Components of Rapid Sequence Intubation

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Components of Rapid Sequence Intubation




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Presentations text content in Components of Rapid Sequence Intubation

Slide1

Components of Rapid Sequence Intubation

Ryan J Fink, MD

Raquel Bartz, MD

Duke University Medical Center

Dept. of Anesthesiology

Slide2

Learning Objectives

Components of Rapid Sequence Intubation (RSI)

Basic Equipment

Preparation

Reasons for RSI

Slide3

Good Clinical Judgment Required

Clinical judgment is required who, when, and how to support ventilation in a patient

Choices, Choices, and more Choices

Mechanical ventilation via

endotracheal

tube or

Bilevel

positive airway pressure (BIPAP)

Which tools to use

How to intubate: awake versus unconscious and/or paralyzed

Which induction agent or paralytic

Slide4

Intubation Goal

Provide means for improved oxygenation, improved ventilation, securing the airway

Minimize risk of complication and/or death associated with the procedure of intubation

Slide5

Reported Complications

Mort

Study;

N = 102

Jaber

Study;

N = 251

Schwartz Study; N = 238

Hypoxemia : 17%Hypoxemia: 26%Aspiration: 1.7%Aspiration: 4%Aspiration: 4%Regurgitation: 4.4%Dental Injury: 1%Surgical Airway: 0.4%Pneumothorax: 1%Esophageal Intubation: 10%Esophageal Intubation: 4%Esophageal Intubation: 8%Bradycardia: 3.5%Severe Hemodynamic Collapse: 25%Cardiac Arrest: 2%Cardiac Arrest: 1%Cardiac Arrest/ Death 3%> 3 Attempts: 10%> 3 Attempts: 11%

Mort TC J

Clin

Anesth

2004; 16: 508-516

Schwartz DE Anesthesiology 1995; 82:367-376

Jaber

S

Crit

Care Med 2006; 34:2355 - 2361

Slide6

Rapid Sequence Induction/Intubation

Purpose:

To decrease the risk of pulmonary aspiration

Improve likelihood of quick intubation with minimal physiologic compromise

Indications:

Patients considered to have a “full stomach”

NPO < 8 hours

Pregnancy

Significant GERD, delayed gastric emptying, hiatial herniaIleus, SBO, acute abdomen, or traumaMany times this is unknown in the Emergency Room or Intensive Care UnitContraindication to RSI:Predicted difficult mask ventilation or intubationConsider awake fiberoptic intubationEven the most experienced practitioners ask for help

Slide7

What is Rapid Sequence Induction/Intubation

Preparation (equipment and patient)

Induction agent

To cause hypnosis/unconsciousness

To prevent memory of intubation

Maintain

hemodynamics

Paralytic

To increase success of

endotracheal tube placementTo prevent aspirationCricoid PressureTo reduce risk of aspirationNo mask ventilationIntubation

Slide8

Basic Equipment (MS-MAIDS)

M

machine (

ambubag

, ventilator)

S

suction is available and turned onM – monitors, O2 saturation tone is audible A – airway to include endotracheal tube with stylet, LMA, blades or other intubating deviceI – IV free, functioning, and flowingD – drugs available – Induction agent, Paralytic agent, drugs to increase blood pressure, drug to increase heart rate S – suction again/Special stuff

Slide9

Preparation For RSI: Pt Positioning

Position your patient for success

Patient at the head of the bed

Bed is locked and fully inflated

Bed is at proper height

“Sniffing position”

Contraindicated:

Cervical spine injury

Goal is to align airway axes

Slide10

Preparation For RSI: Pt Positioning

Slide11

Preparation For RSI: Pt Positioning

Sniffing Position

Slide12

Preparation For RSI

Pre-oxygenation:

5 minutes while preparing for intubation

BiPAP

works well, with F

I

O

2

at 100%

Assist with bag-mask ventilation if decreased level of consciousnessSupply 100% oxygen into bag-valve maskHave more than one practitioner available to help with intubation

Slide13

Why

Preoxygenate

?

Slide14

Time of Apnea

90%

100%

8 min

Why

Preoxygenate

?

Slide15

Preparation For RSI

Suction should be audible

Monitors in place:

Non-invasive BP at least every 1-3 minutes

ECG

O

2

saturation monitor with audible tone

Airway devices should be readily available:

Endotracheal tube – multiple sizes (7.0 for women, 8.0 for men)Stylet if needed, endotracheal tube cuff checkedLaryngeal Mask Airway (LMA)Blades (Multiple types – Miller, MacIntosh, Phillips, etc.Oral/nasal airways IV should be checked and free-flowing

Slide16

Preparation For RSI: Drugs

Induction agent (next module)

Etomidate

/

Propofol

/Midazolam/

Ketamine

Paralytic (next module)

Succinylcholine/RocuroniumVasopressor – to treat hypotension if it developsAnticholinergic – to treat bradycardia Atropine 0.2 – 1 mgGlycopyrrolate 0.2 – 0.6 mgPost-intubation sedation/anesthesia

Slide17

Preparation For RSI:

Cricoid

Pressure

Pressure on

cricoid

cartilage

Backwards against cervical vertebra

Purpose: to occlude esophagus

(Possibly) prevents aspiration

Slide18

Preparation For RSI:

Cricoid

Pressure – Warn your patient

Slide19

Preparation For RSI:

Cricoid

Pressure

Controversy still exists

Amount of pressure: 10 - 40

Newtons

May cause retching/vomiting in awake patients

Decreases lower esophageal sphincter tone

Aspiration can still occur

May limit laryngeal visualizationPushes esophagus to the side, not always compressedStill a standard of care

Slide20

RSI: Completion

No mask ventilation

Confirm

endotracheal

tube placement

End-tidal carbon dioxide monitoring

May be inaccurate in cases of cardiac arrest (no CO = no EtCO2)

Condensation in the tube

Chest rise

Bilateral breath sounds Bronchoscopy Esophageal detection deviceDo not release cricoid pressure until confirmedBegin post-intubation sedation

Slide21

Prepare equipment and patientPreoxygenate for 5 min with 100% O2

Assistant holds

cricoid

pressure

Lightly when patients is still awake

Assistant pushes induction agent and then paralytic

Intubate

after approximately 45 seconds

Confirm

endotracheal tube placementBegin sedation/anesthesiaRapid Sequence Intubation (RSI)

Slide22

Rapid Sequence Intubation (RSI): Conclusions

Preparation is key!

MSMAIDS mnemonic

Free flowing IV

Assistance available for drugs and

cricoid

pressure

Multiple airway devices

Have a back-up plan if intubation is difficult

Slide23


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