Rapid sequence intubation in ED

RAPID SEQUENCE INTUBATION IN EMERGENCY DEPT

1. rapid sequence intubation IN EMD Dr ASHMAL KT JR, EMERGENCY MEDICINE GMC,KANUR

2. RSI is the simultaneous administration of an induction and a neuromuscular blocking agent to facilitate tracheal intubation and is preferred for emergency intubation . RSI is usefull in patient with intact gag reflex ADVANTAGES : Increased success rate and decreased time to intubate. Minimize trauma ,hypoxia ,hypercapnia. Minimize aspiration Better C spine control CONTRA INDICATION : Cardiopulmonary arrest , Operator inexperiance Distorted anatomy of face or airway

3. Emergency Airway management algorithm.

4. STEPS OF RSI ( 7 P’S)

5. PREPARATION ASSESED FOR INTUBATION DIFFICULTY DETERMINING DOSAGE , DRUGS ,TUBE SIZE ,LARYNGOSCOPE TYPE,BLADE . CONTINOUS CARDIAC MONITORING AND PULSE OXIMETRY. > 1 GOOD QUALITY IV LINES. REDUNDANCY IS ALWAYS DESIRABLE IN CASE OF EQUPIMENT FAILURE RESCUE PLAN FOR INTUBATION FAILURE PROPER COMMUNICATION BETWEEN OTHER TEAM MEMBERS .

6. Identification of the Difficult Airway L—Look Externally. E—Evaluate 3-3-2. 3 fingers are placed along the floor of the mouth,beginning at the mentum . 3 of his fingers between the open incisors 2 fingers are placed in the laryngeal prominence ., M— Mallampati Scale. O—Obstruction or Obesity N —Neck Mobility.

7. MALLAMPATI SCALE 3-3-2 RULE

8. Teeth out to intubate , teeth in to ventilate . Impossible BMV was five times more likely if one of these factors was present and 25 times more likely with four or more. upper airway device, often can convert acan’t intubate , can’t oxygenate situation to a can’t intubate , can oxygenate situation, which allows time for rescue of a failed airway.

9. PREOXYGENATION Preoxygenation optimizes blood oxygen content and also displaces nitrogen in the alveoli, creating a potential reservoir of oxygen. Administer 100% oxygen for 3 minutes, using a non- rebreather mask supplied with 15 L/min of oxygen . Permit 6 to 8 minutes of safe apnea before oxygen desaturation to less than 90% occurs. Additional preoxygenation does not improve arterial oxygen tension. If time is insufficient for a full 3-minute preoxygenation phase, eight vital capacity breaths with high-flow oxygen can achieve oxygen saturations. Desaturation time in obese patients can be prolonged by preoxygenating with the patient in a head-up position and by continuing supplemental oxygen via nasal cannula at a flow rate of 5–15 L/min. In obese patients, it extends the time to desaturation to 95% from 3.5 to 5.3 minutes. Apneic oxygenation takes advantage of a physiologic principle termed aventilatory mass flow.

10. PRETREATMENT Decreases adverse physiologic responses to laryngoscopy and intubation. Reflex sympathetic response to laryngoscopy (RSRL) causes increases in heart rate and blood pressure; this may be harmful in patients with elevated intracranial pressure, myocardial ischemia, and aortic dissection. Fentanyl can decrease the reflex sympathetic response to air way manipulation. It may aid in patients in whom a rise in blood pressure and heart rate could be detrimental, such as patients with elevated intracranial pressure and cardiovascular conditions. Lidocaine has a vanishing role in emergency airway management and may disappear completely in the near future from emd . Reactive airway disease: Albuterol , 2.5 mg, by nebulizer. If time does not permit albuterol nebulizer, give lidocaine 1.5 mg/kg IV.

11. PARALYSIS WITH INDUCTION INDUCTION AGENTS : Etomidate used in more than 90% of all ED intubations . No sufficient evidence to support the recommendation that etomidatebe avoided in patients with septic shock.

