Indiana ENA 2010 RSI And Difficult Intubation

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The Critical Airway:RSI & Failed Intubation

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Andrew J. Bowman

Acute Care Nurse PractitionerTrauma Nurse Specialist

Registered NurseParamedic

Emergency Department Emergency DepartmentWitham Health Services Clarian Arnett Hospital

KATS Transport Ambulance

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Disclaimer

I have no financial disclosures and I have no affiliation with any company to promote use of any drug or device described in this presentation.

Every Single Training Program

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AIRWAY COMES FIRST!!!!!

But…..

Not always as easy as it sounds!

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Attempts to Intubate

• <= 2 Attempts • > 2 Attempts

Overview

• What is RSI?

• RSI: The 10 “P’s”

• Failed Intubation

• Alternative airways and devices

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What is RSI?

• Rapid Sequence Intubation = RSI

• Cornerstone of emergency department (ED) airway management

• Timed delivery of medications to sedate and paralyze a patient to facilitate rapid placement of an endotracheal tube (ETT)

Copyright © 2007 ENA 9

Who Needs RSI?

• One or more of the following: Inability to maintain a patent airway Inability to protect against aspiration Compromised or impaired ventilation Failure to adequately oxygenate blood Anticipation of patient deterioration that will lead to

any/all of the above


Why RSI?

• Results in rapid unconsciousness and chemical paralysis

• Most ED patients are not fasting

• Ideally, intubation without bag/mask ventilation


When NOT to RSI

• Unconscious

• Apneic

• Need “Crash” airway

• Immediate BVM and ETT without pre-treatment


When NOT to RSI

• Total upper airway obstruction

• Loss of facial or oropharyngeal landmarks

• Need surgical airway


Cautious Use of RSI

• Suspected difficult airway or BVM

“LEMON”, “BONES”, “SHORT”

Mallampati Classification

3-3-2 Rule



The 10 “P’s” of RSI


The 10 “P’s” of RSI1. Preparation2. Pre-oxygenation3. Pre-treatment4. Put to sleep5. Paralyze6. Protect7. Position8. Placement9. Proof10.Post-Intubation management

Preparation

• Best defense against the chaos of achieving an emergent airway

• Why is it a dying patient only vomits when the suction has not been checked?????



PreparationStart of shift preparation

Airway cart or CRASH cart is stocked and readyFunctioning equipment

Pre-arrival / arrival of patient preparationAdequate staffMedicationsAirway equipmentLength based resuscitation tape if pediatricsDetermine if potential for difficult airway or difficult BVM

Difficult ETT Prediction

• LEMON

• Mallampati Classification

• 3-3-2


LEMON• Look externally

• Evaluate internally

• Mallampati

• Obstruction

• Neck mobility


Look Externally

• Beard

• Small jaw, receding chin

• “Buck” teeth

• Craniofacial deformity or trauma


Evaluate Internally

• 3-3-2

3 fingers of mouth opening

3 fingers mentum to hyoid

2 fingers hyoid to thyroid


3-3-2


Mallampati


Obstruction

• Pre-glottic obstructions

Tongue enlargement

Airway edema


Neck Mobility

• Trauma

• Anklosing spondylitis

• Arthritis


Difficult BVM Prediction

• “BONES” Beard/mustache Obesity No teeth Elderly Snores


Difficult Surgical Airway Prediction

• “SHORT” Surgery Hematoma of neck Obesity Radiation to neck Trauma


Pre-Oxygenation

• AKA: Nitrogen Washout


Pre-Oxygenation

• Best supplied by high flow non-rebreather mask for at least 5 minutes prior to RSI

• Creates a reservoir of oxygen in lungs, alveoli, blood and tissue

• Use positive pressure ventilation with BVM only when necessary (8 vital capacity breaths)


Time to Desaturation


Pre-Treatment

• Use of medications to blunt or decrease adverse physiologic responses to laryngoscopy and intubation

• “LOAD”


“LOAD”

