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RSI sheet-2007
 

RSI sheet-2007

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    RSI sheet-2007 RSI sheet-2007 Document Transcript

    • 12/15/2007 RSI in Emergency Department Rapid Sequence Intubation (RSI) Outline in Emergency Room • Indications for intubation • Considerations in Emergency intubation • Rapid Sequence Intubation (RSI) Siriporn Pitimana-aree, MD • The Failed Airway Dept. of Anesthesiology, • Defining the Difficult Airway Faculty of Medicine Siriraj hospital. • Rescue Devices (The Royal College of Anesthesiologists of Thailand) Indications for ETT intubation Emergency ETT intubation: Considerations • Time pressure • Absent or inadequate respiration • Unstable patient • Impending airway obstruction • Physiologic responses • Inability to protect airway • Possibly difficult situation • Uncooperative / combative • Not fasted • Difficult airway Emergency ETT intubation: Physiologic responses to intubation • Incidence of difficult & failed intubation: 8% •Gagging • Frequency of esophageal intubation: 8% •Rise in ICP 40% of these - difficult intubation almost all recognized by clinical criteria •Rise in BP but 3, decrease saturation detected by SpO2 •Tachycardia / Bradycardia • Incidence of pulmonary aspiration: 4% •Dysrhythmias • Hemodynamic consequences: 3% died during or within 30 min. of intubation 1
    • 12/15/2007 Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI) Definition Definition Incorporates: The virtually simultaneous administration • Every patient has a full stomach of a potent sedative agent • Preoxygenation & a neuromuscular blocking agent • No interposed ventilations to induce unconsciousness • Sellick’s maneuver & motor paralysis for tracheal intubation. Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI) Contraindications: Advantages of RSI Anticipate of difficult airway& intubation •Minimizes risk of aspiration •Facilitate intubation Staff inexperienced in RSI •Blunt untoward physiologic responses •Avoid awake intubation Patients allergic or contraindication to drugs used in RSI Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI) The Six Ps of RSI 10 min The Sequence Preparation Preparation Preoxygenation Paralysis with Sedation Preoxygenation Protection Placement the time of administration of ………..Zero Postintubation care Succinylcholine. 2
    • 12/15/2007 Rapid Sequence Intubation (RSI) Rapid Sequence Intubation (RSI) The Sequence …10 minutes ---- Zero The Sequence …5 minutes ---- Zero Preparation Preoxygenation • Assess airway difficulty (LEMON) • 100% oxygen for five minutes • Plan approach • 8 vital capacity breaths • Assemble drugs and equipments • Provides essential apnea time • Establish access • Apnea time varies • Establish monitoring Rapid Sequence Intubation (RSI) The Sequence Zero!! Paralysis with Sedation • Sedative / Induction agent IV push • Succinylcholine 1.5 mg/kg IV push Entering the red zone... Rapid Sequence Intubation (RSI) The Sequence …Zero + 30 seconds Protection • Sellick’s Maneuver • Position patient Optimal External Sellick’s maneuver • Do not bag unless SpO2 < 90% Laryngeal Manipulation (Cricoid pressure) (Backwards, Upwards, Rightwards Position (BURP) 3
    • 12/15/2007 Rapid Sequence Intubation (RSI) The Sequence …Zero + 60 seconds Placement • Check mandible for flaccidity • Intubate, remove stylet • Confirm tube placement – EtCO2 • Release Sellick’s maneuver “ Sniffing position ” Rapid Sequence Intubation (RSI) The Sequence Experinced Inexperinced Postintubation care Auscultation 100% 68% •Ongoing sedation and/or paralysis ETCO2 100% 100% •Mechanical ventilation (if needed) Self inflating bulb 96% 98% •Further investigations (CXR, ABG) Trachlight 84% 87% •Postintubation hypotension Rapid Sequence Intubation (RSI) “Failed intubation” What do you do? If you can not intubate after RSI? Rescue Maneuvers • The first rescue from failed intubation is “Failed intubation” bagging. • The first rescue from failed bagging is better bagging. • Rescue devices 4
    • 12/15/2007 The “Failed” Airway The “Failed” Airway • Multiple Definitions… Clinically, 2 types of “failed” airways: – Number of failed attempts (e.g., three) – Failure to ventilate with a BVM 1. Cannot intubate, but can oxygenate – Failure to oxygenate – Failure to visualize the larynx 2. Cannot intubate, and cannot oxygenate The Difficult Airway The Difficult Airway Identification of the Difficult Airway The DIFFICULT AIRWAY is something you 3 Key Attributes PREDICT… A FAILED AIRWAY is something you • Difficult Bag/Mask Ventilation EXPERIENCE!! • Difficult Intubation • Difficult Cricothyrotomy The Difficult Airway The Difficult Airway Difficult Bag Mask Ventilation Difficult Cricothyrotomy Mask seal Surgery scar Obesity Hematoma Aged (>55) Obesity No teeth Radiation Stiff lungs Tumor 5
