Rapid sequence intubation

1. Paleerat Jariyakanjana , MD Emergency Physician Naresuan University Hospital Rapid Sequence Intubation

2. Decision to Intubate Failure to maintain or protect the airway failure of ventilation or oxygenation the patient’s anticipated clinical course and likelihood of deterioration

3. Administration of a potent sedative (induction) agent and an NMBA without interposed assisted ventilation positive-pressure ventilation  air to pass into the stomach  gastric distention  risk of regurgitation & aspiration

4. Requires preoxygenation phase permits pharmacologic control of the physiologic responses to laryngoscopy and intubation , mitigating potential adverse effects Increase ICP sympathetic discharge

5. Preparation assessed for intubation difficulty determining dosages and sequence of drugs, tube size, and laryngoscope type, blade and size continuous cardiac monitoring and pulse oximetry ≥1 good-quality IV lines Redundancy is always desirable in case of equipment or IV access failure.

6. Preparation

7. Preparation

8. Preoxygenation 100 % oxygen for 3 minutes of normal, tidal volume breathing normal, healthy adult establishes an adequate oxygen reservoir to permit 8 minutes of apnea before oxygen desaturation to less than 90% occurs “no bagging” time is insufficient 8 vital capacity breaths using high-flow oxygen

9. Pretreatment drugs are before administration of the succinylcholine & induction agent mitigate the effects of laryngoscopy and intubation on the patient’s presenting or comorbid conditions Intubation sympathetic discharge elevation of ICP reactive bronchospasm Bradycardia : children

10. Pretreatment

11. Paralysis with Induction rapid IV push immediately followed by rapid administration of intubating dose of NMBA wait 45 s from the time the succinylcholine is given to allow sufficient paralysis to occur

12. Paralysis with Induction Tintinalli's Emergency Medicine, 7e

13. Paralysis with Induction Tintinalli's Emergency Medicine, 7e

14. Paralysis with Induction Tintinalli's Emergency Medicine, 7e

15. Positioning The patient should be positioned for intubation as consciousness is lost. Sniffing position: head extension , neck flexion

16. Positioning Sellick’s maneuver application of firm backward-directed pressure over the cricoid cartilage minimize the risk of passive regurgitation and , hence, aspiration after administration of the induction agent and NMBA  BMV should not be initiated unless O2 sat ≤ 90%

17. Positioning

18. Placement of Tube assessed most easily by moving the mandible to test for absence of muscle tone O2 sat is approaching 90%, the pt may be ventilated When BMV is performed, Sellick’s maneuver is advisable As soon as the ETT is placed, the cuff should be inflated and its position confirmed

19. Postintubation Management CXR use of long-acting NMBAs (e.g., pancuronium , vecuronium ) toward optimal management using opioid analgesics and sedative agents to facilitate mechanical ventilation

20. Postintubation Management An adequate dose of a benzodiazepine (e.g., midazolam 0.1–0.2 mg/kg, IV) and an opioid analgesic (e.g., fentanyl , 3–5 μg /kg, IV, or morphine, 0.2–0.3 mg/kg, IV) is given to improve patient comfort and decrease sympathetic response to the ETT.

21. Any Questions?