Rapid Sequence Induction: Evidence Based Review
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Cricoid Pressure: Ritual Or Effective Measure?
R eview A rticle Singapore Med J 2012; 53(9) 620 Cricoid pressure: ritual or effective measure? Nivan Loganathan1, MB BCh BAO, Eugene Hern Choon Liu1, MD, FRCA ABSTRACT Cricoid pressure has been long used by clinicians to reduce the risk of aspiration during tracheal intubation. Historically, it is defined by Sellick as temporary occlusion of the upper end of the oesophagus by backward pressure of the cricoid cartilage against the bodies of the cervical vertebrae. The clinical relevance of cricoid pressure has been questioned despite its regular use in clinical practice. In this review, we address some of the controversies related to the use of cricoid pressure. Keywords: cricoid pressure, regurgitation Singapore Med J 2012; 53(9): 620–622 INTRODUCTION imaging showed that in 49% of patients in whom cricoid Cricoid pressure is a technique used worldwide to reduce pressure was applied, the oesophageal position was lateral to the risk of aspiration during tracheal intubation in sedated or the cricoid ring.(5) As oesophageal occlusion was thought to be anaesthetised patients. Cricoid pressure can be traced back to crucial, this study challenged the efficacy of cricoid pressure. the late 18th century when it was used to prevent gas inflation More recently, in magnetic resonance imaging studies, Rice et of the stomach during resuscitation from drowning.(1) Sellick al showed that cricoid pressure causes compression of the post- noted that cricoid pressure could both prevent regurgitation cricoid hypopharynx rather than the oesophagus itself. -
ISPUB - Dilemma in Rapid Sequence Intubation: Succinylcholi
ISPUB - Dilemma In Rapid Sequence Intubation: Succinylcholi... http://www.ispub.com/journal/the_internet_journal_of_emerge... The Internet Journal of Emergency and Intensive Care Medicine 2003 : Volume 7 Number 1 Dilemma In Rapid Sequence Intubation: Succinylcholine Vs. Rocuronium Ozgur Karcioglu MD Emergency Physician Dept. of Emergency Medicine Dokuz Eylul Univ. School of Medicine Izmir Turkey Citation: O. Karcioglu : Dilemma In Rapid Sequence Intubation: Succinylcholine Vs. Rocuronium . The Internet Journal of Emergency and Intensive Care Medicine. 2003 Volume 7 Number 1 Keywords: Rapid sequence intubation | rapid sequence induction | neuromuscular blockade | muscle paralysis | succinylcholine | rocuronium Abstract Succinylcholine is the single ultra-short acting depolarizing neuromuscular blocking agent (NMBA) used in the rapid sequence intubation protocol with 1 of 14 9/8/10 11:29 PM ISPUB - Dilemma In Rapid Sequence Intubation: Succinylcholi... http://www.ispub.com/journal/the_internet_journal_of_emerge... its rapid onset of effect, complete reliability, short duration of action. Rocuronium is diverse from other non-depolarizing NMBA being the first one with a short onset time and devoid of untoward effects. Despite its widespread use, succinylcholine has several potential hazards including an increase in potassium levels, bradycardia for children and prolonged apnea for those with pseudocholinesterase deficiency. Rocuronium is indicated in subjects with disease states such as known or suspected hyperkalemia, crush injury, non-acute burns, increased intracranial or intraocular pressure and neuromuscular disease. Although succinylcholine has many side effects, it remains to be the first-choice NMBA for the majority of attempts for rapid sequence intubation. Rocuronium may be a suitable alternative to succinylcholine with its short onset time. The objective of this article is to update data from studies comparing the use of succinylcholine and rocuronium in rapid sequence intubation protocol in adults. -
Title: Cricoid Pressure During Intubation: Review of Research and Survey of Nurse Anesthetists
