Redundancy of safety (primary and backup chute) Planned stepwise approach to deploy 1 ary chute Simple, fast, easy backup chute deployment Attention

Transcription

1 Rapid Sequence Intubation John Bradley, MD Metropolitan Hospital May 30,

2 Lessons from Skydiving Levitan RM. Patient safety in emergency airway management and rapid sequence intubation: metaphorical lessons from skydiving. Ann Emerg Med. 2003;42: Redundancy of safety (primary and backup chute) Planned stepwise approach to deploy 1 ary chute Simple, fast, easy backup chute deployment Attention to monitoring: exit plane at correct altitude, altimeter determines when to deploy backup chute Equipment vigilance 2

3 Overview Rapid Sequence Intubation Airway Assessment The Difficult Airway The Failed Airway Airway Options Your Approach 3

4 Rapid Sequence Intubation (RSI) Definition Assumptions Goals Indications Contraindications Alternatives Procedure Steps Pharmacology 4

5 RSI Definition The administration of a potent induction agent followed immediately by a rapid acting neuromuscular blocker (NMB) to render unconsciousness and motor paralysis for tracheal intubation 5

6 RSI Assumptions 6

7 RSI Assumptions Intubation is indicated The stomach is full Intubation is anticipated to be successful If intubation fails, ventilation is expected to be successful 7

8 RSI Goals Optimize intubation conditions Minimize aspiration risk by avoiding positive pressure ventilation until after intubation is accomplished 8

9 Indications for Tracheal Intubation 9

10 Indications for Tracheal Intubation Inability to maintain an airway Inability to maintain adequate oxygenation and ventilation Anticipated airway obstruction / Special situations 10

11 RSI Contraindications 11

12 RSI Contraindications Tracheal / laryngeal injury / disruption S/P Laryngectomy Massive facial trauma Anticipated difficult airway 12

13 RSI Alternatives Awake oral intubation with local anesthesia and sedation Blind nasotracheal intubation (BNTI) 13

14 RSI The 7 Ps 14

15 RSI The 7 Ps Preparation Preoxygenation Pretreatment Paralysis with induction Protection with positioning Placement with proof Post-intubation management 15

16 RSI Timeline Time Zero - 10 min Zero - 5 min Zero - 3 min Zero Zero sec Zero sec Zero sec Action Preparation Preoxygenation Pretreatment Paralysis with induction Protection with positioning Placement with proof Post-intubation management 16

17 RSI Compressed Timeline Concurrent preparation and preoxygenation Accelerated (2 min) Shorten preoxygenation to 30 sec with 8 vital capacity breaths (VC) method Shorten pretreatment interval from 3 min to 2 min Immediate Eliminate pretreatment Preoxygenate with 8 VC breaths 17

18 Preparation Patient Discussion, airway assessment, IV access Positioning Equipment Airway, monitoring, failed airway Blade type and size, ETT size OP airway, placement confirmation device Cuff integrity and stylet, laryngoscope fxn Personnel 18

19 Airway Assessment (LEMON) Look externally Evaluate Mallampati Obstruction Neck (Pediatrics) 19

20 Look Externally Difficult BVM Ventilation? Difficult Laryngoscopy / Intubation? Difficult Surgical Airway? 20

21 Beard Obesity No teeth (Elderly) (Snores) Difficult BVM Ventilation (BONES) Severe facial burns / angioedema / trauma Unstable midface and/or mandible 21

22 Difficult Laryngoscopy / Intubation (Severe facial burns / angioedema / trauma) Buck teeth Jay Leno Micronathia Down s syndrome FLK 22

23 Difficult Surgical Airway (SHORT) Surgery Hematoma or infection Obesity Radiation Tumor (including goiter) Anatomic variability Females 23

24 Evaluate (3-3-2 Rule) 3 finger breadths between upper lower teeth Ability to visualize 3 finger breadths between the mandible and hyoid bone < 3: suggests anterior larynx Greater: axes malalignment 2 finger breadths between thyroid cartilage notch and the mandible or floor of the mouth Cephalad larynx 24

