Rapid Sequence Intubation

in Emergency

Adapted from source

 OBJECTIVES
To understand why we use Rapid Sequence Intubation

To help you plan for a Rapid Sequence Intubation

To help you identify the potentially difficult airway

To learn some pharmacology behind airway management

To demonstrate the failed airway algorithm we use in ED

To introduce the Fastrach Intubating LMA

 Definition
The virtually simultaneous administration,
after pre oxygenation, of a potent sedative
agent and a neuromuscular blocking agent
to facilitate rapid tracheal intubation of a
potentially non fasted patient without
interposed positive-pressure ventilation.
 Indications for RSI
• Inability to maintain an adequate airway

• Inability to maintain adequate oxygenation or

ventilation

• Anticipated airway obstruction or special situations

 Aspiration
• the entry of secretions or foreign material into the
trachea and lungs

• lungs are normally protected against aspiration by

a series of protective reflexes such as coughing and
swallowing

• small volumes of gastric acid contents can fatally

damage delicate lung tissue or lead to
bronchopneumonia
BEFORE WE GO FURTHER …

Important Assumptions and Contraindications

• We are assuming that Intubation is indicated, is anticipated to be successful

and, if we fail, ventilation is expected to be successful !!

• We are assuming there is no tracheal / laryngeal injury or disruption or

massive facial trauma

• ie : We do not anticipate a difficult airway

• Alternatives exist such as awake nasal intubation with local anaesthesia and
sedation by a specialist Anaesthetist
 The Seven P’s of RSI
• Preparation
• Pre oxygenation
• Pre treatment
• Paralysis with induction

• Positioning + Protection
• Placement with proof
• Post-Intubation Management
1: Preparation – Intubation Equipment
• Bag and mask (check size) • Stylet + Bougie

• 2 laryngoscope handles
• Syringe (10 ml)
• 2 laryngoscope blades
• OP/NP airway
(Test light bulb)

• 2 endotracheal tubes • Working suction

(Test cuff + lubricate)
• Functioning ETCO2
(Adult women 7.0-8.0mm)

(Adult men 7.5-8.5mm) • Rescue device

 M.A.L.E.S
• Magill's
+ Mask

• Airway
+ Assistant

• Laryngoscope
+ Lubrication

• Endotracheal tube
+ ETC02

• Stylet (Bougie)
+ Syringe
+ Suction !
1: Preparation Airway Assessment
(You don’t want to be a L.E.M.O.N)

• Look externally

• Evaluate 3-3-2

• Mallampati

• Obstruction

• Neck
 Look Externally
Is this patient likely to be a …

Difficult BVM Ventilation ?

Difficult Laryngoscopy / Intubation ?
Difficult Surgical Airway ?
B = Beard
O = Obesity
N = No teeth
E = Elderly
S = Snores
= Severe facial injuries
(burns, mid face fractures or trauma)
 Evaluate (3-3-2 Rule)

3 x fingers between upper and lower incisor teeth

3 x fingers between the mental protuberance of the

mandible and hyoid bone

2 x fingers between thyroid cartilage notch

and the mandible or floor of the mouth

 Mallampati Classification
I Tonsillar pillars and fauces visible
II Upper portion of pillars and uvula visible
III Base of uvula / soft palate visible
IV Only tongue and hard palate visible

“Ask patient’s to open their mouth

and stick their tongue out”

Correlates with laryngoscopy classification but not as sensitive in

predicting grades 3 and 4 intubations
 Obstruction
• Epiglottis

• Abscess

• Burn

• Trauma

• Tumor
 Neck
• Possible cervical spine injury

• In line immobilization OR collar on/off

• Rheumatoid arthritis

• Ankylosing spondylitis
Prepare Yourself and Staff
and Establish a Plan

What if I can’t open the patients

mouth?

What if I can’t find the cords?

What if I can’t pass the tube?

What if I can’t ventilate the patient?

Time Zero in 5 minutes

2: Pre oxygenation

“100%” oxygen for three minutes

8 vital capacity breaths

Provides essential apnoea time

Apnoea time will vary with patient physiology

Brain Teaser 1:
How long is the apnoea time?

