This document outlines procedures for intubation in patients with compromised airways. It indicates that intubation is appropriate for patients in respiratory arrest, with head injuries, who are combative, have altered mental status, hypoxia, seizures, or status asthmaticus. Contraindications include conditions making intubation difficult. Preparation includes assessing the airway, positioning the patient, pre-oxygenating, and administering medications before inducing paralysis and intubating. Placement must be confirmed and the airway secured before providing ongoing care and transport.
Rapid sequence intubation (RSI) is a technique that is used when rapid control of the airway is needed as a precaution for patients that may have a 'full stomach' or other risks of pulmonary aspiration. A short description about RSI procedure according to IQARUS guideline.
Dr. Ummay Sumaiya
ICU DOCTOR
| IQARUS | Medical Treatment Facility / IQARUS - Cox’s Bazar - Bangladesh |
Mail: Ummay.Sumaiya@iqarus.com
Different breathing techniques for resuscitation for neonatesMaher AlQuaimi
This presentation covers the important aspects of different techniques used for breathing resuscitation including ambu-bag ( self inflating) , flow inflating bag, and T-piece ( neopuff)
Artificial Respiration PPT -- By Prof.Dr.R.R.deshpande –
In this PPT Prof.Dr.Deshpande is explaining following points When Artificial Respiration is needed ? Which are the Methods of Artificial Respiration ? Which precautionary measures should be taken before starting artificial respiration ? How Schafer & Holger Nelson method are performed ? How Artificial Respiration is given by Sylvester method & mouth to mouth respiration method ? How External Cardiac Massage is done in cardiac arrest ? What are the signs of death ?
Mobile – 922 68 10630
Also visit – www.ayurvedicfriend.com
RSI is the process of simultaneous administration of an induction and a neuromuscular blocking agent to Facilitate Tracheal Intubation And Is Preferred For Emergency intubation
introduction of Artificial respiration,
defination of Artificial respiration,
indication of Artificial respiration,
manual techniques of Artificial respiration,
methodology of Artificial respiration
Rapid sequence intubation (RSI) is a technique that is used when rapid control of the airway is needed as a precaution for patients that may have a 'full stomach' or other risks of pulmonary aspiration. A short description about RSI procedure according to IQARUS guideline.
Dr. Ummay Sumaiya
ICU DOCTOR
| IQARUS | Medical Treatment Facility / IQARUS - Cox’s Bazar - Bangladesh |
Mail: Ummay.Sumaiya@iqarus.com
Different breathing techniques for resuscitation for neonatesMaher AlQuaimi
This presentation covers the important aspects of different techniques used for breathing resuscitation including ambu-bag ( self inflating) , flow inflating bag, and T-piece ( neopuff)
Artificial Respiration PPT -- By Prof.Dr.R.R.deshpande –
In this PPT Prof.Dr.Deshpande is explaining following points When Artificial Respiration is needed ? Which are the Methods of Artificial Respiration ? Which precautionary measures should be taken before starting artificial respiration ? How Schafer & Holger Nelson method are performed ? How Artificial Respiration is given by Sylvester method & mouth to mouth respiration method ? How External Cardiac Massage is done in cardiac arrest ? What are the signs of death ?
Mobile – 922 68 10630
Also visit – www.ayurvedicfriend.com
RSI is the process of simultaneous administration of an induction and a neuromuscular blocking agent to Facilitate Tracheal Intubation And Is Preferred For Emergency intubation
introduction of Artificial respiration,
defination of Artificial respiration,
indication of Artificial respiration,
manual techniques of Artificial respiration,
methodology of Artificial respiration
Évaluation de la politique des pôles de compétitvité : la fin d'une malédicti...France Stratégie
La France compte aujourd'hui soixante-et-onze pôles de compétitivité. Créés en 2005, ces « clusters à la française », avaient pour objectif de dynamiser l’innovation et de renforcer l’industrie en stimulant les dépenses de R-&-D. Promesse tenue ?
En savoir plus :
http://strategie.gouv.fr/publications/evaluation-de-politique-poles-de-competitivite-fin-dune-malediction
Endotracheal (ET) intubation involves the oral or nasal insertion of a flexible tube through the larynx into the trachea for the purposes of controlling the airway & mechanically ventilating the patient and is Performed by doctors, anesthetist, respiratory therapist or nurse practitioner in the procedure . it is emergency procedure.