• Lidocaine

• Opiates

• Atropine

• Defasciculating agents


Lidocaine

• 1.5mg/kg IV - Given 3 minutes prior to ETT

• Suppresses cough and gag reflex

• MAY decrease rises in ICP

• No good studies that prove benefit


Lidocaine

• May decrease or diminish reflex bronchospasm in patients with reactive airway disease

Asthma

COPD


Lidocaine

• Topical lidocaine may deliver a more consistent blunting of responses to intubation


Opiates

• Fentanyl 1-3mcg/kg IVP – Given 2 - 3 minutes prior to ETT

• Decreases sympathetic response to intubation

• Possible benefit with increased ICP, aortic dissection, ICH, ischemic heart disease


Atropine

• 0.02 mg/kg IV to maximum 1mg (minimum 0.1mg)

• Historically used in pediatrics being treated with succinylcholine to prevent reflexive bradycardia


Atropine

• No longer recommended

• Eliminates a step that has no clear benefit

• Bradycardia, especially in pediatrics, is a hallmark of hypoxemia and should not be masked by medications


Defasciculating Agents

• Use of a competitive neuromuscular blocker (NMB) 3 minutes before succinylcholine to decrease fasciculations

• Decrease increases in ICP

• Shown to have little, if any benefit and again eliminates a step


Pre-Treatment Summary

• Lidocaine Reactive airway disease (good evidence) Increased ICP (conflicting evidence)

• Opiates Increased ICP Cardiovascular disease



• Atropine No longer recommended

• Defasciculating Agents No longer recommended




Put to Sleep

• Administer rapid acting induction (sedation) drug to promote prompt loss of consciousness

• Dose selected to provide rapid unconsciousness


Induction Agents

• Etomidate

• Ketamine

• Propofol

• Midazolam


Etomidate

• 0.3 mg/kg IVP

• Rapid onset with short duration

• Little change in hemodynamics

• May be cerebroprotective


Etomidate

• Concern for adrenal suppression in patients with prior known adrenal dysfunction or in patients with sepsis

• May prefer alternative agent in these scenarios


Ketamine

• 1-2 mg/kg IVP

• Dissociative state with some analgesic properties

• Bronchodilation

• May increase ICP (Recent conflicting data)


Ketamine

• Consider for use in asthmatics or in anaphylaxis

• ???Avoid use with increased ICP???


Propofol

• 2 mg/kg IVP

• Rapid onset and short duration

• Cerebral protection

• Myocardial depressant and decreases systemic vascular resistance


Midazolam

• 0.3 mg/kg IVP

• Slow onset (minutes) and long duration (hours)

• Hypotension common

• Rarely recommended


Paralyze

• Provides neuromuscular blockade and is given immediately after induction agent

• Does not provide sedation, analgesia or amnesia


Paralyze

• Depolarizing Agent Succinylcholine

• Non-Depolarizing Agents Rocuronium Vecuronium


Succinylcholine

• 1.5 – 2 mg/kg IVP

• Rapid onset (45 – 60 seconds)

• Shortest duration (8 -10 minutes)

• Cautious use in hyperkalemia, muscular disorders, open globe injuries


Rocuronium

• Good 2nd line agent after succinylcholine Does not worsen hyperkalemia

• 1 mg/kg IVP

• At this dose has rapid onset similar to succinylcholine but MUCH longer duration of action (30 – 60 minutes)


Vecuronium

• Good 3rd line agent

• 0.15 mg/kg IVP

• Onset 75 -90 seconds, duration 60 -75 minutes


Drug & Weight Considerations• Dose based on TRUE body weight

Succinylcholine Etomidate Midazolam

• Dose based on IDEAL body weight Propofol Rocuronium


Positioning

• If concern for trauma Manual immobilization of head/neck by experienced

assistant C-collar is NOT adequate!!!!

