Transcript Rapid Sequence Intubation

Rapid Sequence Intubation
Delon F.P. Brennen, MD MPH
Pediatric Emergency Medicine
Morehouse School of Medicine
Outline
• Definition
• Indications
• Method
Definition
• The induction of a state of unconsciousness
with complete neuromuscular paralysis to
achieve intubation without interposed
mechanical ventilation in efforts to facilitate
the procedure and minimize risks of gastric
aspiration
Indications
• Failure of airway maintenance/protection
- lost or diminished gag reflex
• Failure of oxygenation/ventilation
- asthma, aspiration, pneumonia
• Anticipated clinical course
- multiple trauma, head injured
- intoxication, air transport
Method (6P’s)
• Preparation: T-10mins
– Positioning
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Preoxygenation: T-5mins
Premedication: T-3mins
Paralysis: T-1min
Placement of tube: T-0mins
Post management
Preparation
• Evaluate
– LEMON
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Equipment Check
Positioning
Drug Selection
IV’s, monitor, oximetry
Ancillary Staff
Anticipate alternative airway maneuver
LEMON
• LEMON
– L-Look
– E-Evaluate
– M-Mallampati
– O-Obstruction
– N-Neck mobility
Preoxygenation
• 100% O2 for 5 minutes or 5 vital capacity
breaths can theoretically permit 3-5 minutes
of apnea before desaturation to less than 90%
occurs
• NOT Positive Pressure Ventilation
– If possible
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© 2005 Elsevier
Premedication
• Goal
– blunt the patient’s physiologic responses to intubation
• Which are ?
– bradycardia
– hypoxemia
– cough/gag reflex
– increases in intracranial, intraocular, and intragastric
pressures
Premedication
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Lidocaine
Opioid
Atropine
Defasciculating doses “priming”
Lidocaine
• Thought to blunt the rise in ICP associated
with airway manipulation and the use of
depolarizing neuromuscular blocking agents
• Dose:
– 1.5 - 3 mg/kg (3 mins prior to intubation)
Atropine
• Minimize vagal effects, bradycardia, secretions
– Infants and children < 8 yrs may develop profound
bradycardia during intubation
• 0.02 mg/kg (minimum 0.1 mg IV, max 1 mg)
3 minutes prior to intubation
Defasciculating Doses
• Decreases muscle fasiculations caused by the
depolarizing agents (succinylcholine)
• Attenuates rise in intracranial pressure
• Agents - non-depolarizing blocking agents
(vecuronium, pancuronium, etc.)
– Usually 1/10 of standard dose
Sedation
• Sedative agents administered at doses capable
of producing unconsciousness with little or no
cardiovascular effects
• No ideal agent exists
• Sedation should nearly always be used when
paralyzing the patient
Sedation
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Barbiturates/hypnotics
Non-barbiturate
Neuroleptics
Opiates
Benzodiazepines
Barbiturates/Hypnotics
• Thiopental (Pentothal), Methohexital (Brevital)
• Short onset - 10-20secs,
• Duration - 5-10 mins
• May reduce ICP, cerebro-protective
• Histamine release, hypotension, bronchospasm
Barbiturates/Hypnotics
• Etomidate (Amidate)
– nonbarbiturate hypnotic
• Rapid onset, short duration
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Decreases ICP/IOP
Minimal hemodynamic effects
No histamine release
Increases seizure threshold
Etomidate
• No malignant hyperthermia reported
• Watch for myoclonus, vomiting
• May decrease cortisol synthesis (adrenal
insufficiency)
• Dose 0.3 mg/kg IV
Barbiturates/Hypnotics
• Propofol (Diprivan)
– sedative hypnotic
• Extremely rapid onset (10 sec),
• Duration of 10-15 minutes
• Decreases ICP, Can cause profound hypotension
• Dose 1-3 mg/kg IV for induction
• Dose: 100-200 mcg/kg/min for maintenance
• Ketamine
Ketamine
– dissociative anesthetic, not a sedative
• Rapid onset (1-2mins), short duration (~15mins)
• Potent bronchodilator, useful in asthmatics
• Increases ICP, IOP, IGP, (beware in head injuries)
• Increases bronchial secretions
• “Emergence” phenomenon
– rarely in children <10 yrs , common in adults
• Dose: 1-2 mg/kg
Opiates
Fentanyl
• Rapid onset (<1 min), long duration - 30 min
– Does not release histamine
• May decrease tachycardia and hypertension
associated with intubation