Airway management is the cornerstone of resuscitation and is a defining skill for the specialty of emergency medicine. The emergency clinician has primary airway management responsibility, and all airway techniques lie within the domain of emergency medicine. Although rapid sequence intubation (RSI) is the most commonly used method for emergent tracheal intubation, emergency airway management includes various intubation techniques and devices, approaches to the difficult airway, and rescue tech- niques when intubation fails.
The decision to intubate should be based on careful patient assessment and appraisal of the clinical presentation with respect to three essential criteria: (1) failure to maintain or protect the airway; (2) failure of ventilation or oxygenation; and (3) the patient’s anticipated clinical course and likelihood of deterioration.
In most patients, intubation is technically easy and straightfor- ward. Although early ED-based observational registries reported cricothyrotomy rates of about 1% for all intubations, more recent studies have shown a lower rate, less than 0.5%.3 As would be expected with an unselected, unscheduled patient population, the ED cricothyrotomy rate is greater than in the operating room, which occurs in approximately 1 in 200 to 2000 elective general anesthesia cases.4 Bag-mask ventilation (BMV) is difficult in approximately 1 in 50 general anesthesia patients and impossible in approximately 1 in 600. BMV is difficult, however, in up to one-third of patients in whom intubation failure occurs, and dif- ficult BMV makes the likelihood of difficult intubation four times higher and the likelihood of impossible intubation 12 times higher. The combination of failure of intubation, BMV, and oxy- genation in elective anesthesia practice is estimated to be exceed- ingly rare, roughly 1 in 30,000 elective anesthesia patients.4 These numbers cannot be extrapolated to populations of ED patients who are acutely ill or injured and for whom intubation is urgent and unavoidable. Although patient selection cannot occur, as with a preanesthetic visit, a preintubation analysis of factors predicting difficult intubation gives the provider the information necessary to formulate a safe and effective plan for intubation.
Preintubation assessment should evaluate the patient for potential difficult intubation and difficult BMV, placement of and ventilation with an extraglottic device (EGD; and cricothyrotomy. Knowledge of all four domains is crucial to successful planning. A patient who exhibits obvious difficult airway characteristics is highly predictive of a challenging intuba- tion, although the emergency clinician should always be ready for a difficult to manage airway, because some difficult airways may not be identified by a bedside assessment.
Airway difficulty exists on a spectrum and is contextual to the provider’s experience, environment, and armamentarium of devices.
Please share your valuable opinions.
Rapid Sequence Intubation
RSI describes a coordinated, sequential process of preparation, sedation, and paralysis to facilitate safe, emergency tracheal intubation.
Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal intubation.
The goal of RSI is to intubate patients quickly and safely using sedation and paralysis.
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The Critical Care track of the Society for Emergency Medicine in Singapore Annual Scientific Meeting 2014.
For more information and conference videos, go to singem.blogspot.sg
3. Indications:
A critical need for airway control exists, such as:
Any patient in respiratory arrest who have a gag reflex or are
clenched.
Patients with severe head and facial injuries.
Combative patients with compromised airways.
Patients with depressed LOC.
Patients with hypoxia refractory to oxygen (CPAP or Supplemental
Oxygen)
Any time risk for potential/actual airway compromise is suspected
such as acute burn injury.
Uncontrolled seizure activity (to provide airway control).
Status asthmaticus nearing respiratory arrest.
4. Relative Contraindications:
Patients in whom cricothyroidotomy would be difficult or impossible
(SHORT).
Massive neck swelling/injury.
Patients who would be difficult or impossible to intubate/ventilate
after paralysis.
LEMON
MOANS
RODS
SHORT
Acute epiglottitis.
Upper airway obstruction.
Known hypersensitivity to the drugs.
Note: The benefit of obtaining airway control must always be weighed
against the risk of complications in these patients.
5. COMPLICATIONS ASSOCIATED WITH INTUBATION
Increased intragastric pressure (emesis).
Bradycardia/asystole (especially in children less than 1 yr not premedicated
with Atropine.)
Malignant hyperthermia.
Prolonged apnea.
Inability to intubate/ventilate after paralytic administration.
Hypotension.
Aspiration.
Dysrhythmias.
Fasciculations.
Histamine flush
Tachycardia.
Hyperkalemia.
Inability to recognize decreased neurologic status.
Bronchospasm
6. USE THE FOLLOWING TO DETERMINE DIFFICULT AIRWAY:
LEMON (Predicts difficult laryngoscopy).