25 Mallampati Classification I Tonsillar pillars and fauces visible II Upper portion of pillars and uvula visible III Base of uvula / soft palate visible IV Only tongue and hard palate visible Patient s mouth open, tongue sticking out Correlates with laryngoscopy classification, but not as sensitive in grades 3 and 4 25

26 Laryngoscopic Classification Grade I Entire glottis visible Grade II Arytenoid cartilage and posterior glottis visible Grade III Epiglottis only visible Grade IV Tongue or soft palate visible Grade III and IV are considered difficult intubations (about 5% of OR cases) Visualization predicts intubation success 26

27 Obstruction Angioedema Epiglottis Abscess Burn Trauma Tumor 27

28 Neck Possible cervical spine injury Rheumatoid arthritis Ankylosing spondylitis 28

29 High Risk Patients ASA Class III and higher Chronic pulmonary or cardiac disease Fever, volume depletion, current URI Airway assessment suggestive Consider OR, anesthesia consult and/or awake intubation 29

30 ETT Size and Depth Size Females 7.5-8; Males Broslow tape, little finger diameter 4 + age/4 Depth Females - 21 cm; Males - 23 cm Broslow tape, markings on ETT ETT size x 3 (cm); age

31 Preoxygenation Establish an O2 reservoir in the lungs & body Essential to no bagging principle of RSI Function residual capacity is primary reservoir Permits several minutes of apnea without desaturation 100% O2 via nonrebreather for 5 minutes OR 8 VC breaths with 100% O2 via bag/mask 31

32 Pretreatment (LOAD) 32

33 Pretreatment (LOAD) Mitigate adverse effects of laryngoscopy Lidocaine 1.5 mg/kg Airway bronchospasm / cough reflex Increased ICP Opiates (Fentanyl 3-6 mcg/kg) Increased ICP, aortic dissection, ruptured aortic or IC aneurysm, ischemic heart disease Blunts reflex sympathetic response to laryngoscopy Not recommended under age 1 33

34 Pretreatment (LOAD) Atropine mg/kg (0.1 to 0.5 mg) Children <= 10 yo Blunts vagal response to laryngoscopy Defasiculation (with succinylcholine) Increased ICP 1/10 th dose of a non-depolarizing NMB Not indicated under age 5 34

35 Paralysis with Induction Rapid IV administration of sedation followed immediately by rapid administration of a neuromuscular blocking agent 35

36 Protection and Positioning Sellick s maneuver Firm pressure (10 #) Maintain until placement confirmation and cuff inflation Positioning Keep the pillow to maximize POGO Height of bed, height in bed 36

37 Placement with Proof Test for jaw flaccidity Extend head on neck Gentle controlled technique Blade entry on right, sweep tongue to left Lift handle up and away Suction prn Insert into esophagus, then slowly withdraw Visualize vocal cords Watch ETT pass through vocal cords Check ETT depth Never let go of the tube! Inflate cuff Auscultation 37

38 Placement with Proof Confirm tracheal placement Direct visualization plus either EtCO2 detector or Esophageal detector Preferred in cardiopulmonary arrest Confirm depth (cords > bronchus) Auscultation CXR 38

39 Post-Intubation Management Secure ETT Reassess VS PCXR for depth of placement Bradycardia / Hypoxia -> Nontracheal tube placement until proven otherwise (DOPE) Hypertension->inadequate sedation/analgesia Hypotension 39

40 Post-intubation Management Tension PTX (Hypotension) High PIP, hard to bag, decreased BS, hypoxia Immediate thoracostomy Decreased venous return High PIPs 2ndary to high intrathoracic pressure Fluids, bronchodilators, Increase expiratory time, decrease TV 40

41 Post-intubation Management Induction agent (Hypotension) Other causes excluded Fluid bolus, consider reversal agent, expectant Cardiogenic Usually a compromised pt Check EKG, exclude other causes Fluid bolus (caution), pressors 41