12. PARALYTIC AGENTS 1. DEPOLARIZING NMBA Depolarizing neuromuscular blocking agents have high affinity for cholinergic receptors of the motor end plate and are resistant to acetylcholinesterase. Succinylcholine : The most commonly used agent for neuromuscular blockade in ED RSI Succinylcholine is rapidly hydrolyzed by plasma pseudocholinesterase to succinylmonocholine Succinylcholine is two joined acetylcholine molecules and is rapidly hydrolyzed by plasma cholinesterase . Rapid onset after IV dosing and a shorter duration of action

13. IM succinylcholine (4 milligrams/kg) will act more slowly and last longer; however, this is best reserved for the rare setting where paralysis is required absent IV access. After brief fasciculation, complete relaxation occurs at 60 seconds, with maximal paralysis at 2 to 3 minutes Succinylcholine provides excellent intubation conditions and is the preferred agent for RSI in the ED Serum potassium will transiently rise an average of 0.5 mEq /L with succinylcholine, usually without any clinical impact. Do not use succinylcholine in patients with suspected preexisting significant hyperkalemia (especially renal failure), myopathies, or myasthenia gravis. Succinylcholine remains the agent of choice for RSI in acute burn, trauma, stroke, and spinal cord injury if intubation occurs earlier than 5 days after onset of the condition.

14. ROCURONIUM . Rocuronium is an intermediate-duration nondepolarizing agent . There are no absolute contraindications to rocuronium . The onset of action approximates that of succinylcholine , but the duration of action is prolonged. VECURONIUM BROMIDE Intermediate- to long-acting nondepolarizing agent Vecuronium has no cardiac effects , Exretion is biliary . Sugammadex is a reversal agent that encapsulates the molecules of the nondepolarizing agent that are circulating in plasma.Reverses blockade from rocuronium or vecuronium within minutes. Paralysis After Intubation : A sedating dose of a benzodiazepine, such as midazolam (0.1 mg/kg IV), combined with an opioid analgesic, such as fentanyl (3–5 μg /kg IV) or morphine (0.2–0.3 mg/kg IV)

15. Patient Positioning This phase of RSI refers to protecting airway against aspiraion prior to placement of ETT Flex the lower neck and extend the atlantooccipitaljoint (sniffing position) to align the oropharyngeal –laryngeal axis for a direct view of the larynx. Ensure bed is at appropiate height for person intubating.Patient head just below intubators xiphoid The bestposition occurs when the ear is horizontally aligned with the sternal notch . The Sellick or cricoid maneuver (application of direct pressure on the cricoid ring in the unconscious or paralyzed patient) can impair bag-mask ventilation, worsen the laryngoscopic view, and hamper insertion of the tube. Do not recommend routine use of the Sellick maneuver, and it should beconsidered optional, applied selectively, BMV should not be initiated unless the oxygen saturation falls to 90% , after administration of an induction agent and NMBA.

16. PLACEMENT WITH PROOF patient is relaxed sufficiently to permit laryngoscopy . This is assessed most easily by moving themandible to test for mobility and absence of muscle tone . Glottic exposure may be aided by backward-upward-rightward pressure ( BURP maneuver) applied to the thyroid cartilage. The typical correct tube insertion depth is 22 cm, To minimize oxygen desaturation , limit each intubation attempt (insertion of blade) to no more than 30 seconds. Between intubation attempts, use a bag-valve mask to reoxygenate the patient to 100% oxygen saturation. First-pass success is higher with bougie -assisted intubation.

17. STEPS OF TRACHEAL INTUBATION

18. CONFIRM ATION OF ET TUBE LOCATION Mainstem bronchial or esophageal intubation may cause hypoxia, hypoxemia, hypercarbia , bradycardia , and cardiac arrest. CLINICAL VERIFICATION 2. MECHANICHAL 5 Point Auscultation - Pulse oximetry Visualize cord placement -End Tidal Co2 detection Clinical improvement -Esophageal detection device Tube fogging - POCUS -CXR

19. END TIDAL CO2 Capnometers and capnographs measure carbon dioxide in expired air of the ETT. Colorimetric end-tidal carbon dioxide detectors have a pH-sensitive filter paper that changes color from yellow to purple with carbon dioxide exposure. Capnography measures expired carbon dioxide in real time, displaying either the peak value with each breath or continuous graphical waveforms

20. POCUS Position the probe cephalad to the cricoidmembrane , just above the sternal notch. The visualization of two separate structures (“DOUBLE TRACK SIGN”) likely indicates esophageal intubation.

21. Post Intubation Management. chest radiograph to confirm that mainstem intubation has not occurred and to assess the lungs. place the patient on continuous monitoring. long-acting NMBAs ( eg , pancuronium , vecuronium ) are better to avoide . Benzodiazepine ( eg , midazolam ,( 0.1–0.2 mg/kg IV ) and Opioid analgesic ( eg , 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, Propofol infusion(5–50 μg /kg/min IV) helpful for managementof neurologic emergencies because iduration of action is very short (<5 minutes), allowing frequent neurologicexaminations .

22. COMPLICATIONS OF ENDOTRACHEAL INTUBATION