Transcript RSI Intubation power point by Dave Taylor

Intubation 101
From start to finish
Objective
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Recognizing landmarks and anatomy
Overview of equipment
Overview of techniques
Ventilation vs. oxygenation
RSI
Anatomy
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PAGE 74
View of larynx
Mallampati class
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This test is supposed to be done on a
conscious and cooperative pt, sitting
upright, leaning forward….not unresponsive
in a ditch.
You still need an airway!!!
Non-traumatic position of
head pre-intubation
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Adult: Proper head to chest relationship for
ventilation defined by a horizontal line
connecting the ear to sternal notch
Children: Have large heads vs. adults tend
to have large chests. Proper head to chest
position is defined by a horizontal line
connecting ear to anterior shoulder
Pre-intubation position
4 steps to patent airway
1)
2)
3)
4)
Proper patient position
-ear horizontal to sternum
Insertion of oral or nasal airway
Lifting of the mandible
Suctioning the airway
Oxygenation and
Ventilation
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Maximizing oxygenation requires maximizing
the inspired concentration of O2 as well as
effective elimination of carbon dioxide from
the alveolas.
DON’T HYPERVENTILATE!!!!
Hyper-oxygenate with BVM or NRB mask
with high-flow O2.
BVM using small volume 6-7 cc/kg, over 1-2
seconds, low pressure
Cricoid Pressure
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Application of downward pressure at the
cricoid ring causes compression of the
underlying esophagus prevents passive
regurgitation of stomach contents.
– Recommeded during BVM ventilations with
pediatrics
- Over aggressive pressure causes tracheal
compression making it hard to bag or intubate!!!
Criciod Pressure
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Once criciod pressure has been
applied, this should be continued until
intubations is complete and verified.
Equipment
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Curved blades or Macintosh blades
Straight blades or Miller
Stylet shaping
Handle and how to hold it
Curved blades
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Begin SLOW insertion directly down the
middle of the tongue not the right side to
find the epiglottis.
Blade tip is advanced into the vallecula
pressing on the hyoepiglottic ligament,
raising the epiglottis out of the way.
If the epiglottis is missed upon blade
insertion, the tip of he blade will enter the
esophagus.
Straight blade
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Directly lifts the epiglottis.
Proper epiglottis identification, tongue
control, and tube passage are
important in curved blades, are even
more critical with straight blades.
Flanges are much smaller with less
control of tongue
Recommended in infants
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Enter on the right side of the mouth,
the epiglottis edge is lifted by the tip
of the blade and the tip is advanced
into the laryngeal inlet.
The first structure seen is the
interarytenoid notch, followed by the
posterior cartilage, then the vocal
cords and glottic opening.
Dangers with straight
blades
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Never blindly advance into the
esophagus and then withdraw due to
risk for puncture or perforation to the
hypo pharynx, upper esophagus, and
larynx.
Stylet shaping
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Straight-to-cuff tube/stylet aids in
maneuverability and laryngeal view.
With the main body perfectly straight,
with about a 35 degree angle
beginning just behind the cuff. The
stylet stopped 2-3 cm before the tip of
the tube.
Holding the handle
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Correct grip of a laryngoscope is low
down on handle, with your thumb
pointing upwards.
With proper hand grip, keep your
elbow close to torso, it is easy to
transmit force along forearm and to
blade tip, making effective use of
instrument without straining.
Proper grip
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Know whether you are right or left eye
dominant.
Left eye dominance rotate there heads
slightly to the right bring the target closer
and widens there view.
Right eye dominance do not need to
compensate keeping there heads straight.
Multiple intubations
attempts
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The decision about whether to temporarily suspend
intubation attempts and bag the pt (or not intubate
a child at all) is dependent upon pulse oximetry and
pulse rate.
Without sufficient preoxygenation the onset of
critical hypoxia will be quick.
PALS does state that it is acceptable to not intubate
a pediatric patient as long as the patient is
sufficiently oxygenated and ventilated during
transfer to a higher level of care. Do not delay
transport and other vital care for difficult
intubations if BVM is effective
PaO2
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By maximizing oxygen concentration in
the alveoli, blood and tissues, the
more time the patient will tolerate
apnea before becoming dangerously
hypoxic.
