INTUBATION DR.MANISHA(RSI & DSI).pptx ppt

1. RAPID SEQUENCE
INTUBATION/
DELAYED
SEQUENCE
INTUBATION
DR.MANISHA.T
EMERGENCY RESIDENT

2. RAPID SEQUENCE INTUBATION
 RAPID SEQUENCE INTUBATION IS THE VIRTUALLY SIMULTANEOUS ADMINISTRATION OF A
SEDATIVE AND A NEUROMUSCULAR BLOCKING (PARALYTIC)AGENT
 TO RENDER A PATIENT RAPIDLY UNCONSCIOUS AND FLACCID IN ORDER TO FACILITATE
EMERGENT ENDOTRACHEAL INTUBATION
 TO MINIMIZE THE RISK OF ASPIRATION

3. DELAYED SEQUENCE INTUBATION
 A TECHNIQUE FOR PATIENTS REQUIRING EMERGENT AIRWAY MANAGEMENT
 BUT WHO ARE RESISTENT TO PRE INTUBATION PREPARATIONS BECAUSE OF ALTERED
MENTAL STATUS

5. ADVANTAGES OF RSI
FACILITATES AND
EXPEDITES
ENDOTRACHEAL
INTUBATON
(INCREASED
SUCCESS RATE)
(DECREASED
TIME TO
INTUBATE)
MINIMIMIZES
TRAUMA DURING
LARYNGOSCOPY
MINIMIZES
HYPOXIA
MINIMIZES
HYPERCAPNIA
MINIMIZES RISK
OF ASPIRATION
MINIMIZES
HEMODYNAMIC
EFFECTS OF
INTUBATION

6. INDICATIONS:
INABILITY TO
MAINTAIN AIRWAY
PATENCY.
ACUTE
RESPIRATORY
FAILURE DUE TO
POOR OXYGENATION
OR VENTILATION
PERSISTENT
HYPOXIA
ACUTE UPPER
GASTROINTESTINAL
BLEED WITH A HIGH
RISK OF ASPIRATION
LOW GCS (8/15)
IMPENDING AIRWAY
OBSTRUCTION
FACIAL FRACTURES
NO ORAL EXCESSIVE
ORAL BLEEDING
FACIAL BURNS
INHALATION INJURY
EXPANDING
RETROPHARYNGEAL
HEMATOMA
EXCESSIVE WORK
OF BREATHING
REFRACTORY
SHOCK

7. CONTRAINDICATIONS:
• COMPLETE UPPER AIRWAY OBSTRUCTION
• LOSS OF FACIAL OR OROPHARYNGEAL LANDMARKS, WHICH WILL REQUIRE A SURGICAL
AIRWAY TO BE PLACED.
• RELATIVE CONTRAINDICATION: PROCEDURAL FAILURE DUE TO INJURIES TO THE AIRWAY,
ANATOMIC ABNORMALITIES,
• THESE RELATIVE CONTRAINDICATIONS CAN BE EVALUATED BY L.E.M.O.N. AND CORMACK
LEHANE GRADING SYSTEM

8. CORMACK – LEHANE
CLASSIFICATION

10. LEMON
GRADING:

11. SEVEN ‘‘ P’’ OF RSI
 PREPARATION
 PREOXYGENATION
 PRETREATMENT
 PARALYSIS WITH INDUCTION
 PROTECTION AND POSITIONING
 PLACEMENT WITH PROOF
 POST INTUBATION MANAGEMENT

12. PREPARATION :(10 MINS BEFORE
INTUBATION)
 CHECK ENDOTRACHEAL TUBE
 STYLET
 BLADES
 SUCTION
 BVM
 CARDIAC MONITORING
 ETCO2
 ONE(PREFERABLY TWO) IV LINES
 DRUGS
 DIFFICULT AIRWAY KIT INCLUDING CRIC KIT
 PATIENT POSITIONING

13. PREOXYGENATION:(5 MINUTES)
 ADMINSTRATION OF 100% OF OXYGEN 3 MINUTES OF NORMAL TIDAL VOLUME
BREATHING IN HEALTHY ADULTS
 WITH PERMISIBLE 6-8 MINUTES OF SAFE APENIC PERIOD
 PREOXYGENATION IS ALSO ESSENTIAL STEP IN NON BAGGING APPROACH IN RSI
 DESATURATION IN OBESE PATIENTS CAN BE REDUCED BY HEAD UP POSITION AND BY
CONTINUING SUPPLEMENTAL OXYGEN AFTER PARALYSIS AND INSERTION OF SCOPE TILL
ETT IS PLACED
 CONSTANT DIFFUSION OF ALVEOLAR OXYGEN INTO THE PULMONARY CIRCULATION
CREATES A NATURAL DOWNWARD GRADIENT WITH PASSIVE OXYGEN FROM UPPER
AIRWAY INTO LUNG GASEOUS PORTIONS.

