Rapid Sequence Induction

Transcription

1

2 Rapid Sequence Induction Virtual simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to facilitate rapid tracheal intubation without interposed mechanical ventilation Ron Walls, MD» Manual of Emergency Airway Management

3

4 To Intubate or not to Intubate? 6 questions to ask: Can the patient maintain an airway? Can the patient protect this airway? Is the patient appropriately ventilating? Is the patient appropriately oxygenating? Is the patient s condition likely to deteriorate? Is the scene appropriate: safety, moving the patient while apneic

5 Examples of RSI Indications Conditions requiring oxygenation/ventilation control or positive pressure ventilation: Traumatic brain injury with ALOC Severe thoracic trauma (flail chest, pulmonary contusions with hypoxemia) Clinical condition expected to deteriorate Unconscious or ALOC with potential for or actual airway compromise or vomiting And patient has A clenched jaw An active gag reflex

6 Complications Increased intracranial pressure Increased intraocular pressure Increased intragastric pressure Aspiration due to decreased gag reflex Malignant hyperthermia Dysrhythmias Hypoxemia Airway trauma Failure to intubate / failure to ventilate DEATH Medication induced or procedural?

7 3 Major Assumptions of RSI 1. The patient has a full stomach 2. The Paramedic can secure an airway Failure = DEATH for the patient DO NOT take away what you cannot give back! 3. The Paramedic can resuscitate the patient Equipment & Knowledge readily available

8

9 Key Question BVM Difficult Airway Protocol Crash Airway Protocol Failed Airway Protocol

10 KISS Simplicity - limits complications and death Limit number of steps/meds Rapid onset Hemodynamically stable or minimal impact

11 Preparation is the KEY for an organized, smooth intubation Remember the 7 P s!! Proper Prior Planning Prevents Piss Poor Performance

12 RSI 7 Ps Prep PreO Pretreat Paralysis Protection/Positioning Placement with Proof Postintubation Management

13 Assess the Risks

14 Some Predictors of a Difficult Airway C-spine immobilized trauma patient Protruding tongue Short, thick neck Prominent upper incisors ( buckteeth ) Receding mandible High, arched palate Beard or facial hair Dentures Limited jaw opening Limited cervical mobility Upper airway conditions Face, neck, or oral trauma Laryngeal trauma Airway edema or obstruction Morbidly obese

15

16 Joint disease Acromegaly Thyroid or major neck surgeries Tumors, known abnormal structures Genetic anomalies Epiglottitis Additional Predictors: Medical History Previous problems in surgery Diabetes Pregnancy Obesity Pain issues

17 Prep Assess potential difficulties MOANS Mask seal Obesity/Obstruction Age > 55 No teeth Stiff LEMON Look Evaluate Mallampati Obstruction Neck mobility

18 So, give me some good news: The Rule Bottom of Jaw/Chin to Neck > 3 fingers > 7cm usually a sign of easy intubation < 6cm is an indicator of a difficult airway Jaw/Palate > 3 fingers wide Mouth opens > 2 fingers wide Any single indicator has poor specificity

19 Paralysis with Induction Ketamine Sedation 50mg/ml Rocuronium (Zemuron) Paralytic 10mg/ml

20 Rocuronium (Zemuron) Very similar properties to Vecuronium Does not need to be reconstituted, can be stored at room temp for 60 days Less vagolytic properties

21 Rocuronium Onset: seconds Fastest onset of all non-depolarizing NMBs Dose: 1 mg/kg IVP 10mg/ml Vials of 100mg/10ml Duration: minutes Maintenance dose is 1/2 the initial dose

22

23 rotection/positioning Sellick? BURP? Falling out of favor? Tracheal positioning

24 BURP Backward, Upward, Rightward Pressure: manipulation of the trachea 90% of the time the best view will be obtained by pressing over the thyroid cartilage Differs from the Sellick Maneuver

25 Direct Visualization

26 Placement with Proof View cords if possible End tidal CO2

27 Postintubation Management Secure tube Monitor VS Manage oxygenation Sedation, analgesia and paralysis maintenance Rocuronium ½ Dose Ketamine ½ Dose

28

29 Always have a back-up plan. Plans A, B, and C Know the answers before you begin

30 Plan A : (ALTERNATIVES) Different: Size of blade Type of blade Miller Macintosh Specialty IE: McGrath Position (patient & provider) Hockey stick bend in ETT or Directional tip ETT Gum Elastic Bougie Endotracheal Tube Introducer Remove the stylette as you pass through the cords BURP 2-person technique OR Have someone else try

31 Plan B : BVM and BACKUP AIRWAY Can you ventilate with a BVM? (Consider two NPA s and an OPA, + Cricoid pressure w/ gentle ventilation) *****KING LT********

32 King-LT? Is this appropriate?

33 What do we do when faced with a Can t Intubate Can t Ventilate situation? Plan C : Last resort (CRIC) Surgical Know the skill and equipment!!!

34 Unable to intubate (including blind devices) and unable to ventilate with a BVM and maintain an Sp02 > 90 %. Failed Airway

35 Indication: Failed Airway Inability to maintain oxygenation / ventilation after previous intubation attempts Precaution: Anticipation during previous airway procedures will allow for rapid deployment of rescue airway or Cricothyrotomy Cardiac Monitor, ETCO2 and Pulse Oximetry are recommended for all airway attempts Technique: Maintain oxygenation with 100% oxygen via non-rebreather mask Passive oxygenation via nasal cannula at 15 lpm Placement of a King LT Airway as a rescue device If unsuccessful or unable to maintain oxygenation; perform Cricothyrotomy Complications and Special Notes: Receiving facility should be notified and advised that you are managing a Failed Airway

36 Final Thoughts on the Failed Airway In all cases of a failed airway, the Paramedic must continually assess the adequacy of oxygenation and ventilation 7% of all trauma patients will require intubation

37

38 Lets practice! Ketamine Roc Maint 220lbs 155lbs 98lbs 365lbs 178lbs 265lbs MG ML MG ML K / R