Rapid-Sequence Induction For Emergency Intubation Purpose of RSI ♦ RSI Rapid-Sequence – Rapidly induce anesthesia Intubation (RSI) – Rapidly achieve N-M blockade (paralysis) ♦ Purpose Jack CF Chong, MD – Facilitate intubation 張志華 – Blunt CV & ICP responses to intubation 新光醫院 急診科主治醫師 APLS + PALS APLS + PALS Infant v.s. Adult Airways Difficult Intubation ♦ Congenital anomaly – difficulty visualizing the cords ♦ Trauma / tumor – difficulty opening the mouth, airway compression, and/or hemorrhage ♦ Obstruction / infection – difficulty visualizing the cords APLS + PALS APLS + PALS ♦ 5 yr boy, 20 kg Indications for Intubation ♦ Protect airway ♦ Respiratory failure ♦ IICP / brain herniation ♦ A: Unconscious ♦ Decompensated shock ♦ B: RR 10 ♦ C: PR 140, BP 70/? Proceed to RSI !! ♦ D: E2M4V2, P 5/3 APLS + PALS APLS + PALS Prepare for RSI: SOAP-ME SOAP-ME ♦ Airway Equipment ♦ S : Suction – Oral and nasal airways ♦ O : Oxygen – Bag-valve-mask (BVM) devices and masks ♦ A : Airway Equipment – Endotracheal (ET) tubes and stylets ♦ P : Pharmacology – Laryngoscope handles and blades – Magill forceps ♦ ME : Monitoring Equipment – Surgical airway equipment – Tracheostomy tubes APLS + PALS APLS + PALS SOAP-ME SOAP-ME ♦ P - Pharmacology – Atropine ♦ ME - Monitoring Equipment – Lidocaine – ECG monitor – Sedatives – Pulse oximeter • Ketamine, BDZ, thiopental, fentanyl, – BP monitor etomidate, proporfol – End-tidal CO2 detector / monitor – N-M blocking agents • Succinylcholine, vecuronium, rocuronium APLS + PALS APLS + PALS 急診 RSI 之前題 RSI 之步驟 : Overview ♦ AMPLE & anatomy ♦ Assume full stomach ♦ Prepare: SOAP-ME ♦ Assume IICP ♦ Preoxygenation: 100% O2 +/- BVM ♦ Assume difficult airway ♦ Premedications ♦ Act before respiratory failure or apnea ♦ Paralysis ♦ Pressure: Sellick maneuver ♦ Pass the tube ♦ Check & secure the tube APLS + PALS APLS + PALS Initial Assessment: History Anatomic Assessment ♦ Head: ♦ A-M-P-L-E – Trauma • Allergies ♦ Face / mouth: • Medications, drugs of abuse – Trauma, open mouth, tongue size, uvula, loose • Past medical problems, problems with teeth, dentures anesthesia ♦ Neck / C- spine: • Last meal – Trauma, masses / hematomas, short thick neck, • Events, including prehospital course tracheal shift ♦ Brief NE – Document any neurologic deficits before paralysis APLS + PALS APLS + PALS Preoxygenation Premedication ♦ Adequate ventilation ♦ Atropine – 100% O2 via non-rebreathing mask ♦ Lidocaine ♦ Inadequate spontaneous ventilation ♦ Sedatives – 100% O2 via BVM – Ketamine, BDZ, thiopental, fentanyl, ♦ Apnea without hypoxemia etomidate, proporfol – Up to 30 seconds ♦ Defasciculating agents – Vecuronium APLS + PALS APLS + PALS Atropine Lidocaine ♦ Function – Prevent / treat bradycardia ♦ Blunt ICP response to intubation – Decrase secretions ♦ Indications ♦ Dose: – Age < 1Y – 1 mg/kg, slow IV push – Age < 5Y receiving succinylcholine (SCh) – 1 to 2 minutes before the paralytic drug – Any patient receiving a second dose of SCh – Any patient with bradycardia at time of intubation ♦ Dose: 0.02 mg/kg, min 0.1 mg, max 