Title: Cricoid Pressure During Intubation: Review of Research and Survey of Nurse Anesthetists Tania A. Lalli, BSN School of Nursing, University of North Carolina at Greensboro, Greensboro, NC, USA Michael Rieker, DNP School of Medicine, Nurse Anesthesia Program - Wake Forest School of Medicine, Winston Salem, NC, USA Donald D. Kautz, PhD Adult Health, School of Nursing, University of North Carolina Greensboro, Greensboro, NC, USA Session Title: Scientific Posters Session 2 Keywords: Aspiration, Cricoid pressure and Effectiveness References: Baskett, P.J.F., & Baskett, T.F. (2004). Brian sellick, cricoid pressure and the sellick manouevre. Resuscitation, 61(1). doi:10.1016/j.resuscitation.2004.03.001 Beavers, R.A., Moos, D.D., & Cuddeford, J.D. (2009). Analysis of the application of cricoid pressure: Implications for the clinician. The Journal of PeriAnesthesia Nursing, 24(2), 92-102. Black, S.J., Carson, E.M., & Doughty, A. (2012). How much and where: Assessment of Knowledge level of the application of cricoid pressure. The Journal of Emergency Nursing, 28(4), 370-374. Brimacombe, J.R., & Berry, A.M. (1997). Cricoid pressure. The Canadian Journal of Anesthesia, 44(4), 414-425. Engelhardt, T., & Webster, N.R. (1999). Pulmonary aspiration of gastric contents. The British Journal of Anesthesia, 83, 453-460. Ewart, L. (2007). The efficacy of cricoid pressure in preventing gastro-oesophageal reflux in rapid sequence induction of anaesthesia. The Journal of Preoperative Practice, 17(9), 432-436. Garrard, A., Campbell, A., Turley, A., & Hall J. (2004). The effect of mechanically-induced cricoid force on lower oesophageal sphincter pressure in anaesthetised patients. Anaesthesia, 59(5), 435-439. -
Rapid Sequence Induction Will Ross and Louise Ellard
Update in Anaesthesia Rapid sequence induction Will Ross and Louise Ellard Correspondence: [email protected] Originally published as Anaesthesia Tutorial of the Week 331, 24 May 2016, edited by Dr Luke Baitch Table 1. Common modifications of RSI technique in INTRODUCTION current practice Rapid sequence induction (RSI) is a method of achiev- Omitting the placement of an oesophageal tube articlesClinical overview ing rapid control of the airway whilst minimising Supine or ramped positioning the risk of regurgitation and aspiration of gastric Titrating the dose of induction agent to loss of contents. Intravenous induction of anaesthesia, with consciousness the application of cricoid pressure, is swiftly followed Summary by the placement of an endotracheal tube (ETT). Use of propofol, ketamine, midazolam or etomidate to Rapid sequence induction induce anaesthesia (RSI) is intended to reduce Performance of an RSI is a high priority in many the risk of aspiration by emergency situations when the airway is at risk, and Use of high-dose rocuronium as a neuromuscular blocking agent minimising the duration is usually an essential component of anaesthesia for of an unprotected airway. Omitting cricoid pressure emergency surgical interventions. RSI is required only Preparation and planning in patients with preserved airway reflexes. In arrested – including technique, or completely obtunded patients, an endotracheal tube medications, team member can usually be placed without the use of medications. CRICOID PRESSURE roles and contingencies -
Cricoid Pressure Pendulum When Dr
Brandon Morshedi, MD, DPT The Cricoid Pressure Pendulum When Dr. Sellick first introduced the idea of “cricoid pressure” in 1961, he stated that "the maneuver consists of temporary occlusion of the upper end of the esophagus by backward pressure of cricoid cartilage against bodies of cervical vertebrae."[1] His published research, however, had some noted limitations. They were small, non- randomized, uncontrolled case series that were performed on patients undergoing induction with anesthesia. The patients were positioned "head down slightly with head turned" and there was no mention of the sequence of administration or dosing of the induction agent and paralytics that were used in the anesthesia.[1][2] Sellick also did not discuss the actual technique of cricoid pressure, including how much pressure to apply, and admitted that it was performed by untrained personnel. Despite these major limitations, this technique was rapidly and rather uncritically adopted by anesthetists all over the world.[2] Over the past two decades, many providers have questioned the utility of cricoid pressure and many studies have been published which further support or refute its efficacy. Specifically, the following is the evidence regarding the question of whether cricoid pressure does what it is suppose to do or not, whether it can make our management of the airway more difficult, and whether or not we should be using it. Does Cricoid Pressure Occlude the Esophagus and Prevent Regurgitation? According to one author, crucial to the theorized effectiveness of cricoid pressure is the idea that the cricoid cartilage, esophagus, and vertebral bodies are all perfectly aligned in the axial plane.[2][3] In a retrospective review of 51 cervical CT scans and a prospective analysis of 22 cervical MRI scans, there was some degree of lateral displacement of the esophagus relative to the midline in 49% and 53%, respectively, even without cricoid pressure. -
