia Paralytic

  19. Paralytic Contraindications • – Personal or family history of malignant • hyperthermia • – Significant, verified, hyperkalemia is an • absolute contraindication • – End-stage renal disease / dialysis dependent • patients with unknown potassium level

  20. 5. Placement of Tube • Position patient • Do not bag unless SpO2 < 90% • Sellick’s Maneuver (Cricoid pressure)

  21. Placement of tube

  22. Placement and Proof • Confirm tube placement • – ETCO2 • – Bilateral breath sounds • – Absent epigastric sounds

  23. Failed attempt What if the intubation attempt is not successful? • 1st step = bag/mask ventilation for support Rescue Maneuvers • – The first rescue from failed intubation is bagging • – The first rescue from failed bagging is better bagging

  24. 6. Post-intubation Management • Secure tube • ETCO2 • Chest x-ray • Long acting sedation (+/- paralysis) • – Midazolam 0.2mg/kg • – Propofol 25-50μg/kg/min • Establish ventilator parameters

  25. 6P’s RSI Summary • Preparation (zero – 10 minutes) • Preoxygenation (zero – 5 minutes) • Pretreatment (zero – 3 minutes) • Paralysis with induction (time zero) • Positioning (zero + 30 seconds) • Placement (zero + 45 seconds) • Post-tube management (zero + 90 seconds)

  26. Questions?

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