0.5 mg APLS + PALS APLS + PALS Sedative Agents Thiopental ♦ Short-acting barbiturate ♦ Induce unconsciousness ♦ Benefits in head trauma – Minimize reflex responses to intubation – Decreases ICP ♦ Choice and dose – Blunts ICP response to intubation – Depend on clinical settings ♦ Myocardial depressant – Avoid or use low dose when hypotension or hypovolemia present ♦ Dose: 3-5 mg/kg IV APLS + PALS APLS + PALS Ketamine Ketamine – Dissociative anesthetic agent ♦ Hallucinations, nightmares, and "emergence – Unaware of surroundings reactions" – Analgesia and amnesia – Adolescents and adults – Maintains airway reflexes – BDZ may prevent emergence reactions – Cardiorespiratory stability: may increase ♦ Increase ICP BP, HR, cardiac output – Contraindicated in head trauma – Bronchodilating effect ♦ Increase oral & airway secretions – 1-2 mg/kg IV or 4-7 mg/kg IM – Can use in combination with atropine APLS + PALS APLS + PALS Benzodiazepines Fentanyl ♦ Sedative, amnestic, anticonvulsant properties ♦ Rapid-onset, short-acting narcotic ♦ No analgesic effects ♦ Potential uses in RSI ♦ Potential cardiovascular and respiratory depression – Sedative and induction agent ♦ Midazolam has fastest onset, shortest – Dose for induction (2-10 ug/kg) of duration; dose = 0.1-0.2 mg/kg, max 5 mg unconsciousness much higher than dose for premedication or conscious sedation ♦ Induction doses in RSI are much higher than usual doses for sedation APLS + PALS APLS + PALS Propofol, Etomidate Paralysis: N-M Blockade ♦ Rapid onset, short duration ♦ Depolarizing agents ♦ Cerebral protective effects – Succinylcholine (SCh) ♦ Non-depolarizing agent ♦ Cardiovascular depression uncommon with etomidate – Vecuronium – Rocuronium ♦ Propofol may decrease BP – Pancuronium – Others APLS + PALS APLS + PALS Succinylcholine Succinylcholine ♦ Binds to ACh receptors on muscle and ♦ Increased intragastric pressure depolarizes muscle persistently ♦ Increased intraocular pressure ♦ Fastest onset ♦ Increased ICP ♦ Shortest duration – Mechanism unclear – Prevent or blunt with: ♦ Dose: • Lidocaine – 1.0-1.5 mg/kg (BW > 10 kg) • Induction agents – 1.5-2.0 mg/kg (BW < 10 kg) • Small dose nondepolarizing NMB agent APLS + PALS APLS + PALS Succinylcholine Nondepolarizing NMB Agents ♦ Bradycardia ♦ Compete with ACh for muscle ACh – Premedicate young children with atropine receptors ♦ Tachycardia – Sympathetic stimulation ♦ No muscle stimulation or fasciculations ♦ Hyperkalemia ♦ Slower onset, longer duration than SCh – Develops several days after burns, massive ♦ Usually given before induction agent muscle trauma, neurologic injuries, various because of slower onset neuromuscular diseases ♦ Fasciculations – Pain, increase intragastric / intraocular pressure APLS + PALS APLS + PALS Vecuronium (1) Vecuronium (2) ♦ May be used as paralyzing agent in RSI, Purpose Dose, mg/kg Onset Duration, min especially if SCh contraindicated Defasciculation 0.01 ♦ Minimal cardiovascular effects ♦ “Standard” dose: 0.1 mg/kg RSI 0.2-0.3 60-90 90-120 sec ♦ RSI dose: 0.2 to 0.3 mg/kg, has