MAKING RSI SAFER Nick Taylor ETU THK 2015
GOALS 1. AIRWAY ASSESSMENT AND PLAN 2. MAXIMALLY PREOXYGENATE 3. HAEMODYNAMIC STABILITY
PART 1 : AIRWAY ASSESSMENT AND PLAN
LEMON: AIRWAY ASSESS AND PLAN Look Evaluate 3-3-2 Mallampatti Obstructions Neck Validated assessment technique to help predict poor laryngoscopy view. Emerg Med J 2005;22:99 102
LOOK externally: Large incisors, facial hair, facial trauma, large tongue EVALUATE 3-3-2 Interincisor distance (3 fingers) Hyomental distance (3 fingers) Floor of mouth to thyroid notch (2 patients own fingers)
MALLAMPATTI
Obstructions: Masses, blood, teeth Stridor Swallowing difficulty OBSTRUCTIONS AND NECK Neck mobility Especially Hard collar, Ank spond, RA etc
OPTIMISE POSITIONING EARLOBE AT LEVEL STERNUM THIS MAY REQUIRE PILLOWS, TOWELS, RAMPING
OPEN AIRWAY Naso pharygeal airways Oro pharyngeal airways Occasionally x 3
VERBALLY EXPRESS YOUR PLAN BASED ON ASSESSMENT Should include primary and back up plan Pre allocate roles for back up if expected difficult
SUMMARY OF AIRWAY Formally assess each time Optimise position and adjuncts Verbally express primary and backup plan Use a checklist
PART 2 PREOXYGENATION
WHY PREOXYGENATE Extends safe apnoea time by 1. Get sats as high as possible 2. Denitrogenate lungs 3. Denitrogenate and oxygenate blood
STEP 1: DELIVER HIGH FI02 Self inflating bag and mask has a one way valve
RESERVOIR FACE MASK NRB only gives 60-70% FiO2 Turn up flow rate to beyond 15L/min Sit up 30 deg or incline bed 3-5 minutes or 8 VC breaths
STEP 2: ADDING PEEP Multiple studies show apnoea time extended and haemodynamics not affected Use NIV (CPAP) or PEEP valve Should consider if sats <95 after Pre 02 Leave on until laryngoscope
STEP 3: APNOEIC OXYGENATION Standard nasal prongs or high flow Use standard prongs at 15L/min Leave on during whole process High flow can extend out apnoea time to up to 20min
STEP4: CONSIDER BAGGING When Pre 02 has not achieved >95% When hypercarbia is dangerous Raised ICP Sodium Channel blocker overdose
STEP 5: CONSIDER DSI Ketamine 0.5mg/kg to facilitate NIV Especially in agitated patients We have done >10 minutes in severely ill patients with very good effect
SUMMARY OF PRE 02 Goal should be sats>95% Use: High flow mask 02 and nasal cannula in all Consider: Add PEEP or NIV Add bagging Add DSI
PART 3: HAEMODYNAMIC OPTIMIZATION
IDENTIFY THE AT RISK PATIENT Most/All Induction drugs are vasodilators and/or negative inotropes Hypotension during RSI can be catastrophic
HAEMODYNAMIC PREPARATION 2 Working large Cannulae All patients should be fluid loaded unless truly contraindicated (0.5-1L NS) Consider bolus vasoconstrictor or infusion if at risk (especially distributive shock, raised ICP)
DRUG CHOICE Propofol: Vasodilator, negative inotrope Hypotension in almost every patient Excellent drug for sedation Not used as much for induction
DRUG CHOICE Thiopentone: Vasodilator, negative inotrope Less hypotension than propofol Judicious dose important neuroprotective effect less important than BP maintenance
DRUG CHOICE Ketamine: Sympathomimetic Will still be a negative inotrope in at risk patient Excellent drug for sedation Raised ICP effect not as important as prevention of hypotension
DRUG CHOICE Fentanyl: In isolation, provides sympathetic ablation in high dose Additive effects when combined Need 5-10mcg/kg Chest wall rigidity not an issue when using MR
DRUG CHOICE Midazolam: Mild Vasodilator, negative inotrope esp when combined Slow onset and offset leads to non optimal timing when used as part of RSI Not used for induction in Oz
PART 4: PUTTING IT ALL TOGETHER CASES
CASE 1 24 yo male with head injury from MBA GCS 7 BP 100/45 P100 Sats 98% RA DOES HE NEED A TUBE?
Inline immobilisation required Unable to adequately position May have other injuries STEP 1: ASSESS AIRWAY AND PLAN May not be able to use NPA if BOS # May have facial injuries Desat associated with adverse neuro outcome
AIRWAY Collar off, inline needed Tilt bed to 15-30deg Have OPA/NPA ready Primary plan: RSI with laryngoscope backup is LMA
STEP 2: PRE02 Main issues are positioning and prevention desat High flow mask 02 and NP 02 Probably wont need PEEP/NIV/DSI given starting sats
STEP 3: HD PREP BP is borderline already BP <90 = bad outcome in head injury Needs IVF load 1L NS at least If BP not improved, consider using pressor cover for induction Choice of agent: Fentanyl 300-500mcg Ketamine 1-2mg/kg Thiopentone 2-3mg/kg
CASE 2 74 yo lady APO Sats 80% on 10L 02 BP 150/100 DOES SHE NEED A TUBE?
ASSESS AND PLAN LEMON Position: will need to stay sitting up as long as possible
PRE 02 Immediate need for PEEP: Start CPAP 10-20cm/H20 Consider DSI approach if not tolerating Remember to treat APO as well (GTN, diuretic if needed) Do not rush in to ETT
PEEP here is extremely important Leave on CPAP until laryngoscope in PEEP valve on BVM Pre setup oxylog
HD PREP Although BP OK now she has LVF Will be much more sensitive to effects of induction drug Drug Choice Fentanyl Ketamine Thio
CASE 3 35 yo man with T 39, BP 85/50, P 130, Sats 85% 15L NRB; GCS 14 Clinical pneumonia DOES HE NEED A TUBE?
AIRWAY AND PLAN LEMON ADJUNCTS POSITION: will need sitting up
PRE02 Needs NIV: PEEP very important DSI strategy if not tolerating
HD PREP Distributive shock Needs substantial filing (3L NS) If BP <120 by induction add norad first Ketamine ideal drug here
CASE 4 19F with large OD of tricyclic BP 85/50 Sats 98 RA P120 GCS 10 Does she need a tube?
AIRWAY AND PLAN LEMON POSITION TCA specific issues
PRE O2 No anticipated problems Needs HF 02 and NP BUT: Acidosis a big issue here, need to minimise apnoea time Use bagging during RSI
HD PREP Issue here is dilated and and risk arrhythmia Aggressive fluid load Bicarbonate pre induction Consider pressor cover Induction drug: rapid onset/offset; careful dosing