Transcript Difficult Airway and Rapid Sequence Intubation

Rapid Sequence Intubation
and Difficult Airway
Andrew Scordato EMT-P
EMS Instructor
Learning objectives
 Define RSI
 List Indications and Contraindications
 Describe Basic Airway Anatomy
 Identify and Describe RSI Pharmacology
 Identify and Describe the seven P’s of RSI
 Differentiate between properly place and
improperly placed ET tubes
 Discuss Difficult Airway
 Factors
 Solutions: extraglotic airways
RSI?
 What is RSI
 Sedatives and NMBA same time
 Protect airway/minimize hypoxia
 Who is it for
 Unable to maintain airway
 GCS <8
 Pt. may lose the ability to protect their airway
 Others?
 Who is it not for
 Inexperience
 Difficult airway?
 No “back-up” capabilities
Airway Anatomy
Upper airway
Normal VS. Abnormal
Abnormal
Airway Anatomy
 Lower Airway
Airway Anatomy
 Properly placed ET Tube
What are the Drugs Doing?
 Cellular level
 Neuron
 Action Potential
 Ion channels
 Synapse
Neuron
Action Potentials
Ion Channels
The Synapse
The Usual Suspects
 Atropine
 Names-Atropine Sulfate
 Actions-parasympatholytic, Blocked vagal effects result in increased
HR, decreased secretions
 Indication-Bradycardia, used to pre-medicate
 Contraindications-Acute hemorrhage, tachycardia, narrow angle
glaucoma
 Lidocaine
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Names-Xylocaine
Actions-Antidysrhythmic properties, Local Anesthetic, Blunts ICP
Indications-pre-medicate in RSI
Contraindications-Second or third degree heart block in the absence
of artificial pacemaker. Caution-apnea induced with suxs may be
prolonged with large doses of lidocaine.
TUS II
 Vercuronium
 Names-Norcuron
 Actions-Provides muscle relaxation by competing with ACH receptors on
the nerve, result is muscle paralysis. Does not cause that initial
depolarization wave that is common with SUCCS.
 Indications-Temporary paralysis where muscle tone or szr prevent
 Dosage-Defasciculating dose 1mg/ivp Paralytic dose= .1mg/kg
 Contraindications-monitor for bradycardia and hypotension. Certain drugs
can enhance the effect including lidoccaine. Lasts-25-30 minutes
 Versed
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Names-Midazolam hydrochloride
Actions-Short acting benzo, conscious sedation and impairs memory
Indications-Premedication for Intubation, SZR
Contraindications-shock, Alcohol intoxication (relative), Concurrent use
with other barbiturates, alcohol, narcotics and CNS depressants.
TUS III
 Etomidate
 Names-Amidate
 Actions-Hypnotic, Anesthetic, Sedation, impairs memory,inhibits
postsynaptic current
 Indications-Medication for Endotracheal intubation
 Contraindications-L and D, effects may be enhanced when given with
other CNS depressants.
 Succinycholine
 Names-Anectine
 Actions-Neuromuscular blocker-bind to ACH sites cause muscle to
relax
 Indications-facilitate intubation, muscle relaxation
 Contraindications-skeletal muscle myopathies, Inability to control
airway and or support ventilations with 02 or BVM
Ketamine
 Ketamine is a non-competitive NMDA receptor antagonist and dissociative, amnestic,
analgesic anesthetic agent.
 Onset & Duration
 Onset: 1-5 minutes.
 Duration: 10-15 minutes
 Contraindications
 Relatively contraindicated in penetrating eye trauma, patients with known cardiovascular
disease. (ketamine causes tachycardia)
 Side Effects
 Laryngospasm: this very rare adverse reaction presents with stridor and respiratory
distress. After every administration of ketamine:
 a. Prepare to provide respiratory support including bag-valve-mask ventilation and suction which are
generally sufficient in rare cases of laryngospasm.
 b. Institute cardiac monitoring, pulse oximetry and continuous waveform capnography
 c. Establish IV or IO access, check blood glucose
 Emergence reaction: presents as anxiety, agitation, apparent hallucinations or nightmares
as ketamine is wearing off. For severe reactions, consider benzodiazepine.
 Nausea and Vomiting/Hypersalivation: Suction usually sufficient.
Pharmacology
 Paralytics
 Notes
 Choice is between Depolarizing or Non-Depolarizing
 Rapid paralysis with rapid recovery
 Depolarizing
 persistent stimulation/Unresponsive to
ACH/Fasciculation
 Fasciculation-What?
