Rapid Sequence Intubation and Difficult Airway Andrew Scordato

Rapid Sequence Intubation and Difficult Airway Andrew Scordato EMT-P EMS Instructor

Learning objectives �Define RSI �List Indications and Contraindications �Describe Basic Airway Anatomy �Identify and Describe RSI Pharmacology �Identify and Describe the seven P’s of RSI �Differentiate between properly place and improperly placed ET tubes �Discuss Difficult Airway �Factors �Solutions: extraglotic airways

RSI? �What is RSI �Sedatives and NMBA same time �Protect airway/minimize hypoxia �Who is it for � Unable to maintain airway � GCS <8 � Pt. may lose the ability to protect their airway � Others? �Who is it not for �Inexperience �Difficult airway? �No “back-up” capabilities

Airway Anatomy Upper airway

Normal VS. Abnormal

Abnormal

Airway Anatomy �Lower Airway

Airway Anatomy �Properly placed ET Tube

What are the Drugs Doing? �Cellular level �Neuron �Action Potential �Ion channels �Synapse

Neuron

Action Potentials

Ion Channels

The Synapse

The Usual Suspects � Atropine �Names-Atropine Sulfate �Actions-parasympatholytic, Blocked vagal effects result in increased HR, decreased secretions �Indication-Bradycardia, used to pre-medicate �Contraindications-Acute hemorrhage, tachycardia, narrow angle glaucoma � Lidocaine �Names-Xylocaine �Actions-Antidysrhythmic properties, Local Anesthetic, Blunts ICP �Indications-pre-medicate in RSI �Contraindications-Second or third degree heart block in the absence of artificial pacemaker. Caution-apnea induced with suxs may be prolonged with large doses of lidocaine.

TUS II � Vercuronium �Names-Norcuron �Actions-Provides muscle relaxation by competing with ACH receptors on the nerve, result is muscle paralysis. Does not cause that initial depolarization wave that is common with SUCCS. �Indications-Temporary paralysis where muscle tone or szr prevent �Dosage-Defasciculating dose 1 mg/ivp Paralytic dose=. 1 mg/kg �Contraindications-monitor for bradycardia and hypotension. Certain drugs can enhance the effect including lidoccaine. Lasts-25 -30 minutes � Versed �Names-Midazolam hydrochloride �Actions-Short acting benzo, conscious sedation and impairs memory �Indications-Premedication for Intubation, SZR �Contraindications-shock, Alcohol intoxication (relative),

TUS III � Etomidate �Names-Amidate �Actions-Hypnotic, Anesthetic, Sedation, impairs memory, inhibits postsynaptic current �Indications-Medication for Endotracheal intubation �Contraindications-L and D, effects may be enhanced when given with other CNS depressants. � Succinycholine �Names-Anectine �Actions-Neuromuscular blocker-bind to ACH sites cause muscle to relax �Indications-facilitate intubation, muscle relaxation �Contraindications-skeletal muscle myopathies, Inability to control airway and or support ventilations with 02 or BVM

Ketamine � Ketamine is a non-competitive NMDA receptor antagonist and dissociative, amnestic, analgesic anesthetic agent. � Onset & Duration � Onset: 1 -5 minutes. � Duration: 10 -15 minutes � Contraindications � Relatively contraindicated in penetrating eye trauma, patients with known cardiovascular disease. (ketamine causes tachycardia) � Side Effects � Laryngospasm: this very rare adverse reaction presents with stridor and respiratory distress. After every administration of ketamine: � a. Prepare to provide respiratory support including bag-valve-mask ventilation and suction which are generally sufficient in rare cases of laryngospasm. � b. Institute cardiac monitoring, pulse oximetry and continuous waveform capnography � c. Establish IV or IO access, check blood glucose � Emergence reaction: presents as anxiety, agitation, apparent hallucinations or nightmares as ketamine is wearing off. For severe reactions, consider benzodiazepine. � Nausea and Vomiting/Hypersalivation: Suction usually sufficient.

