Professional Documents
Culture Documents
Intubation
John Bradley, MD
Metropolitan Hospital
1
Lessons from Skydiving
Levitan RM. Patient safety in emergency airway management and rapid sequence
intubation: metaphorical lessons from skydiving. Ann Emerg Med. 2003;42:81-87.
2
Overview
Rapid Sequence Intubation
Airway Assessment
The Difficult Airway
The Failed Airway
Airway Options
Your Approach
3
Rapid Sequence Intubation (RSI)
• Definition
• Assumptions
• Goals
• Indications
• Contraindications
• Alternatives
• Procedure
– Steps
– Pharmacology
4
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
RSI Assumptions
6
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
RSI Goals
• Optimize intubation conditions
8
Indications for Tracheal Intubation
9
Indications for Tracheal Intubation
10
RSI Contraindications
11
RSI Contraindications
12
RSI Alternatives
• Awake oral intubation with local
anesthesia and sedation
• Blind nasotracheal intubation (BNTI)
13
RSI
The 7 Ps
14
RSI
The 7 Ps
• Preparation
• Preoxygenation
• Pretreatment
• Paralysis with induction
• Protection with positioning
• Placement with proof
• Post-intubation management
15
RSI Timeline
Time Action
Zero - 10 min Preparation
Zero - 5 min Preoxygenation
Zero - 3 min Pretreatment
Zero Paralysis with induction
Zero + 20-30 sec Protection with positioning
Zero + 45-60 sec Placement with proof
Zero + 60-90 sec Post-intubation management
16
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
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
Airway Assessment (LEMON)
• Look externally
• Evaluate 3-3-2
• Mallampati
• Obstruction
• Neck
• (Pediatrics)
19
Look Externally
• Difficult BVM Ventilation ?
• Difficult Laryngoscopy / Intubation ?
• Difficult Surgical Airway ?
20
Difficult BVM Ventilation
(BONES)
• Beard
• Obesity
• No teeth
• (Elderly)
• (Snores)
• Severe facial burns / angioedema / trauma
– Unstable midface and/or mandible
21
Difficult Laryngoscopy / Intubation
22
Difficult Surgical Airway
(SHORT)
• Surgery
• Hematoma or infection
• Obesity
• Radiation
• Tumor (including goiter)
• Anatomic variability
• Females
23
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
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
25
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
27
Neck
• Possible cervical spine injury
• Rheumatoid arthritis
• Ankylosing spondylitis
28
High Risk Patients
• ASA Class III and higher
• Chronic pulmonary or cardiac disease
• Fever, volume depletion, current URI
• Airway assessment suggestive
29
ETT Size and Depth
• Size
– Females 7.5-8; Males 8-8.5
– 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 + 10
30
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
Pretreatment (LOAD)
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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
Pretreatment (LOAD)
• Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg)
– Children <= 10 yo
– Blunts vagal response to laryngoscopy
• Defasiculation (with succinylcholine)
– Increased ICP
– 1/10th dose of a non-depolarizing NMB
– Not indicated under age 5
34
Paralysis with Induction
• Rapid IV administration of sedation
followed immediately by rapid
administration of a neuromuscular
blocking agent
35
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
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
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
Post-Intubation Management
• Secure ETT
• Reassess VS
• PCXR for depth of placement
39
Post-intubation Management
(Hypotension)
• Tension PTX
– 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
Post-intubation Management
(Hypotension)
• Induction agent
– Other causes excluded
– Fluid bolus, consider reversal agent, expectant
• Cardiogenic
– Usually a compromised pt
– Check EKG, exclude other causes
– Fluid bolus (caution), pressors
41
Medications
• Pretreatment drugs (LOAD)
– Lidocaine
– Opiates
– Atropine
– Defasiculation
• Sedation
• Paralysis
42
Sedation
• Midazolam
• Etomidate
• Methohexital / Thiopental
• Ketamine
• Propofol
43
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
Succinylcholine (SCh) (Anectine)
45
SCh Adverse Effects
46
SCh Adverse Effects
• Malignant hyperthermia
• Masseter spasm
• Hyperkalemia
• Increased ICP / Increased IOP
– Fasciculations
• Bradycardia (peds)
• Prolonged NMB
• Hypotension (histamine release, (-) inotrope)
47
SCh Contraindications
48
SCh Contraindications
• Personal or FH of malignant hyperthermia
50
Competitive, Nondepolarizing NMB
51
Competitive, Nondepolarizing NMB
52
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
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
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
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
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
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
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
Resources
• Manual of Emergency Airway
Management by Ron Walls et al
• Airway Courses
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