MOANS (Predicts difficult mask ventilation).
RODS (Predicts difficult EGD).
SHORT (Predicts difficult cricothyrotomy).
11. Preparation
Assemble necessary equipment:
Suction
BVM with correct sized mask
Working suction equipment
Appropriate sized ET tubes
Working laryngoscope
Appropriate drugs drawn up in syringes
Pulse oximeter
End-tidal CO2 monitoring device
12. Preparation cont.
Assess patient for possible difficult intubation via LEMON, MOANS,
RODS, and SHORT.
If there is a potential for a difficult airway, go to the Difficult
Airway Algorithm PAGE 488.
Position patient properly in sniffing position or use in-line
stabilization if indicated.
Assure at least one secure well running IV line.
Connect patient to cardiac monitor and pulse oximeter.
Assign specific duties to personnel on scene (i.e., assistance with
bagging, pushing of medications.)
13. Pre-Oxygenation
Place patient on continuous oxygen via nasal cannula at 6 lpm.
Once the patient is sedated and/or paralyzed, increase the flow
rate to 15 lpm via nasal cannula. Continue nasal cannula
oxygen throughout your intubation attempt while patient is
paralyzed.
Pre-oxygenate for three minutes via BVM (leave nasal cannula
in place until patient is intubated). This establishes oxygen
reservoir:
Flushes out nitrogen
Increases functional residual capacity of lung.
Once intubated, discontinue the nasal oxygen.
When adequately preoxygenated, a healthy 70 kg adult can
remain apneic for up to 6-8 minutes.
Children experience oxygen desaturation more quickly due to
their fast metabolism.
Obese patients experience oxygen desaturation more quickly
due to adipose tissue metabolizing faster.
14. Pre-Treatment
Pre-medicate as appropriate:
Lidocaine 1.5 mg/kg IVP 2 - 3 minutes before intubation:
For possible head injury patients, to mitigate increased intracranial
pressure (ICP) which may occur during intubation.
For patients with reactive airway disease, i.e. severe asthma.
For dysrhythmia control in patients at risk for ventricular
dysrhythmias.
NOTE: Lidocaine is contraindicated if there is known hypersensitivity
to the drug.
15. Pre-Treatment cont.
Fentanyl 3 mcg/kg (~200 mcg IV in average adult) Given as the last pre-
treatment drug. Administer over 30 – 60 seconds.
Give as pre-medication for suspected head injury or increased
intracranial pressure.
DO NOT use on children under the age of 10.
Atropine 0.02mg/kg/IV (max 1 mg) – for children less than 12 months
receiving RSI.
16. Paralysis with Induction
Induce with ONE of the following:
Amidate (Etomidate) 0.3 mg/kg IV push for sedation.
NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE- NEVER REPEAT ETOMIDATE
Versed 0.10 - 0.15 mg/kg IVP for awake patients to achieve amnestic
effect. Pediatric dosage is 0.03 mg/kg.
Versed is contraindicated if the patient is hypotensive.
Alternative drug: Valium 2-10 mg IVP
Ketamine (Ketalar) 1 – 2 mg/kg IV (last resort 4 mg IM)
First choice for reactive airway disease.
17. Paralyze with one of the following:
Anectine (Succinylcholine - depolarizing) 1.5mg/kg IV over 10- 30 sec
NOTE: Onset 30 – 45 seconds.
Duration 4 – 10 minutes.
Rocuronium (Zemuron - non-depolarizing) 1mg/kg IV in adults
Children 0.6mg/kg IV
NOTE: Onset 45 – 60 seconds.
Duration: 20 – 90 minutes.
19. Use NON-Fasciculating agent (Rocuronium) on patients at
risk for or having problems related to:
Hyperkalemia (elevated potassium). Only if EKG Changes
show peaked T waves or wide QRS.
Penetrating eye injuries (do not use depolarizing blocker).
History of malignant hyperthermia.
Unstable fractures (secondary to muscle fasciculation).
20. PARALYZE CONT.
Once paralytic has been given IV, discontinue bagging patient with
BVM and monitor pulse ox. It is not necessary to resume bagging
patient until patient is intubated (at which time you ventilate with
ambu-bag via the ET tube) or the oxygen saturation drops below 91%,
at which time you re-oxygenate before trying to intubate again.
