Rapid Sequence Intubation (RSI).pptx

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.

1. R apid S equence I ntubation (RSI) By T urki M . A lanazi

2. Introduction 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. RSI is generally recommended because it is more successful and safer than intubation without sedation and paralysis for patients with varying levels of consciousness, active protective airway reflexes, and/or a full stomach. Sedation and paralysis are unnecessary prior to intubation for some patients, such as those who are in cardiac arrest or already deeply comatose.

3. Preparation: Providers; Primary laryngoscopist Back-up laryngoscopist Respiratory therapist Registered nurse

4. Airway equipment for pediatric patients Supplemental oxygen : Nasal cannulae (infant, child, and adult) Clear oxygen masks (standard and nonrebreathing - infant & child) Suction : Suction catheters (6 through 16 French) Yankauer suction tip (two sizes) Bag-mask ventilation : Masks (neonate, infant, child, adult) Self-inflating resuscitator bag (450 and 1000 mL)

5. Intubation equipment : Endotracheal tubes (uncuffed and cuffed) Stylets Laryngoscope handle Laryngoscope blades: straight (sizes 0, 1, 2, and 1.5 Wis-Hipple) and curved (sizes 2 and 3)

6. ---------------------------------- Use formula for children 2 years of age and older. Use 3.5 mm internal diameter cuffed endotracheal tube for children 1 to <2 years of age and a 3.0 mm internal diameter cuffed endotracheal tube for children <1 year of age.

7. Depth of ETT = ETT size X 3

8. Rescue airway devices Laryngeal mask airway Miscellaneous End-tidal CO2 detector Bulb suction

9. Physical assessment to identify signs of a difficult airway in children

10. Preoxygenation — ( 5 minutes Before Intubation ) Preoxygenation with 100 percent inspired oxygen should begin as soon as possible once the need for endotracheal intubation becomes evident: Spontaneously breathing patients : Apply a nonrebreather mask for a minimum of three minutes. From a practical viewpoint, oxygen should be administered at the highest concentration available as soon as RSI is potentially needed.

11. Pretreatment (optional) Atropine: Although not routinely recommended, many experts suggest atropine as pretreatment for: Children ≤1 year Children in shock Children <5 years receiving succinylcholine Older children receiving a second dose of succinylcholine Dose: 0.02 mg/kg IV without a minimum dose (maximum single dose 1 mg; if no IV access, can be given IM).

12. Induction (sedation) Etomidate: Safe with hemodynamic instability, neuroprotective, transient adrenal cortico-suppression. Do not use routinely in patients with septic shock. Dose: 0.3 mg/kg IV. Ketamine: Safe with hemodynamic instability if patient is not catecholamine depleted. Use in patients with bronchospasm and septic shock. Use with caution in hypertensive patients with increased intracranial pressure. Dose: 1 to 2 mg/kg IV (if no IV access, can be given IM dose: 3 to 7 mg/kg). Propofol: Causes hypotension. May use in hemodynamically stable patients with status epilepticus. Dose 1 to 1.5 mg/kg IV. Midazolam: May use in hemodynamically stable patients with status epilepticus. Time to clinical effect is longer; inconsistently induces unconsciousness. May cause hemodynamic instability at doses required for sedation. Dose: 0.2 to 0.3 mg/kg IV (maximum dose 10 mg; onset of effect requires 2 to 3 minutes). Fentanyl: Optional for cardiogenic shock or catecholamine-depleted shock (eg, persistent hypotension despite vasopressor therapy). Limited evidence in children. Dose 1 to 5 mcg/kg titrated to effect. Start at lower end of range in hypotensive patients. Give over 30 to 60 seconds to avoid respiratory depression or chest wall rigidity. Pretreatment

13. Paralytic Selection of paralytic agent — Paralytic agents provide complete muscle relaxation, which facilitates rapid tracheal intubation. They do not provide sedation, analgesia, or amnesia. Thus, a sedative agent must also be used both for RSI and when paralysis is maintained after intubation. Rocuronium : Use for children with contraindication for succinylcholine or as primary paralytic if sugammadex is immediately available. Dose: 1 mg/kg IV.* Succinylcholine: Do not use with extensive crush injury with rhabdomyolysis, chronic skeletal muscle disease (eg, Becker muscular dystrophy) or denervating neuromuscular disease (eg, cerebral palsy with paralysis); 48 to 72 hours after burn, multiple trauma, or denervating injury; patients with history or malignant hyperthermia; or pre-existing hyperkalemia. Dose: Infants and children ≤2 years: 2 mg/kg IV, older children and adolescents: 1 to 1.5 mg/kg IV (if IV access unobtainable, can be given IM, dose: 4 mg/kg) ¶ .

