Professional Documents
Culture Documents
Objectives
Definition Key Challenges RSI = really stupid idea and why you should avoid it Helpful strategies Illustrative cases
Acknowledgements
Dr Scott Weingart lecture Preoxygenation and reoxygenation, www.emcrit.blog Dr Richard Levitan s Emergency Airway handbook Dr Richard Levitans article No Desat www.epmonthly.com
Case 1
55yo man Chest pain for 16hrs Dyspnoeic Coughing pink frothy sputum O/E: GCS 12, BP 70/50, HR 110, SaO2 88% on 15l/Min, creps to apices bilaterally
His ECG
Why?
Rapid Sequence Induction and Intubation: Current Controversy Mohammad El-Orbany, MD and Lois A. Connolly, MD Anesthesia & Analgesia,2010, 110(5):1318-1325
The changing opinion regarding some of the traditional components of rapid sequence induction and intubation (RSII) creates wide practice variations that impede attempts to establish a standard RSII protocol.
RSI protocol
Lesson learnt
Cookbook recipe RSI in the prehospital setting is hazardous to your patients health
Do not adhere to protocol rigidly
Dont be a gambler
But classic RSI preoxygenation achieves the first goal of safety...?? Oh really..
How do you maintain oxygenation in the critically ill or high risk airway patient?
Jaw thrust Apnoeic oxygenation with NRBM Nasal cannula at 5L/min during laryngoscopy Frova bougie technique gentle BVM during apnoeic period BVM MUST BE DONE WITH TWO PERSON TECHNIQUE. DONT TRY TO PLAY THE HERO
Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. Ramachandran et al. Journal of Clinical Anesthesia (2010) 22, 164168
Main Results: Nasal O2 administration was associated with significant prolongation of SpO2 95% time (5.29 1.02 vs. 3.49 1.33 min, mean SD), a significant increase in patients with SpO2 95% apnea at 6 minutes (8 vs. one pt), and significantly higher minimum SpO2 (94.3 4.4% vs. 87.7 9.3%). Resaturation times were no different between the groups.
Induction agents
Classically something rapid onset and short acting = Thiopentone (AUS), Etomidate (rest of the world) I would argue ketamine in most situations is better I would suggest titration till loss of response/reflex rather than crash bolus method Koerber et al survey = 10% anaesthetists used crash bolus method Makes more sense and no evidence to prove any way is superior to another
Thiopental-rocuronium versus ketamine-rocuronium for rapidsequence intubation in parturients undergoing cesarean section Baraka et al, Anesthesia &Analgesia, 1997,84(5):1104-1107
Tracheal intubation at 50% NMB was easily performed in all patients in the ketaminerocuronium group but was difficult in 75% of the thiopental-rocuronium group. We concluded that ketamine 1.5 mg/kg followed by rocuronium 0.6 mg/kg may be suitable for rapid-sequence induction of anesthesia in parturients undergoing cesarean section.
We have demonstrated that non-physicians may administer ketamine safely and effectively to facilitate endotracheal intubation. We believe that ketamine is a suitable choice for the intubation of critically ill patients in the HEMS and potentially other EMS settings
Suxamethonium
THE RSI agent Give a decent dose at least 1.5mg/kg..I would suggest 2mg/kg for occasional intubators Evidence indicates shorter onset and better intubating conditions more likely Caveat = longer time to recovery (7.7 min for 2mg/kg dose)
The incidence of excellent intubating conditions was significantly more frequent (P 0.001) in patients receiving succinylcholine than in the controls and in patients who received 2.0 mg/kg succinylcholine (P 0.05) than in those who received 0.3 mg/kg succinylcholine
Conclusions of authors = 1.5mg/kg dose is just right
Comparison of Succinylcholine and Rocuronium for First-attempt Intubation Success in the Emergency Department
Asad E. Patanwala, PharmD, Sara A. Stahle, PharmD, John C. Sakles, MD, and Brian L. Erstad, PharmD Abstract
Conclusions: Succinylcholine and rocuronium are equivalent with regard to first-attempt intubation success in the ED when dosed according to the ranges used in this study. ACADEMIC EMERGENCY MEDICINE 2011; 18:1114
Cricoid pressure in emergency rapid sequence induction, Butler, Best BETS EMJ 2005
Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: Essential safety measure or a hindrance to rapid safe intubation. Ellis et al, Resuscitation,2010,81(7):810-816
Results 402 patients were included over a 16-month period. We intubated 98.8% patients on the first or second attempt. In 61 intubations (in 55 patients, 13.6%) the larynx required manipulation to facilitate intubation. In 22 intubations cricoid pressure was removed with the laryngeal view improving in 50%. Bimanual laryngeal manipulation was used in 25 intubations and the larynx better visualised in 60% of these. Backwards upwards rightwards pressure was applied to the larynx in 14 intubations and the laryngeal view improved in 64%. Two patients regurgitated when cricoid pressure was released. Both had prolonged periods of bag valve mask ventilation and difficult intubations.
Bougie tips
Practice before trying Suggest using this first line for C Spine immobilisation intubations ( FDEAR data) Leave laryngoscope in once bougie inserted trachea Oxygenation tips with bougie
Case 1
55yo man Chest pain for 16hrs Dyspnoeic Coughing pink frothy sputum O/E: GCS 12, BP 70/50, HR 110, SaO2 88% on 15l/Min, creps to apices bilaterally
His ECG
Case 2
24yo man, fall from 12 m into river Obvious C spine injury with quadriplegia Respiratory failure with episodic apnoea O/E GCS 10, BP 60/40, HR 70, SaO2 90% on 15L/min, RR 12 weak
Is classic RSI appropriate? How would you modify RSI in this case?