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Rapid Sequence Intubation

• John Bradley, MD
• Metropolitan Hospital
• November 13, 2012

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Lessons from SkydivingLevitan RM. Patient safety
in emergency airway management and rapid sequence
intubation metaphorical lessons from skydiving.
Ann Emerg Med. 20034281-87.

• Redundancy of safety (primary and backup chute)
• Planned stepwise approach to deploy 1ary chute
  Simple, fast, easy backup chute deployment
• Attention to monitoring exit plane at correct
  altitude, altimeter determines when to deploy
  backup chute
• Equipment vigilance

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Overview

• Rapid Sequence Intubation
• Airway Assessment
• The Difficult Airway
• The Failed Airway
• Airway Options
• Your Approach

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Rapid Sequence Intubation (RSI)

• Definition
• Assumptions
• Goals
• Indications
• Contraindications
• Alternatives
• Procedure
• Steps
• Pharmacology

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RSI Definition

• The administration of a potent induction agent
  followed immediately by a rapid acting
  neuromuscular blocker (NMB) to render
  unconsciousness and motor paralysis for tracheal
  intubation

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RSI Assumptions

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RSI Assumptions

• Intubation is indicated
• The stomach is full
• Intubation is anticipated to be successful
• If intubation fails, ventilation is expected to
  be successful

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RSI Goals

• Optimize intubation conditions
• Minimize aspiration risk by avoiding positive
  pressure ventilation until after intubation is
  accomplished

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Indications for Tracheal Intubation

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Indications for Tracheal Intubation

• Inability to maintain an airway
• Inability to maintain adequate oxygenation and
  ventilation
• Anticipated airway obstruction /
• Special situations

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RSI Contraindications

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RSI Contraindications

• Tracheal / laryngeal injury / disruption
• S/P Laryngectomy
• Massive facial trauma
• Anticipated difficult airway

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RSI Alternatives

• Awake oral intubation with local anesthesia and
  sedation
• Blind nasotracheal intubation (BNTI)

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RSIThe 7 Ps

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RSIThe 7 Ps

• Preparation
• Preoxygenation
• Pretreatment
• Paralysis with induction
• Protection with positioning
• Placement with proof
• Post-intubation management

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RSI Timeline

• Time Action
• Zero - 10 min Preparation
• Zero - 5 min Preoxygenation
• Zero - 3 min Pretreatment
• Zero Paralysis with induction
• Zero 20-30 sec Protection with positioning
• Zero 45-60 sec Placement with proof
• Zero 60-90 sec Post-intubation management

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RSI Compressed Timeline

• Concurrent preparation and preoxygenation
• Accelerated (2 min)
• Shorten preoxygenation to 30 sec with 8 vital
  capacity breaths (VC) method
• Shorten pretreatment interval from 3 min to 2 min
• Immediate
• Eliminate pretreatment
• Preoxygenate with 8 VC breaths

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Preparation

• Patient
• Discussion, airway assessment, IV access
• Positioning
• Equipment
• Airway, monitoring, failed airway
• Blade type and size, ETT size
• OP airway, placement confirmation device
• Cuff integrity and stylet, laryngoscope fxn
• Personnel

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Airway Assessment (LEMON)

• Look externally
• Evaluate 3-3-2
• Mallampati
• Obstruction
• Neck
• (Pediatrics)

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Look Externally

• Difficult BVM Ventilation ?
• Difficult Laryngoscopy / Intubation ?
• Difficult Surgical Airway ?

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Difficult BVM Ventilation(BONES)

• Beard
• Obesity
• No teeth
• (Elderly)
• (Snores)
• Severe facial burns / angioedema / trauma
• Unstable midface and/or mandible

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Difficult Laryngoscopy / Intubation

• (Severe facial burns / angioedema / trauma)
• Buck teeth
• Jay Leno
• Micronathia
• Downs syndrome
• FLK

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Difficult Surgical Airway(SHORT)

• Surgery
• Hematoma or infection
• Obesity
• Radiation
• Tumor (including goiter)
• Anatomic variability
• Females

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Evaluate(3-3-2 Rule)

• 3 finger breadths between upper lower teeth
• Ability to visualize
• 3 finger breadths between the mandible and hyoid
  bone
• lt 3 suggests anterior larynx
• Greater axes malalignment
• 2 finger breadths between thyroid cartilage notch
  and the mandible or floor of the mouth
• Cephalad larynx