14. PRETREATMENT:(3MINUTES)
• DRUING THIS PHASE ,DRUGS ARE ADMINISTRED 3 MINUTES BEFORE THE
ADMINISTRATION OF MUSCLE RLEXANTS AND AN INDUCTION AGENT TO MITIGATE THE
ADVERSE PHYSIOLOGIC EFFFECTS OF LARYNGOSCOPY AND INTUBATION .
• PRE TREATMENT APPROACH DOWN TO THE BARE ESSENTIALS WITH A FOCUS ON
OPTIMISING PATIENT’S PHYSIOLOGY PRIOR TO ANY INTUBATION ATTEMPT .
• INTUBATION IS INTENSLY STIMULATING AND RESULTS IN A SYMPATHETIC DISCHARGE
DISCHARGE OR REFLEX SYMPATHETIC RESPONSE TO LARYNGOSCOPY (RSRl)

15. • IF A PATIENT SUFFERING FROM HYPERTENSIVE EMERGENCY , SYMPATHOLYSIS
FENTANYL (3 MCG /KG IV)
• ADMINISTER 3 MIN BEFORE RSI CAN OPTIMISE THE PATIENT HEMODYNAMICS BY
ATTENUATING SPIKES IN BP AND SHEER FORCES .
• PATIENT WITH REACTIVE AIRWAY DISEASE CAN EXHIBIT WORSENING PULMONARY
MECHANISM AFTER INTUBATION AS A RESULT OF BRONCHOSPASM .

16. CONTROVERSISES
• CONTROVERSIES EXIST REGARDING WHETHER LIDOCAINE (1.5 MG/KG IV ) CONFERS ANY
ADDITIONAL BENEFITS BEYOND ALBUTEROL AND SHOULD BE CONSIDERED OPTIMAL AND
BEST .
• ASTHMA PATIENT BEING INTUBATED IN ED FOR STATUS ASTHMATICUS WILL HAVE
RECEIVED ALBUTEROL BEFORE INTUBATION .
• UNLIKELY IN THIS PATIENT LIDOCAINE HAS ADDITIVE , PROTECTIVE EFFECT .
• LIDOCAINE HAS A VANISHING ROLE IN AIRWAY MANAGEMENT AND MAY DISSAPEAR IN
NEAR FUTURE .

17. REACTIVE AIRWAY DISEASE
 ALBUTEROL 2.5 MG BY NEB. IF TIME DOES NOT PERMIT ALBUTEROL NEB .
 GIVE LIDOCAINE 1.5 MG/KG
REFENCE FROM :TEXTBOOK ROSEN’S(10TH EDITION)

18. PARALYSIS WITH INDUCTION:
HEAD INJURY OR STROKE:
 GOAL IS TO MAINTAIN ADEQUATE CEREBRAL PERFUSION AND MAINTAIN ARTERIAL
PRESSURE.

19. ETOMIDATE:
 (0.3MG/KG)
 EXCELLENT SEDATION AND DOES NOT
CAUSE HYPOTENSION

20. KETAMINE:
 (1-2MG/KG)
 USESED IN (SEPTIC
SHOCK,BRONCHOSAPSM ,AND
HYPOTENSION)
 HEAD INJURY
 AVOID IN CEREBRAL HEMORRHAGE

21. STATUS EPILEPTICUS
 MIDAZOLOM (0.2-0.3MG/KG)
 CAN CAUSE HYPOTENSION,USE
ETOMIDATE IF PATIENT HAS HEMODYNAMIC
COMPROMISE

22. BRONCHOSAPASM:
 HEMODYNAMICALLY STABLE: USE KETAMINE,PROPOFOL,ETOMIDATE,MIDAZOLOM
 HEMODYNAMICALLY UNSTABLE:KETAMINE OR ETOMIDATE