A healthy young ED doctor is fully pre oxygenated

with 100% oxygen and SUX is administered.

How long until their SpO2 drops below 90%?

A. 60 - 90 seconds
B. 91 - 180 seconds
C. 181 - 360 seconds
D. > 360 seconds
Brainteaser 2:

Which fully pre oxygenated patient

desaturates quicker?

A. Normal healthy 47 yr old 70 kg male

B. 60 yr old 80 kg male with moderate COPD

C. 14 month old “hell on wheels” toddler

D. 22 yr old 55kg intoxicated female OD

Time Zero in 3 minutes

3: Pre treatment
Laryngoscopy causes stimulation of afferent
receptors in the posterior pharynx, hypopharynx
and larynx

Reflexes can cause:

Increased intracranial pressure (ICP)

Stimulation of upper & lower respiratory tract

increasing airway resistance.

Stimulation of autonomic nervous system, with

increase heart rate and BP
 Laryngoscopy Effects
CNS response to airway stimulation

Increase cerebral metabolic demand

Increase cerebral blood flow

Increase ICP if ‘intracranial elastance’ is

compromised
 Laryngoscopy Effects
Respiratory system response

Upper airway reflexes lead to

laryngospasm & coughing

Coughing may cause increase in ICP

Lower airway reflexes can lead to an

increase in airway resistance bronchospasm

 Laryngoscopy Effects
Cardiovascular system response

Overall increase in heart rate and blood pressure

up to twice normal limits

Can be detrimental in patients with myocardial

ischemia, aortic or intracerebral aneurysm
or any penetrating trauma where increase in shear
pressure may reactivate previous haemorrhage

Increase in blood pressure may cause significant

increase in ICP if auto-regulation is lost
 PATIENTS AT RISK
Intracranial pathology

• “tight brain”

Cardiovascular disease

• “tight heart”

Reactive airways disease

• “tight lungs”
 FENTANYL
FENTANYL 1 - 3 mcg/kg given slowly over 1 minute

Attenuates normal physiologic & pathophysiological

reflex responses caused by airway manipulation during
laryngoscopy and insertion of an ETT

Caution: Contraindicated in patients overtly hypotensive and

dependent on sympathetic tone

( can use Fentanyl 1mg/kg OR occasionally lignocaine )

Brain Teaser 3:
Aspiration is always a risk with intubation and can
lead to significant morbidity and mortality

• From the answers below which patient has a high risk of

aspiration ?

A. A 60 yr old male with acute respiratory distress and

subacute bowel obstruction
B. A 28 yr old 34 week pregnant women with preeclampsia

C. A 6 yr old given morphine in ED and now 4 hours post

displaced supracondylar fracture
D. A 45 yr old presenting to ED with GCS 8/15 following OD
of unknown quantity of amitriptylline

E. All of the above

 Time ZERO !!!

4: Paralysis with Induction

Near simultaneous administration of
intravenous Induction agent and
Neuromuscular blocker

Both given as iv pushes with large saline flush

 Induction Agents
• The ‘Ideal agent’ would quickly render patients
unconsciousness, and amnesic and maintain stable
cerebral perfusion, cardiovascular stability and be
reversible with no side effects

Does NOT exist !!

Different agents have advantages and disadvantages

We try to use them to suit our clinical needs

 ETOMIDATE
• 0.3 mg/kg

Primary choice as induction agent in emergency RSI

Rapid onset, hemodynamic stability, positive CNS results

and rapid recovery

No contraindications

(widely used overseas !!!)

Attenuates elevated ICP by decreasing cerebral

blood flow and metabolic oxygen demand

Second only to ketamine regarding haemodynamic

stability of induction agents

Half-dose for haemodynamic instability (shock)

 PROPOFOL
• 1-2 mg/kg

A highly lipid soluble and highly potent intravenous

sedative hypnotic agent

Does cause significant hypotension

• Contraindication
- Elderly patients ( reduce dose to 0.5 mg/kg )
- Hypovolaemic patients ( preload with fluids )

Onset of action = 30 seconds from start administration

Duration of action = 3 to 5 minutes

 MIDAZOLAM
• 0.05 – 0.1 mg/kg

A short acting benzodiazepine sedative hypnotic agent

• NOT IDEAL BUT SAFE

- Risk of Awareness !