The Cricoid Cartilage and the Esophagus Are Not Aligned in Close to Half of Adult Patients
CARDIOTHORACIC ANESTHESIA, RESPIRATION AND AIRWAY 503 The cricoid cartilage and the esophagus are not aligned in close to half of adult patients [Le cartilage cricoïde et l’œsophage ne sont pas alignés chez près de la moitié des adultes] Kevin J. Smith MD,* Shayne Ladak MD,† Peter T.-L. Choi MD FRCPC,* Julian Dobranowski MD FRCPC† Purpose: To determine the frequency and degree of lateral dis- de 3,3 mm ± 1,3 mm d’écart type par rapport à la ligne médiane du placement of the esophagus relative to the cricoid cartilage cricoïde. Soixante-quatre pour cent des déplacements latéraux de (“cricoid”) using computed tomography (CT) images of normal l’œsophage allaient au delà du bord latéral du cricoïde (moyenne de necks. 3,2 mm ± 1,2 mm d’écart type). Nous avons noté une distribution Methods: Fifty-one cervical CT scans of clinically normal patients relativement normale des mesures groupées de pourcentage de were reviewed retrospectively. Esophageal diameter, distance diamètre œsophagien déplacés. De ces déplacements, 48 % présen- between the midline of the cricoid and the midline of the esopha- taient plus de 15 % de la largeur totale de l’œsophage déplacé gus, and distance between the lateral border of the cricoid and the latéralement et 20 % avaient plus de 20 % de déplacement. lateral border of the esophagus were measured. Conclusion : La fréquence de déplacement latéral de l’œsophage Results: Lateral esophageal displacement was observed in 49% d’un certain degré par rapport au cricoïde est de 49 %. (25/51) of CT images. When present, the mean length of displaced esophagus relative to the midline of the cricoid was 3.3 mm ± SD 1.3 mm. -
Cricoid Pressure Alison M Berry* MS CI-IB FRCA
414 Review Article Joseph R Brimacombe MD CHB FRCA, Cricoid pressure Alison M Berry* MS CI-IB FRCA Purpose: Although crico~d pressure (CP) is a superficially simple and appropriate mechanical method to protect the patient from regurgitation and gastric insuffiation, in practice it is a complex manoeuvre which is difficult to per- form optimally. The purpose of this review is to examine and evaluate studies on the application of (CP). It deals with anatomical and physiological considerations, techniques employed, safety and efficacy issues and the impact of CP on airway management with special mention of the laryngeal mask airway. Source of material: Three medical databases (48 Hours, Medline, and Reference Manager Update) were searched for citations containing key words, subject headings and text entries on CP to October 1996. Principle Findings: There have been no studies proving that CP is beneficial, yet there is evidence that it is often ineffective and that it may increase the risk of failed intubation and regurgitation. After evaluation of all avail- able data, potential guidelines are suggested for optimal use of CP in routine and complex situations. Conclusions: If CP is to remain standard practice during induction of anaesthesia, it must be shown to be safe and effective. Meanwhile, further understanding of its advantages and limitations, improved training in its use, and guidelines on optimal force and method of application should lead to better patient care. Objectif : Bien qu'elle salt une m&hocle m&anique en apparence simple et appropnEe ex&utEe pour pro- tEger contre la regurgitation et I'insufflation gastrique, la compression du cricoide (CC), en pratique, constitue une manoeuvre complexe et difficile ~ rEaliser parfaitement. -
Significant Modification of Traditional Rapid Sequence Induction Improves Safety and Effectiveness of Pre-Hospital Trauma Anaesthesia Lyon Et Al
Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia Lyon et al. Lyon et al. Critical Care (2015) 19:134 DOI 10.1186/s13054-015-0872-2 Lyon et al. Critical Care (2015) 19:134 DOI 10.1186/s13054-015-0872-2 RESEARCH Open Access Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia Richard M Lyon1†, Zane B Perkins1,3*†, Debamoy Chatterjee1, David J Lockey2, Malcolm Q Russell1 and on behalf of Kent, Surrey & Sussex Air Ambulance Trust Abstract Introduction: Rapid Sequence Induction of anaesthesia (RSI) is the recommended method to facilitate emergency tracheal intubation in trauma patients. In emergency situations, a simple and standardised RSI protocol may improve the safety and effectiveness of the procedure. A crucial component of developing a standardised protocol is the selection of induction agents. The aim of this study is to compare the safety and effectiveness of a traditional RSI protocol using etomidate and suxamethonium with a modified RSI protocol using fentanyl, ketamine and rocuronium. Methods: We performed a comparative cohort study of major trauma patients undergoing pre-hospital RSI by a physician-led Helicopter Emergency Medical Service. Group 1 underwent RSI using etomidate and suxamethonium and Group 2 underwent RSI using fentanyl, ketamine and rocuronium. Apart from the induction agents, the RSI protocol was identical in both groups. Outcomes measured included laryngoscopy view, intubation success, haemodynamic response to laryngoscopy and tracheal intubation, and mortality. Results: Compared to Group 1 (n = 116), Group 2 RSI (n = 145) produced significantly better laryngoscopy views (p = 0.013) and resulted in significantly higher first-pass intubation success (95% versus 100%; p = 0.007). -
Rsii Rapid-Sequence Induction of Anaesthesia and Intubation of the Trachea
Disaster and Emergency Medicine Journal 2017, Vol. 2, No. 1, 33–38 REVIEW ARTICLE DOI: 10.5603/DEMJ.2017.0006 Copyright © 2017 Via Medica ISSN 2451–4691 RSII RAPID-SEQUENCE INDUCTION OF ANAESTHESIA AND INTUBATION OF THE TRACHEA Bogumila Woloszczuk-Gebicka Department of Intensive Care and Toxicology, Chair of Rescue Medicine, Institute of Midwifery and Rescue Medicine, Faculty of Medicine, University of Rzeszów ABSTRACT Rapid sequence induction and intubation (RSII) is the preferred method of tracheal intubation in emergen- cy situations for patients presenting with a full stomach. The aim of RSII is to intubate the trachea within 60 seconds, without having to use bag-valve-mask ventilation to avoid air insufflation into the stomach. After preoxygenation and while cricoid pressure is applied, an induction dose of intravenous anaesthetic agent is administered and rapidly followed by a fast-acting muscle relaxant, and after 60 seconds tracheal intubation is performed. Preoxygention increases apnoea tolerance. This is particularly important for infants and young children, and in patients who are in critical condition, obese or pregnant. Cricoid pressure (the Sellick manouver) is recommended to prevent regurgitation of the gastric contents to the throat. Propofol or thiopental are routinely used for induction. Ketamine or etomidate may be used if propofol or thiopental administration is contraindicated. Succinylcholine or rocuronium are used to facilitate tracheal intubation. Poor jaw relaxation, patient resistance to a laryngoscope, closed or closing vocal cords, vigorous limb movements or sustained coughing after tube insertion are not clinically acceptable. Modified rapid sequence induction, used in patients at risk of rapid development of hypoxaemia, allows gentle positive pressure ventilation after administration of the induction agent and muscle relaxant, but before the tracheal intubation. -
The Essential Bronchoscopist© Learning Bronchoscopy-Related Theory in the World Today
The Essential Bronchoscopist© Learning bronchoscopy-related theory in the world today Henri Colt MD, FCCP University of California, Irvine Irvine, California [email protected] http://www.bronchoscopy.org/education This page intentionally left blank. The Essential Bronchoscopist© Learning bronchoscopy-related theory in the world today Contents Module I ……………………………………………………………………………… Page 3 Module II ……………………………………………………………………………..Page 41 Module III …………………………………………………………………………….Page 77 Module IV …………………………………………………………………………….Page 113 Module V ……………………………………………………………………………..Page 149 Module VI …………………………………………………………………………….Page 187 Conclusion with Post-Tests .………………………………………………….Page 233 1 This page intentionally left blank. 2 The Essential Bronchoscopist© Learning bronchoscopy-related theory in the world today MODULE 1 http://www.bronchoscopy.org/education 3 This page intentionally left blank. 