Muscle contraction cannot reoccur leading to relaxation
 Example-Succinylcholine
 Non-depolarizing
 Blocks ACH sites
 Slower onset
 No fasciculation
 Longer duration of Action
 Example-Vecuronium
Depolarizing/Non-Depolarizing
Pharmacology
 Pre-Medicating Agents
 Atropine
 Bradycardia (Peds)
 Decrease Vagal tone/secretions
 Dose=.02mg/kg
 Lidocaine
 Head injury/ other conditions?
 It’s believed to blunt ICP/open smaller airways
 Dose=1mg/kg 3-5 minutes prior to intubation
 Defasciculating agents
 Vecuronium-Head Injury/ Penetrating Eye Injury
Pharmacology
 Induction agents (sedation)
 Notes
 Review VS
 Paralyzed and Sedated not paralyzed alone
 Multiple Agents available
 Versed
 Benzodiazepine/Short Acting
 onset=1-3 minutes/ duration 2-6 hours
 2-2.5mg sivp
 Etomidate=Rapid onset, short acting, sedative
hypnotic
 Onset=10-15 seconds/duration 5-15 minutes
 Dosage=0.3mg/kg
Pharmacology
 Succinylcholine
 Depolarizing
 Primary agent with NDMB as secondary
 Onset=within 1 minute/Duration=2-5
minutes
 Dosage=1.5mg/kg
 Pt.'s with burn >24 hours/precaution difficult
intubations
 Vecuronium
 NDMB
 Onset approx. 3 minutes
 Dosage= Defasciculating 1mg/ivp Paralytic=0.1mg/kg
The Seven P’s of RSI
 1.Prepare
 2.Pre-Oxygenate
 3.Pre-medicate
 4.Put under=sedate
 5.Paralyze
 6.Pass the tube
 7.Post-Intubation Management
Prepare
 Assess
 Difficult Airway?
 Gather Equipment=“Soap me”
 Suction/02/Airway
equipment/Pharmacology/Monitoring Equipment
 Prep the Patient
Difficult Airway
 Predictors of a difficult airway
 Short Fat neck
 Small receding chin
 Presence of a beard
 Large tongue
 Trauma
 Infection or tumor
 Spinal disease
 Low set ears
 Swelling of the face or neck
What do you see?
Pedictors
Mnemonics, Mnemonics, Mnemonics!
 What are our tools to assess the difficult airway
and problems we may encounter-What are the
chances for success?
 Lemon-intubation
 L=Look Externally-abnormal face, sunken cheeks, narrow
mouth, receding mandible, obesity
 Evaluate the 3-3-2 rule=3 pt. sized fingers in mouth/Hyoid to
chin 3 fingers/ 2 fingers from thyroid cart. to floor of mouth
 Mallampati
 Obstruction
 Neck Mobility=can you extend and flex the neck
3-3-2
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Mallampati
Mallampati scoring
 Class I and II
 Can see
 Soft palate
 Uvula
 Class III and IV
 Can see
 Hard palate
 Base of uvula
Obstructed Airway
 Four Main signs
 Muffled Voice
 Difficulty Swallowing/Secretions
 Stridor
 Sensation of Dyspnea
Mnemonics
 Moans=ventilating
 Mask seal
 Obstruction
 Age
 No teeth
 Stiff Neck
 RODS=extraglottic device
 Restricted-mouth opening
 Obstruction
 Distorted-tumor or surgery
 Stiff lungs-asthma ,COPD, ARDS
Pre-Oxygenate
 Two to Five minutes before the initiation of sedation and
Neuromuscular blockade
 Buys time during patients period of Apnea before they de-
saturation
 Allows for “Nitrogen Washout”
 100% 02 via NRB or BVM
 Make sure equipment is operating 02 sat and Capnography
Desaturation Curve
Pre-Medicate
 Why are we pre-medicating the patient?
 What are we pre-medicating them with?
 Atropine-Peds/Bradycardia
 Lidocaine-Head Injury
 Defasciculating Agents
 What are they?
 Vecuronium
 Allow 2-3 minutes for them to take effect.