Effects can be reversed by Flumazenil (Annexate)

Onset of action = 2 MINUTES from start administration

Duration of action = 15 - 45 minutes

 KETAMINE
• 1.0 – 1.5 mg/kg

Phencyclidine (PCP) derivative

Does cause catecholamine release

• Contraindication
- Closed head injury (elevated ICP)
- Ischaemic heart disease

May cause increase in upper airway secretions

Onset of action = 45 – 60 seconds

Duration of action = 20 – 30 minutes

 Induction Agents for Specific
Conditions
Reactive airways disease

– Ketamine, Propofol, Midazolam

Increased intracranial pressure

- Propofol, Midazolam, ketamine, Thiopentone

Hypotensive patient

– Ketamine, Midazolam
 NEUROMUSCULAR
BLOCKING AGENTS

Depolarizing

Suxamethonium

Non-depolarizing

Rocuronium

Vecuronium
Suxamethonium
NMBA best suited for RSI in emergency
due to its rapid onset and quick recovery time

Contraindications

Personal or family history of malignant

hyperthermia

Significant, verified, hyperkalemia is an

absolute contraindication

End-stage renal disease / dialysis dependent

patients with unknown potassium level
SUX Related Hyperkalemia
Receptor Up regulation

Burns, crush injury, spinal cord injury > 72hrs

UMN lesions, including stroke
Mortality11%
MS, ALS, other denervation states
Prolonged ICU care

Myopathic Processes
Mortality30%
Muscular dystrophy
Rare idiopathic
SUXAMETHONIUM
Dosage

Adult = 1.5 mg/kg

Paediatric = 2.0 mg/kg

Neonatal = 3.0 mg/kg

Onset of action = 45 – 60 seconds

Duration of action = 7 – 10 minutes

Non depolarising Agents
Rocuronium = 1 mg/kg ( INTUBATING DOSE )

– Onset of action: 55 – 70 sec

– Duration: 30 – 60 min

- Full recovery 1 – 2 hrs

Vecuronium = 0.1 mg/kg – 0.15 mg/kg

– Onset of action = 90 – 120 sec

– Duration: 60 – 75 min

- Full recovery 1.5 – 2hrs

Time Zero + 30 seconds

• 5:Positioning
Time Zero + 45 seconds

6: Placement and Proof

Check mandible for flaccidity + end of fasciculation

Intubate, remove stylet / bougie and ‘hold’ ETT

Confirm tube placement

– Direct visualisation
– ETCO2 / capnography
– Bilateral breath sounds
– Absent epigastric sounds
 Failed Attempt = oxygenate
1st step = can I bag/mask ventilate this patient ?

Think about the six attributes:

» – Operator
» – Optimum patient position
» – BURP
» – Paralysis
» – Length of blade
» – Type of blade

Rescue Manoeuvres

• The first rescue from failed intubation is bagging

• The first rescue from failed bagging is better bagging

Zero + 90 seconds

7: Post-intubation Management
Secure tube / ‘bite block’
Monitor ETCO2 continuously
Arrange Chest x-ray

Start long acting sedation (+/- paralysis)

– 60mg morphine + 30mg midazolam up to 60mls in saline at 10ml/hr
– intermittent boluses of vecuronium (5mg) approx every 30 minutes

Establish ventilator parameters

- tidal volume 7- 8 ml/kg at RR 12
 Rapid Sequence Intubation
Summary

• Preparation (10 mins - zero)

• Pre oxygenation (5 mins - zero)
• Pre treatment (3 mins - zero)

• Paralysis with induction (time zero)

• Positioning (zero + 30 sec)

• Placement (zero + 45 sec)
• Post-tube management (zero + 90 sec)
FASTRACH Intubating LMA
 VIDEO ??
• http://www.youtube.com/watch?v=UA1wWm
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