4 ESSENTIAL BRONCHOSCOPIST MODULE I LEARNING OBJECTIVES TO MODULE I Welcome to Module I of The Essential Bronchoscopist©, a core reading element of the Introduction to Flexible Bronchoscopy Curriculum of the Bronchoscopy Education Project. Readers of the EB should not consider this module a test. In order to most benefit from the information contained in this module, every response should be read regardless of your answer to the question. You may find that not every question has only one “correct” answer. This should not be viewed as a trick, but rather, as a way to help readers think about a certain problem. Expect to devote approximately 2 hours of continuous study completing the 30 question-answer sets contained in this module. Do not hesitate to discuss elements of the EB with your colleagues and instructors, as they may have different perspectives regarding techniques and opinions expressed in the EB. While the EB was designed with input from numerous international experts, it is written in such a way as to promote debate and discussion. -
Rapid Sequence Intubation
Challenges and Advances in Intubation: Rapid Sequence Intubation a,b,c,d, Sharon Elizabeth Mace, MD, FACEP, FAAP * KEYWORDS Intubation Rapid sequence intubation Endotracheal intubation DEFINITION/OVERVIEW Rapid sequence intubation (RSI) is a process whereby pharmacologic agents, specif- ically a sedative (eg, induction agent) and a neuromuscular blocking agent are admin- istered in rapid succession to facilitate endotracheal intubation.1 RSI in the emergency department (ED) usually is conducted under less than optimal conditions and should be differentiated from rapid sequence induction (also often ab- breviated RSI) as practiced by anesthesiologists in a more controlled environment in the operating room to induce anesthesia in patients requiring intubation.2–6 RSI used to secure a definitive airway in the ED frequently involves uncooperative, nonfasted, unstable, critically ill patients. In anesthesia, the goal of rapid sequence induction is to induce anesthesia while using a rapid sequence approach to decrease the possibil- ity of aspiration. With emergency RSI, the goal is to facilitate intubation with the addi- tional benefit of decreasing the risk of aspiration. Although there are no randomized, controlled trials documenting the benefits of RSI,7 and there is controversy regarding various steps in RSI in adult and pediatric pa- tients,8–13 RSI has become standard of care in emergency medicine airway manage- ment14–17 and has been advocated in the airway management of intensive care unit or critically ill patients.18 RSI has also -
Bag-Valve Mask Ventilation” Page 1
FDNY–EMS CME JOURNAL 2009_J01 “Back to the Basics”: BAG -VALVE MASK VENTILATION lthough all airway skills are important, the most important skill, and perhaps the most difficult, is the ability to use a bag and mask to effectively oxygenate and ventilate a patient. While over A the years there have been important advances in emergency airway management, such as alternative airways (e.g. Combitube), Bag-Valve Mask (BVM) ventilation is a life-saving skill that is often underappreciated. While BVM ventilation may seem mundane compared to placing an advanced airway (e.g. endotracheal tube, Combitube), it is actually a skill that is difficult to master. The false belief that BVM ventilation is an easy skill has led many health-care providers to mistakenly think they are proficient in this skill. The purpose of this article is to review BVM ventilation and associated skills and techniques to effectively ventilate a patient. In the second half of this article is a review of some of the advanced airway tools and techniques. While most applicable for Advanced Life Support (ALS) providers, it is beneficial for all personnel to have an awareness of them. Proper positioning of the patient is a critical element for successful BVM ventilation. The classic teaching for both ventilation and intubation positioning is placing the patient in the “sniffing position” provided there are no spinal precautions that need to be taken. The purpose is to allow for proper alignment of the oropharyngeal axes (Figure 1). Figure 1 FDNY–EMS CME Journal 2009_J01 “Bag-Valve Mask Ventilation” Page 1. However, this still may be inadequate, especially for pediatric and obese patients.