RSI

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Rapid Sequence Intubation

Dr. Manish Taneja


Question?
• You decide to intubate a 70 year old female with ACS with cardiogenic shock
on dual inotropes and vasopressors and pulmonary edema.

• Which drugs would you choose?


Introduction
• An airway management technique that produces inducing immediate
unresponsiveness (induction agent) and muscular relaxation (neuromuscular
blocking agent) and is the fastest and most e ective means of controlling the
emergency airway.

• Useful in the patient with an intact gag re ex, a “full” stomach, and a life
threatening injury or illness requiring immediate airway control

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Indications
• A – airway protection and patency
• B – respiratory failure (hypercapnic or hypoxic), decrease WOB, secretion
management/ pulmonary toilet, to facilitate bronchoscopy

• C – minimise oxygen consumption and optimize oxygen delivery (e.g.


sepsis)

• D – unresponsive to pain, terminate seizure, prevent secondary brain injury


• E — temperature control (e.g. serotonin syndrome)
• F — For humanitarian reasons (e.g. procedures) and for safety during
transport (e.g. psychosis)
Why its difficult?
1. Dynamically deteriorating clinical situation, i.e., there is a real “need for
speed”

2. Non-cooperative patient

3. Respiratory and ventilatory compromise

4. Impaired oxygenation

5. Full stomach (increased risk of regurgitation, vomiting, aspiration)

6. Extremely short safe apnea times

7. Secretions, blood, vomitus, and distorted anatomy


Procedure
• Plan
• Preparation (drugs, equipment, people, place)
• Protect the cervical spine
• Positioning (some do this after paralysis and induction)
• Preoxygenation
• Pretreatment (optional; e.g. atropine, fentanyl and lignocaine)
• Paralysis and Induction
• Placement with proof
• Postintubation management
Team
The airway team should be a minimum of 3 people:

• airway proceduralist
• airway assistant
• drug administrator
Procedure
• Suction
— at least one working suction, place it between mattress and bed

• Oxygen
— NRBM and BVM attached to 15 LPM of O2, preferably with nasal prongs for apneic oxygenation

• Airways
— 7.5 ET tube with stylet ts most adults, 7.0 for smaller females, 8.0 for larger males, test balloon by lling with 10 cc of
air with a syringe
— Stylet – placed inside ET tube for rigidity, bend it 30 degrees starting at proximal end of cu (i.e. straight to cu , then
30 degree bend)
— Blade – Mac 3 or 4 for adults – curved blade
— Miller 3 or 4 for adults – straight blade
— Handle – attach blade and make sure light source works
— Backups – ALWAYS have a surgical cric kit available!
— have video laryngoscope, LMA and bougie at bedside

• Pre-oxygenate – 15 LPM NRBM


• Monitoring equipment/Medications
— Cardiac monitor, pulse ox, BP cu opposite arm with IV
— Medications drawn up and ready to be given

• End Tidal CO2


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Induction Agent
• smoothly and quickly render the patient unconscious, unresponsive and
amnestic in one arm/heart/brain circulation time

• provide analgesia
• maintain stable cerebral perfusion pressure and cardiovascular
haemodynamics

• be immediately reversible
• have few, if any, side e ects
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Induction Agent
• Ketamine 1.5-2 mg/kg IBW
• Etomidate 0.3-0.4 mg/kg TBW
• Fentanyl 2-10 mcg/kg TBW
• Midazolam 0.1-0.3 mg/kg TBW
• Propofol 1-2.5 mg/kg IBW + (0.4 x TBW) (others simply use 1.5 mg/kg x
TBW as the general guide)

• Thiopental 3-5 mg/kg TBW


Paralytics
• Suxamethonium 1-2 mg/kg TBW
• Rocuronium 0.6-1.2 mg/kg IBW
• Vecuronium 0.15-0.25 mg/kg IBW
Ketamine
• Dose: 1.5 mg/kg IV (4mg/kg IM)
• Onset: 60-90 sec
• Duration: 10-20 min
• Use: any RSI, especially if hemodynamically unstable (OK in TBI, does not
increase ICP despite traditional dogma) or if reactive airways disease
(causes bronchodilation)