• Seizures and chest wall rigidity
– Can be reversed with Naloxone
• Dose: 2-10 mcg/kg IV
Morphine Sulfate
• Longer onset (3-5) minutes and duration (2-6)
hours
• May not blunt the rise in ICP, hypertension
and tachycardia as well as fentanyl
• Histamine release
• Dose 0.1-0.2 mg/kg IV
Benzodiazepines
Benzodiazepines
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Midazolam, Diazepam, Lorazepam
Provide excellent amnesia and sedation
Broad dose-response relationship
Reversed with Flumazenil
Doses required are higher for RSI than for
general sedation
Midazolam
• Slower onset (3-5) min than the
barbiturate/hypnotic agents
• Considered short-acting (30-60 min)
• Does not increase ICP
• Causes respiratory and cardiovascular
depression
• Dose: 0.1-0.4mg/kg IV
Diazepam and Lorazepam
• Moderate/long acting agents
• Longer onset time than midazolam
• May be more beneficial post-intubation for
sedation
Paralysis
Neuromuscular Blocking Agents
• Chemical paralysis facilitates intubation by
allowing visualization of the vocal cords and
optimizing intubating condition
• Only CONTRAINDICATION is anticipated
difficult airway
– Mallampati Class (I-IV)
– Thyromental Distance
Depolarizing Agents
• Exert their affect by binding with acetylcholine
receptors at the neuromuscular junction,
causing sustained depolarization of the
muscle cell
Nondepolarizing
• Bind to acetylcholine receptors in a
competitive, non-stimulatory manner, no
receptor depolarization
• Histamine release
• Reversed with edrophonium or neostigmine
• Caution with myasthenia gravis
Agents
• Depolarizing agents
– Succinylcholine (Anectine)
• Nondepolarizing Agents
– Pancuronium (Pavulon)
– Vecuronium (Norcuron)
– Atracurium (Tracrium)
– Rocuronium (Zemuron)
– Mivacurium (Mivacron)
Succinylcholine
• Gold standard for >50 years
• Stimulates nicotinic/muscarinic cholinergic receptors
• Onset 45 secs, duration 8-10 mins
• Dose: Children 2.0 mg/kg IV
– (adults 1.5 mg/kg IV)
• Inactivated by pseudocholinesterase
Succinylcholine cont
• Prolonged paralysis seen with:
– Pregnancy
– Liver disease
– Malignancies
– Cytotoxic drugs
– Certain antibiotics
– Cholinesterase inhibitors
– Organophosphate poisoning
Succinylcholine
• Adverse reactions
– Muscle fasiculations
– Hyperkalemia
– Bradycardia
– Prolonged neuromuscular blockade
– Trismus
– Malignant hyperthermia
Depolarizing Agents
• Muscle fasiculations
– Thought to increase ICP/IOP/IGP
– Causes muscle pain
– Minimized by “priming” dose of non-depolarizing
NMB
• Hyperkalemia
– Average increase in potassium of 0.5-1 mEq/L
– Burns, crush injuries, spinal cord injuries,
neuromuscular disorders, chronic renal failure
Depolarizing agents
• Bradycardia
– Most common in kids <10 yrs 2o higher vagal tone
– Especially w/ repeated doses of succinylcholine
– Premedicate with atropine
Depolarizing Agents
• Malignant hyperthermia
– From excessive calcium influx through open
channels
– Genetic predisposition
– Rapid rise in temperature, rhabdomyolysis, muscle
rigidity, DIC
– 60% mortality
– Treatment: IV Dantrolene
Depolarizing Agents
• Trismus (Masseter spasm)
– Usually in children
– Unknown cause
– Treat with a nondepolarizing NMB
Pancuronium
• Slow onset (1-5 min)
• Long-acting agent (45-90 min)
• Renal excretion
• Vagolytic tachyarrythmias common
• Dose: 0.10-0.15 mg/kg IV
Vecuronium
• Onset of 1-4 min
• Duration of 30-60 min
• Hypotension may occur from loss of venous
return and sympathetic blockade
• Mostly biliary excretion
• Dose 0.1 mg/kg
– “priming dose” 0.01 mg/kg
Rocuronium
• Shortest onset of the nondepolarizing agents
(1-3 min)
• Duration 30-45 min
• Tachycardia can occur
• Dose: 0.6-1.2 mg/kg (1mg/kg)
Placement of Tube
• Allow medications to work and assure complete
neuromuscular blockade of the patient
• Maintain Sellick maneuver until cuff inflated
• Ventilate with bag-valve mask if unsuccessful
• Additional doses of sedatives/NMB may be
necessary
• Confirm tube placement
Post Intubation Management
• Secure tube
• Continuous pulse oximetry
• Reassess vital signs frequently
• Obtain chest x-ray, ABG
• Restrain (physical/chemical)patient
• Consider long term sedation
Questions??
Thank You!