RSI: Rapid Sequence Intubation What, When, Where, Why

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RSI Rapid Sequence IntubationWhat, When, Where,
Why How

• Michael T. Czarnecki, MD

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Objective

• What is RSI?
• Discuss the 7 Ps of RSI
• Review RSI pharmacologic agents
• Highlight current controversies with RSI

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RSI Defined

• Virtually simultaneous administration of a
  potent sedative agent and a neuromuscular
  blocking agent to induce unconsciousness and
  motor paralysis for tracheal intubation

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Why Bother with RSI?

• Rapid airway control
• Less risk of aspiration
• Highest success rates/lowest complications
• More controlled
• Optimal intubating conditions

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What are The Problems Inherent to Intubation?

• Laryngoscopy and Intubation
• Increased bronchospasm
• Increased ICP
• Increased catecholamine release

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Beneficial Effects of RSI

• Tight Heads
• Intracranial pathology
• Tight Hearts or Tight Vessels
• Cardiovascular disease
• Tight Lungs
• Reactive airway disease

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Assumptions in Airway Management

• Pt. has a full stomach
• Pt. is preoxygenated
• Pts. do not receive BVM ventilation unless
  necessary to keep O2 sat. over 90
• Sellicks maneuver always used

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RSI 7 Ps

1. P Preparation
2. P Preoxygenation
3. P Pretreatment
4. P Paralysis with induction
5. P Protection
6. P Placement of the tube
7. P Post-Intubation management

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RSI Timeline

• T 10 minutes Prepare
• T 5 minutes Preoxygenate
• T 3 minutes Pretreat
• T 0 Paralysis with induction
• T 30 seconds Protection
• T 45 seconds Placement
• T 90 seconds Post-Intubation management

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Preparation T 10 minutes

• Prepare the patient
• Monitoring/access
• Positioning
• Assess for difficult airway
• 4 Ds,LEMON, BONES, SHORT
• Mallampati
• Prepare your equipment
• Prepare yourself (mental checklist)
• Prepare your personnel

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Difficult Airway Assessment

• 4 Ds
• Distortion, Disproportion, Dysmobility, Dentition
• BONES
• Beard, Obese, No teeth, Elderly, Snores (sleep
  apnea)
• SHORT
• Surgery (head/neck/jaw), Hematoma, Obese,
  Radiation, Tumor
• LEMON
• MALLAMPATI
• Always have a Rescue Airway technique ready

JUMP AHEAD
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MALLAMPATI SCORE
Class I Class II Class III Class
IV
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60-SECOND EXAM LEMON

• Look for external difficulty
• Evaluate using 332 rule
• Mallampati (Class I II)
• Obstruction
• Neck Mobility

• 3 fingers fit in mouth
• 3 fingers fit from mentum
• to hyoid cartilage
• 2 fingers fit from mandible
• to top of thyroid cartilage

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Rescue Airways

• Gum Elastic Bougie (GEB)
• Laryngeal Mask Airway (LMA/ILMA)
• Combitube
• Surgical Cricothyrotomy

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Preoxygenate T 5 minutes

• Provides reservoir of oxygen during apnea
• If pt. spont. breathing then NRB for 5
• Provides maximum of 70 FiO2
• Avoid bagging the spont. breathing patient
• If needed, use sellick airway adjunct
• 8 effective Vital Capacity breaths provides best
  preoxygenation

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Pretreat T 3 minutes

• L - Lidocaine
• O - Opiates
• A - Atropine
• D Defasiculating Agent

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Lidocaine (1.5 mg/kg)

• Consider in Tight Head or Tight Lungs
• Blunts ICP rise (??)
• Suppress cough response
• may blunt bronchospasm
• may blunt sympathetic response
• Does Lido help in head trauma?
• No clinical trials have answered question
• Not proven to change outcome
• Little downside in using

Robinson, Emeg Med J 2001 18453
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Opioids

• Fentanyl (3 mcg/kg slow IV over 3)
• Consider in Tight Heads, Tight Heart,
  Tight Vessels
• Beware cautious use in pts dependent on
  sympathetic drive (aka, trauma)

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Atropine

• Only needed in
• Children under 10 y.o.
• Adults receiving 2nd dose of succinylcholine
• 0.01 mg/kg IV push
• Minumum dose 0.1 mg

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Defasiculating Agent

• Use any paralytic at 10 paralyzing dose
• Consider in Tight Heads
• Beware may cause hypoventilation and frank
  paralysis be prepared
• Who needs defasiculation?
• Helps mitigate ICP rise with succinylcholine
• Not really useful in any other ICU situation

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Paralysis with Induction T 0

• Tailor inducing agent to specific needs
• Barbituates
• Etomidate
• Midazolam
• Ketamine
• Propofol