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Mallampati Classification

• I Tonsillar pillars and fauces visible
• II Upper portion of pillars and uvula visible
• III Base of uvula / soft palate visible
• IV Only tongue and hard palate visible
• Patients mouth open, tongue sticking out
• Correlates with laryngoscopy classification, but
  not as sensitive in grades 3 and 4

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Laryngoscopic Classification

• Grade I Entire glottis visible
• Grade II Arytenoid cartilage and
• posterior glottis visible
• Grade III Epiglottis only visible
• Grade IV Tongue or soft palate visible
• Grade III and IV are considered difficult
  intubations (about 5 of OR cases)
• Visualization predicts intubation success

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Obstruction

• Angioedema
• Epiglottis
• Abscess
• Burn
• Trauma
• Tumor

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Neck

• Possible cervical spine injury
• Rheumatoid arthritis
• Ankylosing spondylitis

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High Risk Patients

• ASA Class III and higher
• Chronic pulmonary or cardiac disease
• Fever, volume depletion, current URI
• Airway assessment suggestive
• Consider OR, anesthesia consult and/or awake
  intubation

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ETT Size and Depth

• Size
• Females 7.5-8 Males 8-8.5
• Broslow tape, little finger diameter
• 4 age/4
• Depth
• Females - 21 cm Males - 23 cm
• Broslow tape, markings on ETT
• ETT size x 3 (cm) age 10

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Preoxygenation

• Establish an O2 reservoir in the lungs body
• Essential to no bagging principle of RSI
• Function residual capacity is primary reservoir
• Permits several minutes of apnea without
  desaturation
• 100 O2 via nonrebreather for 5 minutes
• OR
• 8 VC breaths with 100 O2 via bag/mask

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Pretreatment (LOAD)

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Pretreatment (LOAD)

• Mitigate adverse effects of laryngoscopy
• Lidocaine 1.5 mg/kg
• Airway bronchospasm / cough reflex
• Increased ICP
• Opiates (Fentanyl 3-6 mcg/kg)
• Increased ICP, aortic dissection, ruptured aortic
  or IC aneurysm, ischemic heart disease
• Blunts reflex sympathetic response to
  laryngoscopy
• Not recommended under age 1

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Pretreatment (LOAD)

• Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg)
• Children lt 10 yo
• Blunts vagal response to laryngoscopy
• Defasiculation (with succinylcholine)
• Increased ICP
• 1/10th dose of a non-depolarizing NMB
• Not indicated under age 5

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Paralysis with Induction

• Rapid IV administration of sedation followed
  immediately by rapid administration of a
  neuromuscular blocking agent

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Protection and Positioning

• Sellicks maneuver
• Firm pressure (10 )
• Maintain until placement confirmation and cuff
  inflation
• Positioning
• Keep the pillow to maximize POGO
• Height of bed, height in bed

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Placement with Proof

• Test for jaw flaccidity
• Extend head on neck
• Gentle controlled technique
• Blade entry on right, sweep tongue to left
• Lift handle up and away
• Suction prn
• Insert into esophagus, then slowly withdraw
• Visualize vocal cords
• Watch ETT pass through vocal cords
• Check ETT depth
• Never let go of the tube!
• Inflate cuff
• Auscultation

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Placement with Proof

• Confirm tracheal placement
• Direct visualization plus either
• EtCO2 detector or
• Esophageal detector
• Preferred in cardiopulmonary arrest
• Confirm depth (cords gt bronchus)
• Auscultation
• CXR

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Post-Intubation Management

• Secure ETT
• Reassess VS
• PCXR for depth of placement
• Bradycardia / Hypoxia -gt Nontracheal tube
• placement until proven otherwise (DOPE)
• Hypertension-gtinadequate sedation/analgesia
• Hypotension

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Post-intubation Management(Hypotension)

• Tension PTX
• High PIP, hard to bag, decreased BS, hypoxia
• Immediate thoracostomy
• Decreased venous return
• High PIPs 2ndary to high intrathoracic pressure
• Fluids, bronchodilators,
• Increase expiratory time, decrease TV

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Post-intubation Management(Hypotension)

• Induction agent
• Other causes excluded
• Fluid bolus, consider reversal agent, expectant
• Cardiogenic
• Usually a compromised pt
• Check EKG, exclude other causes
• Fluid bolus (caution), pressors

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Medications

• Pretreatment drugs (LOAD)
• Lidocaine
• Opiates
• Atropine
• Defasiculation
• Sedation
• Paralysis

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Sedation

• Midazolam
• Etomidate
• Methohexital / Thiopental
• Ketamine
• Propofol

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Neuromuscular Blocking Agents

