Advanced Emergency Airway Management RSI Techniques for the
- Slides: 26
Advanced Emergency Airway Management • RSI • Techniques for the Difficult or Failed Airway
Dilemmas: • Intubate Awake or Asleep • Oral or Nasal • Laryngoscopy or Blind Intubation • To Paralyze or Not
Techniques • • • DL without pharmacologic aids Awake Direct Laryngoscopy Awake Blind Nasal Rapid Sequence Intubation (RSI) Fiberoptic Surgical Cricothyroidotomy
Blind Nasal Intubation • success rates 65 - 80 % in most series • high complication rates – epistaxis – pharyngeal/ esophageal perforations – increased incidence of O 2 desaturation • Considered second line approach only • reserved for when RSI contraindicated
Oral Intubation Without Drugs • Reserved for the completely unconscious, unresponsive, and apneic • Arrest situations only
Oral Intubation with Sedation • proponents argue use of BZ or opioids – improves airway access – decreases patient resistance – avoids risks of neuromuscular blockade • Generally obtunds patient to point of loss of protective reflexes and respiratory drive • lower success rate, higher complications compared with RSI
Oral Intubation with Sedation • “ In general, the technique of administering a potent sedative agent to obtund the patient’s responses and permit intubation in the absence of NMB is hazardous and to be discouraged… is not an appropriate alternative to properly conducted RSI and affords neither the success rate or the minimal complication rate of RSI. ” – RM Walls, page 4, Chapter 1, Rosen
Oral Intubation with Sedation: Use for the Anticipated Difficult Airway • if time permits – topical anesthesia – careful titrated sedation – avoid obtundation • ‘Awake” intubation technique
Emergency Airway Concerns • • • “full” stomach minimal respiratory reserve hemodynamic instability acute myocardial ischemia increased intracranial pressure The “Difficult” Airway – Laryngoscopy – bag-mask difficulty
The “Intubation Reflex “ • Catecholamine release in response to laryngeal manipulation • Tachycardia, hypertension, raised ICP • Attenuated by beta-blockers, fentanyl • ICP rise possibly attenuated by lidocaine • Midazolam and thiopental have no effect
Rapid Sequence Intubation : Definition • The near simultaneous administration of a sedative-hypnotic agent and a neuromuscular blocker in the presence of continuous cricoid pressure to facilitate endotracheal intubation and minimize risk of aspiration • modifications are made depending upon the clinical scenario
Rapid Sequence Intubation : Advantages • Optimizes intubating conditions/ facilitates visualization • Increased rate of successful intubation • Decreased time to intubation • Decreased risk of aspiration • Attenuation of hemodynamic and ICP changes
Rapid Sequence Intubation : Contraindications • Anticipated difficulty with endotracheal intubation – anatomic distortion • Lack of operator skill or familiarity • inability to preoxygenate
Rapid Sequence Intubation: Principles • • Emergency intubation is indicated The patient has a “full” stomach Intubation is predicted to be successful If intubation fails, ventilation is predicted to be successful
Rapid Sequence Intubation : Procedure • • Pre-intubation assessment Pre-oxygenate Prepare ( for the worst ) Premedicate Paralyze Pressure on cricoid Place the tube Post intubation assessment
Pre-oxygenate ( Time - 5 Minutes) • • • 100 % oxygen for 5 minutes 4 conscious deep breaths of 100 % O 2 Fill FRC with reservoir of 100 % O 2 Allows 3 to 5 minutes of apnea Essential to allow avoidance of bagging If necessary bag with cricoid pressure
Preparation ( Time - 5 Minutes ) • • • ETT, stylet, blades, suction, BVM Cardiac monitor, pulse oximeter, ETCO 2 One ( preferably two ) iv lines Drugs Difficult airway kit including cric kit Patient positioning
Pre-treatment/ Prime ( Time - 2 Minutes ) • Lidocaine 1. 5 mg/kg iv • Defasciculating dose of non-depolarizing NMB • Beta-blocker or fentanyl • Induction agent – Thiopental 3 - 5 mg/kg – Midazolam 0. 1 - 0. 4 mg/kg – Ketamine 1. 5 - 2. 0 mg/kg – Fentanyl 2 - 30 mcg/kg
Paralyze ( Time Zero ) • Succinylcholine 1. 5 mg/kg iv • Allow 45 - 60 seconds for complete muscle relaxation • Alternatives – Vecuromium 0. 1 - 0. 2 mg/kg – Rocuronium o. 6 - 1. 2 mg/kg
Pressure • • Sellick maneuver initiate upon loss of consciousness continue until ETT balloon inflation release if active vomiting
Place the Tube ( Time Zero + 45 Secs ) • Wait for optimal paralysis • Confirm tube placement with ETCO 2
Post-intubation Hypotension • • Loss of sympathetic drive Myocardial infarction Tension pneumothorax Auto-peep
Succinylcholine : Contraindications • Hyperkalemia - renal failure • Active neuromuscular disease with functional denervation ( 6 days to 6 months) • Extensive burns or crush injuries • Malignant hyperthermia • Pseudocholinesterase deficiency • Organophosphate poisoning
Succinylcholine : Complications • • Inability to secure airway Increased vagal tone ( second dose ) Histamine release ( rare ) Increased ICP/ IOP/ intragastric pressure Myalgias Hyperkalemia with burns, NM disease malignant hyperthermia
Difficult Airway Kit • Multiple blades and ETTs • ETT guides ( stylets, bougé, light wand) • Emergency nonsurgical ventilation ( LMA, Combitube, TTJV ) • Emergency surgical airway access ( cricothyroidotomy kit, cricotomes ) • ETT placement verification • Fiberoptic and retrograde intubation
Emergency Surgical Airway Maxims • they are usually a bloody mess, but. . . • a bloody surgical airway is better than an arrested patient with a nice looking neck
- Epiglottic
- Wood pulp
- Rsi medication order
- Hsi rsi
- Rsi protokoll
- Rsi security camera
- Rsi vs dsi
- Deepak sharan recoup
- The sam initiative
- Rsi
- Ctfg rsi
- Ict legal issues
- Rsi ravenna
- What is health and safety in ict
- Ctfg rsi
- Srx idp configuration
- Health and safety on computers
- Expectedness
- Advanced emergency braking
- Indikasi intubasi
- Chapter 10 airway management
- Opa and npa
- Npa measurement
- Abcde airway
- Sandwich manuver
- Stepwise airway management
- Discrete mathematics