Put Under Sedate
 If pt. is paralyzed then they must be sedated
 Multiple sedative agents available(Thiopental, Midazolam, lorazepam, fentanyl,
ketamine, Etomidate, and propofol)
 MCEMD agents Etomidate and Versed
 Etomidate-Rapid onset, short acting, sedative-hypnotic agent
 Onset-10-15 seconds
 Duration 5-15 minutes
 Dosage 0.3mg/kg
 Versed-short acting rapid onset benzodiazepine
 Onset-1-3 minutes
 Duartion-2-6 hours
 Dosage 2-2.5 mg slow ivp
Paralyze
 Neuromuscular blocking agents
 Depolarizing
 Non-depolarizing
 Examples
 Succinylcholine
 Precaution in burn patients/Patients with Renal Failure/Hyperkalemia
 Vecuronium
Passing the Tube
 Take a deep breath/relax
 Make sure equipment is ready
 Maintain c-spine & Monitor VS (ekg and Sp02)
 Pad behind the Pt. head to line up airway
 Have partner use the BURP method
Relax
BURP
 B=Backwards
 U=upwards
 R=right
 P=pressure
Line Up
 Lining up airway axis
 Pad behind Pt.'s head
 Head extension
 Tragus with chest
Tragus to chest
Post-Intubation
 1.Confirm Placement
 Tools
 Visualize
 Auscultate
 Secondary devices
 2.Protect Placement
 Secure
 3.Management
 DOPE
Capnography
What are good values=What to What
Is this a good tracing? Why?
Esophageal
1st, 2nd 3rd attempts?
 1st attempt
 Reposition patient
 Pad more under head
 Lift shoulder off the floor
 Intubator same level as the Patient
 2nd
 Change blades
 Hyper-flex the neck
 Tools
 3rd
 Back-Up airways
 BVM
 Cricothyroidotomy
Back-Up airways
 Combitube
 LMA
 King Airway
King Airway
Cricothyroidotmoy
 CICO event=Can’t intubate-can’t oxygenate
 Placement-find cricothyroid membrane
 Equipment=scalpel et tube or quicktrach kit
 Technique=Protocol dependent
Cric AP
Cric
Pediatric Airway
 Adults VS. Pediatric
 Larger tongue
 Cricothyroid narrowest
 More anterior
 BVM VS. Intubation?
 Transport=Time and distance?
 Key Points
 Premedicate
 Atropine
 Positioning
 Padding under shoulders
Madison RSI
 Look at handouts
 Precautions
 Preparation
 Procedure
 Airway Protection other than RSI
GMVEMS
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{Sedate to intubate may only be utilized with department and medical director approval. Do not
attempt if successful intubation is unlikely due to foreseeable complications.}
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ADULT ONLY:
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A Must be trained on, approved on and have equipment to perform a cricothyrotomy either open
surgical or by device.
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A Pre-oxygenate the patient. In order to reduce gastric distention, avoid using a BVM.
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Apply a cardiac monitor and pulse oximeter.With suspected stroke, intracranial hemorrhage, head
injury, or signs of increased intracranial pressure, administer Lidocaine 100 mg, IV.
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Administer Etomidate 0.3 mg/kg, IV (average initial dose is 15-25 mg). Repeat initial dose within
2 minutes as needed. Apply cricoid pressure to reduce the possibility of aspiration and to facilitate
intubation
Scenarios
 #1
 Dispatched for MVA. Occupant ejected from vehicle.
 Arrival-2 minor patients and another patient was ejected he is
lying in a cornfield. Patient is unresponsive GCS of 5, RR of 8.
Drivers license states his weight approx. 160lbs bruising and
swelling noted to face.
 What airway problems do you expect?
 How would you control this patients airway?
 If you RSI this patient what medications would you give him?
 What back-up airways would you consider?
Scenarios
 #2
 Dispatched for ATV roll over. Family members are driving them to St.
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 Arrival-One minor patient. Second patient is a 4 year old child located in the
back of a pick-up. Patient is found to be unresponsive with a GCS of 3, RR of
4-5, and has blood flowing from his nose and right ear. His jaw appears to be
clenched. No swelling or other injury noted to face. Dad tells you he weighs
42 lbs.What airway problems do you expect?
 How would you control this patients airway?
 If you RSI this patient what medications would you give him?
 What back-up airways would you consider?
 In a Pediatric airway are there other issues to consider?
Ten Tips (adapted from Scott Synder
article)
 1-Place the patient in an optimal position to open airway
 Sniffing/head elevated position
Tips
 2-Use a BLS airway adjunct
 Use several!!!!!
 A OP and 2 NPA (wtf)
 3- Use a jaw thrust maneuver
 4-Use two rescuer BVM and Thenar eminence
TIPS
 5-Long inspiration small tidal volumes
 Manometer/SPO2/Capnography, conjunction.
 6-Did we mention positioning
 7-Apneic Oxygenation during intubation
 8-Use external manipulation
 No cricoid pressure. Operator moves airway.
 9-Endotracheal introducer (bougie)
 Study-Increase from 66% to 96%
 10-Confirm Placement!!!!!!!!!!!!!!!!