    • 12/15/2007 Predicting of difficult airway Difficult Intubation Identification of the Difficult Airway • A short bull neck • Prominent incisors • BMV as important as intubation • A receding chin • Mouth opening/access • Limited mouth opening • Neck extension at AOJ • Chin to hyoid distance • Neck flexion at CTJ < 6 cm (3FB) • Mentum-Hyoid-Thyroid distance • Potential C-spine injury • Presence/Risk of obstruction • Facial deformity • Morbid obesity Difficult Intubation Difficult Intubation Identification of the Difficult Airway Identification of the Difficult Airway The LEMON law L ook externally Development of a consistent approach: E valuate 3-3-2 M allampati The LEMON law O bstruction? N eck mobility © National Emergency Airway Management Course © National Emergency Airway Management Course Difficult Intubation Difficult Intubation Identification of the Difficult Airway Identification of the Difficult Airway L ook externally E valuate 3-3-2 - Difficult BMV (MOANS) - Difficult Cricothyrotomy (SHORT) Or some other thyromental - Intubator Gestalt distance equivalent 6
    • 12/15/2007 Difficult Intubation Difficult Intubation Identification of the Difficult Airway Identification of the Difficult Airway M allampati O bstruction? Difficult Intubation Difficult Intubation Identification of the Difficult Airway Management of the Difficult Airway N eck mobility • Need a consistent approach • Awake techniques by default • Need definition of and preplanned approach to failed airway • No “one trick pony” approach • Alternative devices Difficult Intubation Management of the Difficult Airway • Alternative/Rescue devices? – Supraglottic: LMA, Combitube – Stylet, Gum elastic bougie; GEB – Lighted stylets: Trachlight, Lightwand – Fiberoptic devices: flexible, rigid, hand-held – Surgical: open, transtracheal 7
    • 12/15/2007 L M A I n s e r t i o n Combitube I n s e r t i o n Emergency ETT intubation: Team members & their roles Time Airway doctor/nurse Doctor / Nurse Nurse (Scribe) Preparation IV access Document (drugs/equipments) All events Assist with preparation Assist with Assess airway & drugs admin. Monitor & Plan approach preparation Preoxygenation Cricoid pressure Needle ETT placement Cricothyrotomy Confirmation of ETT placement Emergency ETT intubation (RSI) Emergency ETT intubation (RSI) The commonly used drugs The commonly used drugs Onset Onset Drug Dose; mg/kg (Sec) Precaution/Contraindication Drug Dose; mg/kg (Sec) Precaution/Contraindication Induction agents: Sedation/Analgesia: Midazolam 0.1-0.3 60-90 Long onset / no Thiopental 3-5 10-15 Hypotension/ Porphyria Fentanyl (mcg/kg) 1-2 30-45 Chest wall rigidity / no Propofol 1-2 10-15 Hypotension/Age< 2 yrs. Morphine 0.1-0.2 10-15 Long onset / no Etomidate 0.2-0.6 10-15 Adrenal insufficiency/ Pretreatment: Ketamine 1-2 30-45 ICP / Head injury Lidoocaine 1-1.5 3-5 min. Bradycardia / no 8
    • 12/15/2007 Emergency ETT intubation (RSI) Emergency ETT intubation (RSI) The commonly used drugs The commonly used drugs Dose Onset Duration Precaution/ Drug Dose; mg/kg Considerations Drug (mg/kg) (sec) (min) Contraindication Emergency drugs: Muscle relaxants: Atropine 0.02 Pediatric intubation Succinylcholine 1-2 60 5-10 N-M disease / Severe burn, Hyperkalemia Adrenaline Standard resuscitation Intra-ocular injury Incremental cart in hand dose Levophed (emergency intubation) Rocuronium 0.6-0.9 45-60 45-60 to target BP Metaraminol Can’t intubate Seek HELP The Emergency Difficult Ventilation effective Airway Algorithm ? Can ventilate Maintain Sellick’s Maintain oxygenation Reposition head Unable to ventilate By BVM Use oral/nasal Reattempt intubation airway by rescue devices • Emergency airway management is different • Emergency Airway Algorithm necessity Maintain oxygenation LMA / Combitube By BVM • Prediction tools have limitations: • LEMON criteria cannot be universally applied Emergency LMA / Combitube Unable to ventilate • Consistent use will predict most of the difficult Airway Maintain oxygenation Algorithm Intubation through LMA Cricothyrotomy Await expert help Jet ventilation “ True success is not in the learning, But in it’s application to the mankind F F F F F F F F F 9