23. CARDIOVASCULAR:
 ETOMIDATE PREFERRED IN CAD AND AORTIC DISSECTION
 USE FENTANYL AS A PRETREATMENT

24. SHOCK:
• ETOMIDATE OR KETAMINE
• IF REFRACTORY SEPTIC SHOCK WITH ETOMIDATE GIVE HYDROCORTISONE

25. NEURO MUSCULAR BLOCKING
AGENT
DEPOLARISING AGENT: SUCCINYLCHOLINE (1.5MG/KG)
 BIND TO ACH RECPTOR PRODUCES FASICULATION AND PARALYSIS
 RAPID ONSET(45-60 SEC)
 OFFSET(6-10 MINS)
NON DEPOLARIZING: ROCURONIUM,VECRONIUM
ROCURONIUM SHORT ONSET (45-60 SEC)
(1MG/KG)
VECURONIUM (0.15MG/KG) ONSET ABOUT( 90SEC)

26. POSITIONING:(30SECSONDS)
HEAD
EXTENSION
AND NECK
FLEXION
RAMP
POSITION
MODIFIED
RAMP
POSITION
SNIFFING
POSITION

27. RAMP POSITION :
• HORIZONTAL ALINGMENT BETWEEN
STERNAL NOTCH AND EXTERNAL
AUDITORY MEATUS
• USE:
• PROVIDES SUPERIOR LARYNGEAL VIEW
COMPAREED TO OTHER POSITIONING
• IMPROVES GLOTTIS VIEW IN OBESE
PATIENTS
• MODIFIED RAMP
• POSITIONING WITH SPECIAL PILLOW (
HASANIN PILLOW)

28. SNIFFING
POSITION:
• A COMBINATION OF FLEXION OF THE
NECK AND EXTENSION OF HEAD (30 to
35 degree)
• PROVIDE A SUPERIOR GLOTTIC
VISUALIZATION, DURING DIRECT
LARYNGOSCOPY, ENHANCING THE
EASE OF INTUBATION.
• Axis of sniffing : LA = LARYNGEAL AXIS;
MA = MOUTH AXIS; PA = PHARYNGEAL
AXIS

30. SELLICKS’MANEUVER:
 LOCATE THE CRICOID CARTILAGE BY PALPATING THE THYROID CARTILAGE AND FEEL
THE DEPRESSION JUST BELOW IT(CIRCOTHYROID MEMBRANE)
 USING YOUR THUMB AND INDEX FINGER OF ONE HAND,APPLY PRESSURE TO ANTERIOR
AND LATERAL ASPECTS OF THE CRICOID CARTILAGE JUST NEXT TO THE MID LINE

35. PLACEMENT WITH PROOF:(45
SECONDS)
• FLACCID IS ACHIEVED AND LARYNGOSCOPY IS PERFOMED
• CONFIRMATION OF PROPER ENDOTRACHEAL TUBE PLACEMENT IN CRUCIAL
• END TIDAL DETERMINATION (ETCO2)
• VISUALIZATION OF ETT THROUGH THE CORDS
• MISTINGOF THE TUBE WITH VENTILATION
• 5 POINT ASCULTATION (SOUND INSUFFICIENT MEANS TO CONFIRM TRACHEAL
PLACEMENT)

36. 5 POINT
ASCULTATION
:

37. POST INTUBATION
MANAGEMENT:(2MINUTE
S)
PROVIDE ADEQUATE LONG TERM SEDATION ,ANALGESICS AND PARALYTIC
AGENT IF REQUIRED
MECHANICAL VENTILATION IS INITIATED
POST PROCEDURAL CHEST XRAY IS OBTAINED TO CONFIRM DEPTH OF TUBE
PLACEMENT AND TO EVALUATE FOE EVIDENCE OF BAROTRAUMA AS
ACONSEQUENCE OF POSITIVE PRESSURE VENTILATION.
REASSES ABG
REASSES VITALS
PROPERLY PLACED ENDOTRACHEAL TUBE IS SECURED

38. RECENT RESEARCHES - (International anaesthesia research
society )
• EFFICACY OF THE BURP MANEUVER DURING A DIFFICULT LARYNGOSCOPY –
• BRUP MANEUVER IMPROVED VISUALIZATION OF THE LARNYX MORE EFFECTIVELY THAN
SIMPLE BACK PRESSURE ON LARNYX . ITS SHOULD BE INCLUDED IN ROUTINE METHODS
FOR VISUALIZATION OF LARNYX.

39. REFERENCE :
• TINTINALLI’S BOOK OF EMERGENCY MEDICINE - 9th edition
• ROSENS BOOK OF EMERGENCY EDITION -10TH edition
• INTERNATIONAL ANESTHESIA RESEARCH SOCIETY

40. THANK YOU