• If NO concern for trauma Intubator positions head and airway to facilitate

visualization for intubation


Trauma


Trauma


No Trauma


Protection

• Application of Sellick maneuver (cricoid pressure) to prevent aspiration

• Applied with delivery of induction/paralytic medications

• “BURP”


Protection

• Recent studies show little evidence that aspiration is effectively reduced


Position & Protection

• Bimanual laryngoscopy


Placement

• The intubator places the ETT into the trachea Direct laryngoscopy with conventional laryngoscope Direct laryngoscopy with video laryngoscope Laryngoscopy with bougie device Combination of above


Proof

• Primary Methods

• Secondary Methods

• NO SINGLE METHOD PROVIDES 100% RELIABILITY THAT ETT IS IN THE TRACHEA!


Primary Methods

• Intubator sees tube go through cords

• Symmetrical rise and fall of chest

• Absence of air sounds over epigastrium

• Presence of bilateral breath sounds


Secondary Methods

• Presence of exhaled CO2 Colorimetric Capnography

• Aspiration of air from ETT EDD

• Chest X-Ray Assures proper height above carina


End Tidal CO2 (EtCO2)

• Colorimetric

• Capnography


Aspiration of Air


Chest X-Ray


Post-Intubation Management

• Secure ETT and record depth of insertion

• Initiate mechanical ventilation

• Administer ordered analgesics, sedation agents and possibly prolonged paralysis as required by clinical situation


Post-Intubation Management

• Hypotension is COMMON!

• Often related to: Decreased venous return with positive pressure

ventilation Induction agent side effect Cardiogenic Pneumothorax Auto-PEEP



Failed Intubation

Failed Intubation

• Cannot Intubate – Can Ventilate

• Cannot Intubate – Cannot Ventilate


Can Ventilate

• Call for assistance

• Oxygenation and Ventilation is being maintained with BVM

• Alternative Airway


Alternative Airway• Fiberoptic Method

• Video Laryngoscopy

• Extra-Glottic Device

• Bougie

• Surgical (Cricothyrotomy)


Cannot Ventilate

• Call for assistance

• Simultaneous preparation for cricothyrotomy while MAYBE, BRIEFLY attempting alternative airway

• Cricothyrotomy will usually be THE method of CHOICE in cannot intubate, cannot ventilate scenario!!!



Rescue Airway Devices and Alternative Methods for Intubation or Airway Acquisition

Alternative Airways• Fiberoptic

• Video Laryngoscopy

• Extra-Glottic Device

• Bougie

• Surgical


Fiberoptic

• Flexible fiberoptic

• Fiberoptic stylets and guides


Flexible Fiberoptic


Fiberoptic Stylets & Guides

• Shikani Optical Stylet

• Levitan/FPS Scope

• Airway RIFL


Shikani


Levitan


Airway RIFL


Video Laryngoscopy• Glidescope

• C-MAC Video Laryngoscope

• McGrath Video Laryngoscope

• Pentax Airway Scope

• Res-Q-Scope II


Glidescope


C-MAC Video Laryngoscope


McGrath Video Laryngoscope


Pentax Airway Scope


Res-Q-Scope II


Extra-Glottic Devices

• Combitube

• King LT Airway

• Laryngeal Mask Airway (LMA)


Combitube


Combitube


King LT Airway


LMA


LMA


Bougie


Bougie


? Best in Trauma ?

• Glidescope + Bougie


Surgical Airway

• Cricothyrotomy



Summary

• To simplify RSI, think INDUCTION (etomidate) and PARALYSIS (succinylcholine)

• In trauma, maintain MANUAL c-spine immobilization during intubation

• Adequate pre-oxygenation is paramount to success, best delivered by high flow mask


• Anticipate post-intubation hypotension as it is COMMON

• Anticipate difficult intubation, BVM, surgical airway by “LEMON”, “BONES” & “SHORT”


• Know what methods/devices you have available in case of failed intubation (AND where they are!!!!!)


QUESTIONS?



Thank You!

Documents

Indiana ENA 2010 RSI And Difficult Intubation