Pharmacology � Paralytics �Notes � Choice is between Depolarizing or Non-Depolarizing � Rapid paralysis with rapid recovery �Depolarizing � persistent stimulation/Unresponsive to ACH/Fasciculation � Fasciculation-What? Muscle contraction cannot reoccur leading to relaxation � Example-Succinylcholine �Non-depolarizing � Blocks ACH sites � Slower onset � No fasciculation � Longer duration of Action � Example-Vecuronium

Depolarizing/Non-Depolarizing

Pharmacology � Pre-Medicating Agents �Atropine �Bradycardia (Peds) �Decrease Vagal tone/secretions �Dose=. 02 mg/kg �Lidocaine �Head injury/ other conditions? �It’s believed to blunt ICP/open smaller airways �Dose=1 mg/kg 3 -5 minutes prior to intubation �Defasciculating agents �Vecuronium-Head Injury/ Penetrating Eye Injury

Pharmacology � Induction agents (sedation) �Notes �Review VS �Paralyzed and Sedated not paralyzed alone �Multiple Agents available �Versed �Benzodiazepine/Short Acting �onset=1 -3 minutes/ duration 2 -6 hours � 2 -2. 5 mg sivp �Etomidate=Rapid onset, short acting, sedative hypnotic �Onset=10 -15 seconds/duration 5 -15 minutes �Dosage=0. 3 mg/kg

Pharmacology �Succinylcholine �Depolarizing �Primary agent with NDMB as secondary �Onset=within 1 minute/Duration=2 -5 minutes �Dosage=1. 5 mg/kg �Pt. 's with burn >24 hours/precaution difficult intubations �Vecuronium �NDMB �Onset approx. 3 minutes �Dosage= Defasciculating 1 mg/ivp Paralytic=0. 1 mg/kg

The Seven P’s of RSI � 1. Prepare � 2. Pre-Oxygenate � 3. Pre-medicate � 4. Put under=sedate � 5. Paralyze � 6. Pass the tube � 7. Post-Intubation Management

Prepare �Assess �Difficult Airway? �Gather Equipment=“Soap me” �Suction/02/Airway equipment/Pharmacology/Monitoring Equipment �Prep the Patient

Difficult Airway � Predictors of a difficult airway �Short Fat neck �Small receding chin �Presence of a beard �Large tongue �Trauma �Infection or tumor �Spinal disease �Low set ears �Swelling of the face or neck

What do you see?

Pedictors

Mnemonics, Mnemonics! � What are our tools to assess the difficult airway and problems we may encounter-What are the chances for success? �Lemon-intubation � L=Look Externally-abnormal face, sunken cheeks, narrow mouth, receding mandible, obesity � Evaluate the 3 -3 -2 rule=3 pt. sized fingers in mouth/Hyoid to chin 3 fingers/ 2 fingers from thyroid cart. to floor of mouth � Mallampati � Obstruction � Neck Mobility=can you extend and flex the neck

3 -3 -2

332

Mallampati

Mallampati scoring �Class I and II �Can see �Soft palate �Uvula �Class III and IV �Can see �Hard palate �Base of uvula

Obstructed Airway �Four Main signs �Muffled Voice �Difficulty Swallowing/Secretions �Stridor �Sensation of Dyspnea

Mnemonics � Moans=ventilating �Mask seal �Obstruction �Age �No teeth �Stiff Neck � RODS=extraglottic device �Restricted-mouth opening �Obstruction �Distorted-tumor or surgery �Stiff lungs-asthma , COPD, ARDS

Pre-Oxygenate �Two to Five minutes before the initiation of sedation and Neuromuscular blockade �Buys time during patients period of Apnea before they de-saturation �Allows for “Nitrogen Washout” � 100% 02 via NRB or BVM �Make sure equipment is operating 02 sat and Capnography

Desaturation Curve

Pre-Medicate �Why are we pre-medicating the patient? �What are we pre-medicating them with? �Atropine-Peds/Bradycardia �Lidocaine-Head Injury �Defasciculating Agents �What are they? � Vecuronium �Allow 2 -3 minutes for them to take effect.