14. Protection and positioning : Maintain manual cervical spine immobilization during intubation in the trauma patient. If cervical spine injury is not potentially present, put the patient in the "sniffing position" (ie, head forward so that the external auditory canal is anterior to the shoulder and the nose and mouth point to the ceiling). Utilize external laryngeal manipulation or, in infants, gentle cricoid pressure to optimize the view of the glottis during direct laryngoscopy if the initial view is suboptimal or inadequate despite correct laryngoscope blade positioning.

15. Tongue control during laryngoscopy. A and B) Poor visualization of the cords due to incorrect positioning of the blade. Note how the tongue folds over the blade and obscures the view. C) Correct positioning of the blade to control and move the tongue to the left, providing an optimal view for intubation.

16. Direct laryngoscopy with a straight blade

17. Direct laryngoscopy using a curved blade Selection of the appropriate laryngoscope blade is especially important with this technique. A blade that is too small will impinge on the midportion of the tongue, potentially obscuring the landmarks, whereas a blade that is too large can displace the epiglottis posteriorly over the glottic opening. The blade is inserted under direct vision until the tip is positioned in the vallecula. Pulling upward on the laryngoscope handle at 45-degree angle retracts the tongue and at the same time elevates the epiglottis, revealing the vocal cords and glottis.

18. A ) After initial retraction of the tongue with a straight blade, the epiglottis may remain draped posteriorly, partially or completely covering the glottic opening. (B) Retraction of the epiglottis with the tip of the straight blade allows visualization of the glottis and surrounding structures.

19. Positioning, with placement Initiate positive pressure ventilation — The laryngoscope can now be removed from the mouth while the tube is held securely against the roof of the mouth, or by grasping the tube using the index finger and thumb with the remaining three fingers holding the patient's face. If a cuffed tube is being used, the cuff should be inflated at this time. Confirm tracheal tube placement with end-tidal CO2 detection. Clinical assessment for appropriate tube position includes: Visible chest wall rise Auscultation of breath sounds in both axillae and not heard over the stomach Adequate oxygenation as demonstrated by continuous pulse oximetry Mist should be present in the ETT Postintubation management Obtain a chest radiograph to confirm the depth of tracheal tube insertion. Provide ongoing sedation (eg, midazolam), analgesia (eg, fentanyl 1 mcg/kg), and, if indicated, paralysis. Gastric decompression – An orogastric or nasogastric tube should be placed following intubation to decompress the stomach.

20. Complications ; Acute complications from laryngoscopy and intubation can occur at multiple points during the procedure. During laryngoscopy/intubation: Hypoxemia Bradycardia Increased intracranial pressure (ICP) Mechanical trauma Aspiration – Aspiration of oral or gastric contents during laryngoscopy or intubation can occur. After intubation: Esophageal or tracheal tube malposition. Tube obstruction; hypoxemia and hypercapnia. Barotrauma Adverse events from medications

21. Sedative for Children with specific clinical features : Hypotension other than septic shock – Etomidate . Fentanyl is preferred by some experts for sedation of children with cardiogenic shock. Septic shock : Ketamine , unless otherwise contraindicated (eg, suspected open globe injury or catecholamine depletion [eg, hypotensive despite receiving vasopressor medications. Increased ICP : Etomidate or, in patients who are hemodynamically stable, propofol or, in countries where it is available, thiopental. Hypotensive with head injury : Etomidate . Status asthmaticus – Ketamine or etomidate . Status epilepticus – Choice depends upon hemodynamic status: Hemodynamically stable – Midazolam, propofol , or, if available, thiopental. Hypotensive – Etomidate.

22. Summary of The doses Following are the dosages of RSI medications: Sedatives Used for Induction Etomidate : 0.3 to 0.4 mg/kg Fentanyl: 1 to 5 mcg/kg Midazolam: 0.1 to 0.3 mg/kg Propofol: 1 to 2.5 mg/kg Thiopental 3 to 5 mg/kg Paralytic Agents Succinylcholine: 1 to 2 mg/kg Rocuronium 0.6 to 1.2 mg/kg Vecuronium 0.15 to 0.25 mg/kg

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