42 Medications Pretreatment drugs (LOAD) Lidocaine Opiates Atropine Defasiculation Sedation Paralysis 42

43 Sedation Midazolam Etomidate Methohexital / Thiopental Ketamine Propofol 43

44 Neuromuscular Blocking Agents Noncompetitive depolarizer Succinylcholine (Anectine) Competitive nondepolarizer Benzylisoquinolinium group Atracurium (Tracrium), cisatracurium (Nimbex), mivacurium (Mivacron) Aminosteroid group Pancuronium (Pavulon), vecuronium (Norcuron), rocuronium (Zemuron) 44

45 Succinylcholine (SCh) (Anectine) Rapid onset (45 seconds) and short duration of action (<= 10 minutes) Mechanism of action Metabolism Sequence of action Dosing 45

46 SCh Adverse Effects 46

47 SCh Adverse Effects Malignant hyperthermia Masseter spasm Hyperkalemia Increased ICP / Increased IOP Fasciculations Bradycardia (peds) Prolonged NMB Hypotension (histamine release, (-) inotrope) 47

48 SCh Contraindications 48

49 SCh Contraindications Personal or FH of malignant hyperthermia Known or suspected hyperkalemia > 24 hours post-burn (>10% BSA, 1-2 yrs) > 1 week post crush injury (60-90 days) > 1 week post SCI or CVA (6 months) Neuromuscular disease (indefinite) MS, ALS, muscular dystrophy Anticipated difficult airway 49

50 Competitive, Nondepolarizing NMB Most commonly utilized post-intubation No CIs other than the difficult airway Disadvantage is longer onset and duration Metabolism variable Higher dose reduces time to paralysis but prolongs time to recovery 50

51 Competitive, Nondepolarizing NMB Aminosteroid group dose not cause histamine release Reversible with AChesterase inhibitor Requires 40% spontaneous recovery Consider administering sedation shortly after administering vecuronium or pancuronium for RSI 51

52 Competitive, Nondepolarizing NMB Rapacurium off the market Rocuronium ( mg/kg) Mivacurium (0.15 mg/kg) Vecuronium (0.3 mg/kg) Pancuronium (0.1 mg/kg) 52

53 Awake Oral Intubation Upper airway distortion is anticipated Prepare the patient Anesthetize the airway Lidocaine 4% 4 cc / neosynephrine 0.5% 1cc OR Lidocaine 2% w/epi 5cc / Lidocaine 2% Plain 5 cc Via nebulizer for 10 minutes OR Lidocaine spray Sedation (Midazolam or Etomidate +/- Fentanyl) Onset 3-5 minutes Perform laryngoscopy Immediate intubation / consider RSI / surgical airway Can the epiglottis be visualized? Is an abnormal glottis anticipated? 53

54 Pediatrics Relatively large tongue / more oral secretions High tracheal opening (C1 > C4,5 adult) Large occiput Cricoid ring is narrowest portion Large tonsils and adenoids and greater angle between epiglottis and larygeal opening Minimal cricothyroid membrane until age ¾ Small relative FRC Basal oxygen consumption twice the adult rate 54

55 Pediatrics Appropriately sized equipment (Broslow) Positioning Avoid hyperextension May need to elevate shoulders Effective BVM C-grip / good seal Squeeze, release, release Tidal volume Cricoid pressure 55

56 Pediatrics Atropine < age 10 Avoid fentanyl < age, use cautiously Lower barbituate dose per kg No defasciculation < age 5 / 20 kg Succinylcholine dose Straight blade Uncuffed ETT < age 8 56

57 Pediatrics No BNTI < age 10 Adult EtCO2 detector > 15 kg Securing the tube Place NGT or OGT early Orotracheal intubation for better security No surgical cricothyroidotomy < age 10 57

58 The Second Attempt Learn from your first attempt (experience) Blade type or size (Use Mac as a Miller) ETT size Sellick s technique / stylet BURP Reposition the head and neck Chest pressure looking for air bubble Monitor VS, interposed BVM ventilation Find the epiglottis Call for help 58

59 The Bottom Line The Broslow Tape / Cart Get the trachea intubated efficiently Have a plan Have a back-up plan Call for help early Airway assessment is an integral part of RSI and procedural sedation Practice, practice, practice 59

60 Resources Manual of Emergency Airway Management by Ron Walls et al Airway Courses 60