Put Under Sedate � If pt. is paralyzed then they must be sedated � Multiple sedative agents available(Thiopental, Midazolam, lorazepam, fentanyl, ketamine, Etomidate, and propofol) �MCEMD agents Etomidate and Versed �Etomidate-Rapid onset, short acting, sedative-hypnotic agent �Onset-10 -15 seconds �Duration 5 -15 minutes �Dosage 0. 3 mg/kg �Versed-short acting rapid onset benzodiazepine �Onset-1 -3 minutes �Duartion-2 -6 hours �Dosage 2 -2. 5 mg slow ivp

Paralyze �Neuromuscular blocking agents �Depolarizing �Non-depolarizing �Examples �Succinylcholine �Precaution in burn patients/Patients with Renal Failure/Hyperkalemia �Vecuronium

Passing the Tube �Take a deep breath/relax �Make sure equipment is ready �Maintain c-spine & Monitor VS (ekg and Sp 02) �Pad behind the Pt. head to line up airway �Have partner use the BURP method

Relax

BURP �B=Backwards �U=upwards �R=right �P=pressure

Line Up �Lining up airway axis �Pad behind Pt. 's head �Head extension �Tragus with chest

Tragus to chest

Post-Intubation � 1. Confirm Placement �Tools �Visualize �Auscultate �Secondary devices � 2. Protect Placement �Secure � 3. Management �DOPE

Capnography What are good values=What to What Is this a good tracing? Why?

Esophageal

1 st, 2 nd 3 rd attempts? � 1 st attempt �Reposition patient �Pad more under head �Lift shoulder off the floor �Intubator same level as the Patient � 2 nd �Change blades �Hyper-flex the neck �Tools � 3 rd �Back-Up airways �BVM �Cricothyroidotomy

Back-Up airways �Combitube �LMA �King Airway

King Airway

Cricothyroidotmoy �CICO event=Can’t intubate-can’t oxygenate �Placement-find cricothyroid membrane �Equipment=scalpel et tube or quicktrach kit �Technique=Protocol dependent

Cric AP

Cric

Pediatric Airway �Adults VS. Pediatric �Larger tongue �Cricothyroid narrowest �More anterior �BVM VS. Intubation? �Transport=Time and distance? �Key Points �Premedicate �Atropine �Positioning �Padding under shoulders

Madison RSI �Look at handouts �Precautions �Preparation �Procedure �Airway Protection other than RSI

GMVEMS � {Sedate to intubate may only be utilized with department and medical director approval. Do not attempt if successful intubation is unlikely due to foreseeable complications. } � ADULT ONLY: � A Must be trained on, approved on and have equipment to perform a cricothyrotomy either open surgical or by device. � A Pre-oxygenate the patient. In order to reduce gastric distention, avoid using a BVM. � Apply a cardiac monitor and pulse oximeter. With suspected stroke, intracranial hemorrhage, head injury, or signs of increased intracranial pressure, administer Lidocaine 100 mg, IV. � Administer Etomidate 0. 3 mg/kg, IV (average initial dose is 15 -25 mg). Repeat initial dose within 2 minutes as needed. Apply cricoid pressure to reduce the possibility of aspiration and to facilitate intubation

Scenarios �#1 �Dispatched for MVA. Occupant ejected from vehicle. �Arrival-2 minor patients and another patient was ejected he is lying in a cornfield. Patient is unresponsive GCS of 5, RR of 8. Drivers license states his weight approx. 160 lbs bruising and swelling noted to face. �What airway problems do you expect? �How would you control this patients airway? �If you RSI this patient what medications would you give him? �What back-up airways would you consider?

Scenarios � #2 �Dispatched for ATV roll over. Family members are driving them to St. 291 � Arrival-One minor patient. Second patient is a 4 year old child located in the back of a pick-up. Patient is found to be unresponsive with a GCS of 3, RR of 4 -5, and has blood flowing from his nose and right ear. His jaw appears to be clenched. No swelling or other injury noted to face. Dad tells you he weighs 42 lbs. What airway problems do you expect? � How would you control this patients airway? � If you RSI this patient what medications would you give him? � What back-up airways would you consider? � In a Pediatric airway are there other issues to consider?

Ten Tips (adapted from Scott Synder article) � 1 -Place the patient in an optimal position to open airway �Sniffing/head elevated position

Tips � 2 -Use a BLS airway adjunct �Use several!!!!! �A OP and 2 NPA (wtf) � 3 - Use a jaw thrust maneuver � 4 -Use two rescuer BVM and Thenar eminence

TIPS � 5 -Long inspiration small tidal volumes �Manometer/SPO 2/Capnography, conjunction. � 6 -Did we mention positioning � 7 -Apneic Oxygenation during intubation � 8 -Use external manipulation �No cricoid pressure. Operator moves airway. � 9 -Endotracheal introducer (bougie) �Study-Increase from 66% to 96% � 10 -Confirm Placement!!!!!!!!