faster Paralysis after 0.1 2-3 min 25-40 action and prolonged duration intubation ♦ Defasciculating dose: 0.01 mg/kg APLS + PALS APLS + PALS Rocuronium Defasciculation ♦ Fastest acting nondepolarizing ♦ Agents and dosages NMB agent – Vecuronium 0.01 mg/kg ♦ Dose: 0.8-1.2 mg/kg – Pancuronium 0.01 mg/kg ♦ Duration : Up to 60 minutes ♦ Indication – Age > 5Y – Succinylcholine for paralysis APLS + PALS APLS + PALS ♦ 5 yr boy, 20 kg Head Injury / IICP – Atropine? – Lidocaine? – Defasciculating agents? – Vecuronium, pancuronium ♦ A: Unconscious – Sedatives? ♦ B: RR 10 • Ketamine, BDZ, thiopental, fentanyl, etomidate, proporfol ♦ C: PR 140, BP 70/? – N-M blocking agents? ♦ D: E2M4V2, P 5/3 • Succinylcholine, vecuronium, rocuronium APLS + PALS APLS + PALS Head Injury / IICP 11-year-old girl 9Atropine ♦ PH: Bed-ridden due to cerebral palsy 9Lidocaine ♦ PI: Fever and altered mental status 9Defasciculating dose of vecuronium 9Thiopental ♦ A: Obtunded, rigidity Ketamine will increase ICP ♦ B: Tachypneic 9Succinylcholine ♦ C: Skin, hot and dry APLS + PALS APLS + PALS Muscle disease or paralysis – Atropine? – Lidocaine? – Defasciculating agents? – Vecuronium, pancuronium – Sedatives? • Ketamine, BDZ, thiopental, fentanyl, etomidate, HR 135; RR 36; BP 80/60; T 40oC ; proporfol – N-M blocking agents? BW 18 kg; SO2 84% (room air) • Succinylcholine, vecuronium, rocuronium APLS + PALS APLS + PALS Muscle disease or paralysis 9Atropine ♦ After etomidate is 9Lidocaine given, patient is 9Defasciculating dose of vecuronium paralyzed with 1.0 mg/kg of Rocuronium 9Etomidate ♦ First attempt at Proporfol may cause severe hypotension intubation fails 9Vecuronium / Rocuronium What are your options now? APLS + PALS APLS + PALS Nondepolarizing NMB agent Asthma ♦ Failed intubation ♦ A: Extremely anxious – Begin BVM ventilation ♦ B: Retractions in all areas – Prepare for another intubation attempt ♦ C: Pale and diaphoretic – Consider giving a reversal agent • Neostigmine ♦ No response to O2, albuterol, and • Edrophonium epinephrine. • Pyridostigmine ♦ Lethargic, HR 120; RR 10; SO 82% ** Pretreat with atropine 2 APLS + PALS APLS + PALS Asthma Asthma – Atropine? 9 Atropine – Lidocaine? – Lessen secretions due to use of ketamine – Defasciculating agents? – Lidocaine – Vecuronium, pancuronium – Defasciculating dose of vecuronium – Sedatives? 9 Ketamine + Midazolam • Ketamine, BDZ, thiopental, fentanyl, etomidate, – Thiopental may cause bronchospasm proporfol – BDZ decrease emergence reaction – N-M blocking agents? 9 Succinylcholine • Succinylcholine, vecuronium, rocuronium APLS + PALS APLS + PALS Post-intubation ♦ Patient intubated after atropine, ketamine, ♦ Agents to lessen agitation midazolam and SCh given in RSI – Benzodiazepine ♦ 6.0-mm ET tube inserted and secured • For sedation ♦ Patient agitated and fighting ventilator • E.g. Dormicum, lorazepam – Nondepolarizing NMB agent What agents can be used to lessen the agitation? • For continued paralysis • E.g. Vecuronium APLS + PALS APLS + PALS Always have “plan B” APLS + PALS APLS + PALS.