• Drawbacks: increased secretions, caution in cardiovascular disease


(hypertension, tachycardia), laryngospasm (rare), raised intra-ocular
pressure
Propofol
• Propofol 1-2.5 mg/kg IBW + (0.4 x TBW) (others simply use 1.5-2.5 mg/kg x
TBW as the general guide)

• Onset: 15-45 seconds


• Duration: 5 – 10 minutes
• Use: Haemodynamically stable patients, reactive airways disease, status
epilepticus

• Drawbacks: hypotension, myocardial depression, reduced cerebral


perfusion, pain on injection, variable response, very short acting
Etomidate
• 0.3mg/kg IV
• onset: 10-15 seconds
• Use: suitable for most situations including haemodynamically unstable,
other than sepsis or seizures

• Drawbacks: adrenal suppression, myoclonus, pain on injection.


Fentanyl
• Dose IV 2-10 mcg/kg TBW
• Onset: <60 seconds (maximal at ~5 min)
• Duration: dose dependent (30 minutes for 1-2 mcg/kg, 6h for 100 mcg/kg)
• Use: may be used in a low dose as a sympatholytic premedication (e.g. TBI,
SAH, vascular emergencies); may used in a’modi ed’ RSI approach in low
doses or titrated to e ect in cardiogenic shock and other hemodynamically
unstable conditions

• Drawbacks: respiratory depression, apnea, hypotension, slow onset, nausea


and vomiting, muscular rigidity in high induction doses, bradycardia, tissue
saturation at high doses
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Midazolam
• Dose: 0.3mg/kg IV TBW
• Onset: 60-90 sec
• Duration: 15-30 min
• Use: not usually recommended for RSI, some practitioners use low doses of
midazolam and fentanyl for RSI of shocked patients

• Drawbacks: respiratory depression, apnea, hypotension, paradoxical


agitation, slow onset, variable response
Thiopentone
• Dose: 3-5 mg/kg IV TBW
• Onset: 30-45 sec
• Duration: 5-10 min
• Use: any RSI if haemodynamically stable, status epilepticus
• Drawbacks: histamine release, myocardial depression, vasodilation,
hypotension, must NOT be injected intra-arterially due to risk of distal
ischaemia, contra-indicated in porphyria
Succinylcholine
• Dose: 1.5 mg/kg IV (2 mg/kg IV if myasthenia gravis) and 4 mg/kg IM (in extremis)
• Onset: 45-60 seconds
• Duration: 6-10 minutes
• Use: widely used unless conra-indicated; ideal if need to extubate rapidly
following an elective procedure or to assess neurology in an intubated pateint

• Drawbacks: numerous contra-indications (hyperkalemia, malignant hyperthermia,


>5d after burns/ crush injury/ neuromuscular disorder), bradycardia (esp after
repeat doses), hyperkalemia, fasciculations, elevated intra-ocular pressure, will
not wear o fast enough to prevent harm in CICV situations
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Rocuroium
• Dose: 1.2 mg/kg IV IBW
• Onset: 60 seconds
• Use: can be used for any RSI unless contra-indication or require rapid
recovery for extubation after elective procedure or neurological assessment;
ensures persistent ideal conditions in CICV situation (i.e. immobile patient
for cricothyroidotomy) – can be reversed by sugammadex

• Drawbacks: allergy (Rare)


Vecuronium
• Dose: 0.15 mg/kg IV (may be preceded by a 0.01 mg/kg IV priming dose 3
minutes earlier)

• Osent: 120-180 econds


• Duration: 45-60 minutes
• Use: not recommended for RSI, unless no suxamethonium or rocuronium
cannot be used – can be reversed by sugammadex

• Drawbacks: allergy (rare), slow onset, long duration

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