Preoxygenation can take several
minute. TAKE YOUR TIME!!!!
Combitube following
failed intubations
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Leaving the Combitube in place following
failed intubations is an appropriate stopping
point, assuming oxygenation and ventilation
have been achieved.
Placing the combitube with a laryngoscope
ensures proper placement. Blind insertion
may cause trauma and bleeding.
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Sedation may be required if pt biting on the
tube.
An OG can be placed down the esophageal
tube for decompression of the stomach.
DO NOT remove the Combitube to
intubate. If they haven’t thrown up yet,
they will now!!!
You can intubate around the Combitube by
deflating the pharyngeal balloon, using a
straight miller blade.
Pediatric intubations
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1)
2)
3)
4)
5)
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Differences from adult to pediatrics.
The larynx is positioned higher in neck
The mandible in infants is under-developed,
meaning shorter and narrower.
Increased size of the tongue relative to the size
of the oral cavity in peds.
Pediatrics have a increased length and stiffness of
the epiglottis.
Lastly, the size of the head in peds.
The narrowest point is the subglottic region, not
the vocal cords like adults.
RSI
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The fastest most effective means of
controlling the emergency airway.
Patient safety in RSI is about
managing the inherent risk involved
with the cessation of spontaneous
breathing.
- which you are about to take away!!!!
Indications for RSI
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A.
B.
C.
D.
GCS less than 8 with the following:
Pt is unable to maintain a patent
airway.
Pt is unable to protect his/her airway.
Pt is not being appropriately
ventilated or oxygenated.
Pt requires intubations for specific therapy
or procedure. (flying in an aircraft)
Contraindications for RSI
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Known allergy for necessary
medications.
Suspected epiglottitis, or edema.
Severe oral, mandibular, or neck
trauma.
Age less than 3 months old.
Significant hypotension.
Pre-RSI requirements
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EKG 4-lead
IV with normal saline, X 2 if possible.
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Pulse oximetry
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Bag valve mask attached to high-flow
O2
Suction
Combi-tube and/or cricothyrotomy kit.
RSI chart
RSI Medications
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Lidocaine
Dose: 1.5 mg/Kg IVP
Reduces cardiovascular and
intracranial pressure responses during
intubations.
Should be given at least 2
minutes prior to starting
intubations.
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Atropine
Dose: 0.02 mg/Kg IVP
(minimum dose of 0.1 mg)
Blunts the occurrence of bradycardia from
vagel stimulation during intubations and
from the administration of Succinylcholine.
Also dries up secretions.
Very important in Pediatrics.
Bradycardia during RSI intubations
usually caused by hypoxia!!!
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Zemuron ( for defasiculating dose when
succinylcholine is the paralytic agent.)
Dose: 0.1 mg/Kg IVP
This non-depolarizing neuromuscular
blocker prevents fasiculation's due to
Succinycholine. This is small, involuntary
muscle contractions seen under the skin.
Fasiculations can result in the release of
potassium by the muscles. Consider using
for patients with hyperkalemia.
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Versed
Dose: 0.1 mg/Kg under 50 lbs
2.0 mg IVP for adults
Duration is 5-10 minutes.
This reversible, short-acting
benzodiazepine works as sedation and
analgesia. Administer to pt’s who might be
adversely affected by increased HR and BP.
(MI’s, CHF, HTN’s and head injuries)
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Succinylcholine
Dose: 1.5 mg/Kg IVP
This non-reversible depolarizing
neuromuscular blocker provides paralysis in
30-90 seconds. Duration is 3-6 minutes.
ALL protective reflexes are gone!!!
Cricoid pressure is needed until
intubation is completed to prevent
aspiration.
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Zemuron
Dose: 1.0 mg/Kg
This non-depolarizing neuromuscular
blocker has a duration of 25-35
minutes when given in full dose.
Verification of placement
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Watch it go through the “cords” and
let everyone know.
Auscultation
Chest rise and fall
EtCO2
Pulse Oximetry