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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 - PowerPoint PPT Presentation
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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
The ultimate goal is to secure an airway without having the patient vomit and aspirate.
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%)
6 P's of RSI
Preparation Preoxygenation Pretreatment Paralysis (with induction) Placement of the tube Post intubation management
Preparation
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
Assign roles and responsibilities Leader Intubationist Cricoid pressure Monitoring Medications Documentation
2. Preoxygenate
3-5 minutes with 100% O2 bag mask to ensure adequate oxygen reservoir in lungs during apnea
Assure age appropriate fitting mask
3. Pre-treatment
Laryngoscopy causes stimulation of afferentreceptors 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!)
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
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”
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
Anesthesia
Etomidate Short acting sedative
hypnotic Dose=0.3 mg/kg Induction time= 5-10
min. *Myoclonus
Ketamine
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
Anesthesia
Versed Benzodiazepine, Sedative 1-2 mg IV Onset 1.5 min. to 2H *Hypotension
Anesthesia
Fentanyl Narcotic analgesic 50-100 mcg/kg Lasts 30 min. *Resp. depression
Propofol (Diprivan)
Induction agent Standard dose: 2
mg/kg Rapid onset, short
duration Considerations:
*Hypotension,apnea
Paralytic (Neuromuscular block) VECURONIUM
Skeletal Muscle Relaxer
0.1 MG/KG IV(PARALYZING DOSE)
Lasts 25 to 45 min.
Paralytic
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
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
5. Placement of Tube
Position patient
• Do not bag unless SpO2 < 90%
• Sellick’s Maneuver (Cricoid pressure)
Placement of tube
Placement and Proof
Confirm tube placement
– ETCO2 – Bilateral breath
sounds – Absent epigastric
sounds
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
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
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)
Questions?