Proper pre-oxygenation will allow you 6-8 minutes of allowable apnea
to intubate.
Perform controlled endotracheal intubation with in-line stabilization
if indicated.
21. TECHNIQUE OF ENDOTRACHEAL INTUBATION
Position the patient supine, open the airway.
Open mouth by separating the lips and pulling on upper
jaw with the index finger.
Hold laryngoscope in left hand, insert scope into mouth
with blade directed to right tonsil.
Once right tonsil is reached, sweep the blade to midline
keeping the tongue on the left. This brings epiglottis
into view. “DO NOT LOSE SIGHT OF IT!”
Advance the blade until it reaches the angle between
the base of the tongue and epiglottis (vallecular space).
22. TECHNIQUE OF ENDOTRACHEAL INTUBATION
CONT.
Lift the laryngoscope upwards and away from the nose –
towards the chest. This should bring the vocal cords into
view. It may be necessary for a colleague to press on the
trachea to improve the view of the larynx.
Place the ETT in the right hand, keeping the concave side
of the tube facing the right side of the mouth.
Insert the tube, just so the cuff has passed the vocal cords
and then inflate the cuff.
Using a stethoscope, listen for air entry at both apices
and both axillae to ensure correct placement.
23. Paralyze cont.
Confirm placement by auscultating for bilateral breath sounds,
checking oxygen saturations, and by checking for presence of end-
tidal carbon dioxide (ETCO2) or any three methods in the
confirmation protocol.
If intubation is unsuccessful, remove the tube and ventilate the
patient with 100% oxygen via a BVM until ready to attempt re-
intubation. You should be able to successfully use a BVM to oxygenate
the patient or successfully ventilate until the effects of the paralytic
are gone. Prepare to suction emesis.
Maintain cervical immobilization if necessary.
If after 1-2 repeat intubation attempts fail, go to failed airway
algorithm (4.34 SMART AIRWAY MANAGEMENT), which calls for using
and extra-glottic device or performing a cricothyrotomy. If an extra-
glottic device can be inserted or the patient’s oxygen saturation can
be maintained > 91% with an oral pharyngeal airway and BVM,
transport to hospital.
Only perform a cricothyrotomy if unable to ventilate and unable to
maintain pulse ox > 91%.
24. IF INADEQUATE RELAXATION IS PRESENT
ADMINISTER SECOND DOSE OF:
Anectine (Succinylcholine) 0.6mg/kg IV
Rocuronium is long acting, therefore second dose
not needed.
25. Post Intubation Management
Once intubation is completed and tube placement is confirmed, inflate the
cuff and continue to ventilate with 100% oxygen via BVM.
Secure ET tube in place.
Keep patient sedated with one of the following:
Ketamine 0.25 to 0.5 mg/kg IV every 5 to 10 min prn
Versed 2.5 – 5 mg IV initial, then titrate 1 mg increments prn
AND/OR
Morphine 2-5 mg IV (for post intubation pain control)
OR
Fentanyl 50 -100 mcq (for post intubation pain control)
Continued paralysis will only be ordered by medical control.
26. Take care not to over sedate your patient, post intubation,
particularly in cases when a neuro assessment will be
necessary upon arrival in the ED. (i.e., cases of head injury
or suspected CVA)
27. Post Intubation Management
Proper endotracheal tube placement must be documented by at
least three different methods. These include:
Presence of bilateral breath sounds.
Absence of breath sounds over the epigastrium.
Checking oxygen saturations.
Presence of condensation on the inside of the endotracheal
tube.
End-tidal carbon dioxide monitoring.
Use of an endotracheal esophageal detector (if available).
Visualizing the tube passing through the cords.
Bilateral, symmetrical expansion of the thorax.
At least three verification methods must be documented in the
medical record!
28. Considerations:
Once a neuromuscular blocking agent is given, you assume complete
responsibility for maintaining an adequate airway and ventilations.
Have your backup airway (King Airway) available to use if unable to
intubate.
Be prepared to perform a surgical airway if intubation cannot be
executed and ventilation with a BVM is not possible. (This will be rare.)
Continuously monitor oxygen saturations and end-tidal carbon dioxide.
29. FACILITATED INTUBATION
IS NOT RSI WITHOUT THE PARALYTIC!
THERE IS STILL A RISK OF THE PATIENT VOMITING BECAUSE THE
PATIENT IS SEDATED, NOT PARALYZED.