JUMP AHEAD
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Barbituates

• Decreases GABA dissociation at receptor
• Rapid onset sedation
• Decreases ICP
• Hypotension (especially in hypovolemia)
• Choices
• Thiopental, pentobarbital, methohexital
• Overall Etomidate is better that Barbs

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Thiopental

• Onset 15 seconds, duration 3-5 minutes
• Cardiac depressant, venodilator
• Hypotension
• Dose depedent on pt. profile
• Euvolemic adult (3-5 mg/kg IV)
• Hypovolemic adult (1-3 mg/kg IV)

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Etomidate

• Nonnarcotic, nonbarbituate, nonanalgesic
• Minimal cardio effects, lowers ICP
• Is it the ideal agent for RSI?
• May cause critical adrenal suppression
• Inhibits adrenal mitochondrial hydroxylase
  activity
• Occurs after both single bolus and infusions
• Infusions incr. ICU death rate incr. infections
• Clinical significance is unclear
• Randomized, controlled trials on outcomes needed

Malerba, et al Intensive Care Med 2005
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Etomidate (cont)

• Induction dose 0.2 0.3 mg/kg IV
• Onset 20 30 seconds
• Duration 7 15 minutes
• May cause myoclonic jerking, hiccups, injection
  pain, N/V (also on emergence)
• Risk for adrenal insufficiency incr. 12-fold

Jackson, Chest 2005 MarMurray, Chest 2005 Mar
127707-709
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Midazolam

• Nonanalgesic sedative, anxiolytic, amnestic
• Respiratory depressant and hypotension
• Give slow IV
• Give ½ the dose in elderly or COPD
• Rapid onset (lt 1 minute)
• Induction dose (0.1 - 0.3 mg/kg) DIFFERENT than
  sedation dose (0.01 0.03 mg/kg)
• In RSI, 92 of adults are underdosed

Sagarin, et al Acad Emerg Med 2003 Apr 10329-38
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Ketamine (1 2 mg/kg)

• Dissociative, analgesic, amnestic
• Causes catecholamine release
• Incr. BP, HR, ICP, Laryngospasm risk
• Bronchodilator ? induction agent in asthma
• Onset 15 30 seconds
• Duration 10 15 minutes

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Propofol (0.5 1.2 mg/kg) (white magic, milk of
amnesia)

• Sedative-hypnotic
• Cardiac depressant, venodilator
• Hypotension
• Decr. ICP at expense of CPP

JUMP BACK
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NMBs Neuromuscular Blocking Agents

• Depolarizing
• Succinylcholine
• Non-Depolarizing
• Pan/Vec/Atra/Rocuronium
• Potential Problems
• Inadequate pre-intubation neuro exam
• Failure to sedate
• Inadequate pre-treatment or inadequate dosing
• Aspiration and Dysrhythmias
• Failed intubation ? surgical airway needed

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Succinylcholine (1.5 2.0 mg/kg)

• Onset 15 30 sec Duration 5 12 min
• Contraindications
• FHx malignant hyperthermia, burns, crush
  injuries, progressing neuromuscular disease
• Side Effects
• Brady, hyper-K, fasciculations, MH
• ?HR pretreat all kids adults 2nd dose with
  atropine
• ?K peaks in 5, resolves in 15
• Treat like any hyperkalemia case
• Use actual-body weight for dose

Rose, et al Anesth Analg 2000
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Non-depolarizing NMBs

• Longer duration than SUX, onset about equal
• Aminosteroid compounds
• Pan/Vec/Rocuronium
• Benzylisoquinolinum compounds
• Atracuronium

Vecuronium Rocuronium
0.1 0.2 mg/kg 1 mg/kg
1.5 2.5 minutes 60 seconds
25 45 minutes (90) 30 minutes (45)
Less vagolytic Least cardio effects
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Rocuronium

• Is it equivalent to SUX?
• Meta-analysis 1600 pts ? equivalent in
• Acceptable conditions for intubation
• Rates of intubation success
• But SUX is BEST at creating EXCELLENT conditions

Perry, AEM 2002
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RSI Timeline

• T 10 minutes Prepare
• T 5 minutes Preoxygenate
• T 3 minutes Pretreat
• T 0 Paralysis with induction
• T 30 seconds Protection
• T 45 seconds Placement
• T 90 seconds Post-Intubation management

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• Align the 3 axes critical for success
• Sellicks maneuver

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• Confirm placement/review CXR
• Secure tube
• Vent Settings
• Administer sedation
• Maintain paralysis if indicated
• And..

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Dont Ever Forget the 7 Ps

• P Preparation
• P Preoxygenation
• P Pretreatment
• P Paralysis with induction
• P Protection
• P Placement of the tube
• P Post-Intubation management

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WHEN IN DOUBT, PULL IT OUT!