• Noncompetitive depolarizer
• Succinylcholine (Anectine)
• Competitive nondepolarizer
• Benzylisoquinolinium group
• Atracurium (Tracrium), cisatracurium (Nimbex),
  mivacurium (Mivacron)
• Aminosteroid group
• Pancuronium (Pavulon), vecuronium (Norcuron),
  rocuronium (Zemuron)

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Succinylcholine (SCh) (Anectine)

• Rapid onset (45 seconds) and short duration of
  action (lt 10 minutes)
• Mechanism of action
• Metabolism
• Sequence of action
• Dosing

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SCh Adverse Effects

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SCh Adverse Effects

• Malignant hyperthermia
• Masseter spasm
• Hyperkalemia
• Increased ICP / Increased IOP
• Fasciculations
• Bradycardia (peds)
• Prolonged NMB
• Hypotension (histamine release, (-) inotrope)

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SCh Contraindications

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SCh Contraindications

• Personal or FH of malignant hyperthermia
• Known or suspected hyperkalemia
• gt 24 hours post-burn (gt10 BSA, 1-2 yrs)
• gt 1 week post crush injury (60-90 days)
• gt 1 week post SCI or CVA (6 months)
• Neuromuscular disease (indefinite)
• MS, ALS, muscular dystrophy
• Anticipated difficult airway

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Competitive, Nondepolarizing NMB

• Most commonly utilized post-intubation
• No CIs other than the difficult airway
• Disadvantage is longer onset and duration
• Metabolism variable
• Higher dose reduces time to paralysis but
  prolongs time to recovery

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Competitive, Nondepolarizing NMB

• Aminosteroid group dose not cause histamine
  release
• Reversible with AChesterase inhibitor
• Requires 40 spontaneous recovery
• Consider administering sedation shortly after
  administering vecuronium or pancuronium for RSI

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Competitive, Nondepolarizing NMB

• Rapacurium off the market
• Rocuronium (0.6-1.2 mg/kg)
• Mivacurium (0.15 mg/kg)
• Vecuronium (0.3 mg/kg)
• Pancuronium (0.1 mg/kg)

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Awake Oral Intubation

• Upper airway distortion is anticipated
• Prepare the patient
• Anesthetize the airway
• Lidocaine 4 4 cc / neosynephrine 0.5 1cc OR
• Lidocaine 2 w/EPI 5cc / Lidocaine 2 Plain 5 cc
• Via nebulizer for 10 minutes OR
• Lidocaine spray
• Sedation (Midazolam or Etomidate /- Fentanyl)
• Onset 3-5 minutes
• Perform laryngoscopy
• Immediate intubation / consider RSI / surgical
  airway
• Can the epiglottis be visualized?
• Is an abnormal glottis anticipated?

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Pediatrics

• Relatively large tongue / more oral secretions
• High tracheal opening (C1 gt C4,5 adult)
• Large occiput
• Cricoid ring is narrowest portion
• Large tonsils and adenoids and greater angle
  between epiglottis and larygeal opening
• Minimal cricothyroid membrane until age ¾
• Small relative FRC
• Basal oxygen consumption twice the adult rate

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Pediatrics

• Appropriately sized equipment (Broslow)
• Positioning
• Avoid hyperextension
• May need to elevate shoulders
• Effective BVM
• C-grip / good seal
• Squeeze, release, release
• Tidal volume
• Cricoid pressure

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Pediatrics

• Atropine lt age 10
• Avoid fentanyl lt age, use cautiously
• Lower barbituate dose per kg
• No defasciculation lt age 5 / 20 kg
• Succinylcholine dose
• Straight blade
• Uncuffed ETT lt age 8

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Pediatrics

• No BNTI lt age 10
• Adult EtCO2 detector gt 15 kg
• Securing the tube
• Place NGT or OGT early
• Orotracheal intubation for better security
• No surgical cricothyroidotomy lt age 10

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The Second Attempt

• Learn from your first attempt (experience)
• Blade type or size (Use Mac as a Miller)
• ETT size
• Sellicks technique / stylet
• BURP
• Reposition the head and neck
• Chest pressure looking for air bubble
• Monitor VS, interposed BVM ventilation
• Find the epiglottis
• Call for help

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The Bottom Line

• The Broslow Tape / Cart
• Get the trachea intubated efficiently
• Have a plan
• Have a back-up plan
• Call for help early
• Airway assessment is an integral part of RSI and
  procedural sedation
• Practice, practice, practice

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Resources

• Manual of Emergency Airway Management by Ron
  Walls et al
• Airway Courses