1	Difficult Airway and Rapid Sequence Intubations Dr. Pamela Ramsey
2	Is there a need for airway management? Failure of airway maintenance and protection. Unconscious or nearly conscious No gag reflex, cannot protect own airway Trauma patient Injury to mouth, nose, neck Blood or vomit Foreign body: choked on an object Failure to breath or oxygenate Respiratory distress: asthma: wheezing Pneumonia Heart failure: pulmonary edema Epiglottitus or croup Expected Clinical Course: what patients can be expected to have trouble? Stab wound, neck injury with expanding hematoma Abscess or tumor mass to neck Multiple trauma or burn patient, hypotension, decreasing level of consciousness, pneumothorax
3	Approach to the patient Adequacy of airway Can they speak? Normal voice: no stridor Able to inhale and exhale Inspect mouth Blood, loose teeth, swollen tongue Long protruding upper teeth Small mouth opening Short jaw Short neck Decreased range of motion of neck Beard Obesity Listen Decreased breath sound Fluid, blood, pneumonia Pneumothorax Tension pneumothorax Flail chest Measure O2 Arterial blood gas
4	The Seven P’s of Rapid Sequence Intubation Definition of “Rapid Sequence intubation” Administer a potent induction or sedation agent followed immediately by a rapid acting neuromuscular blockage or paralytic agent Reasons to use this technique: Need intubation but struggling or combative because of hypoxia, drugs, or trauma Teeth Clenched, unable to open mouth Patient has not fasted, recently eaten, at risk for aspiration The seven P’s of RSI Prepare Pre-oxygenate Pretreatment Paralysis Protection and positioning Placement and proof Post-intubation management
5	The 7 P’s of RSI continued… Prepare IV O2: nasal canula or face mask Cardiac monitor Equipment: Laryngoscope and blade, with functioning light Endotracheal tube Stylet Medication ready Personnel ready Preoxygenate: Nasal canula or face mask Bag mask ventilation if necessary Gives you more time to do intubation or other airway techniques before respiratory collapse Pretreatment drugs for RSI Lidocaine: 1.5 mg/kg 1v over 4 minutes to decrease bronchospasm and decrease intracranial pressure Opioids- fentanyl: pain, heart disease Atropine: for children less than the age of ten. Defasicualation: Vecuronium to increase ICP and to decrease fasciculation and decrease aspiration
6	The 7 P’s of RSI continued… Paralysis with induction Sedation charges: Thiopental (pentothal 3-5 mg/kg/hr) Benzodiazepines Midazolam 0.7 mg/kg/hr (Versed) Lorazepam 0.1 mg/kg/hr (Ativan) Diazepam 0.3 – o.5 mg/hr (Valium) Etomidate: very popular now: .15 -.3 mg/Kg/hr, rapid onset, less hypotension Ketamine: good with sever asthma: 1-2 mg/kg Paralytic agent Succhinylcholine profound paralysis in 45 seconds and duration of less than 10 minutes Adverse affects: Fasciculations Hyperkalemia Increased intracranial pressure Increased Intraocular pressure Not good for patients with old burns, old crush injuries, or muscular dystrophy Do not use for head or eye injuries or in renal failure. Dose: 1.5 mg/kg IV Rocuronium: nondepolarizing agent Disadvantage: longer time to onset and longer duration of action So if you fail to intubate, it will require longer rescue breathing.
7	The 7 P’s of RSI continued… 5. Protection and positioning: After giving paralytic and induction agent, apply Sellick maneuver, firm pressure on cricoid cartilage to prevent regurgitation and prevent aspiration of vomitus into lungs 6. Placement and proof: i. Placement: 45 seconds after administration of succinylcholine, intubate patient. Place laryngoscope in open mouth, sweep tongue to the side, visualize vocal cords, pass the endotracheal tube through the cords, remove the stylet, inflate the balloon, connect the bag, and ventilate the patient. ii. Proof: End tidal CO2 detector (not useful in cardiac arrest) Esophogeal detection device (not useful if patient has been bagged for a prolonged period) Continuous end tidal CO2 monitors (expensive technology, but most accurate) 7. Post Intubation Management: i. secure endotracheal tube with commercially available device or tape ii. Chest X-RAY to confirm placement iii. Continued sedation and paralysis:
8	Sequence of RSI Preparation: Zero minus 10 minutes Preoxygenate: Zero minus 5 minutes Premedicate: Zero minus 3 minutes Paralysis with induction: Zero Protection: Zero plus 20-30 seconds Placement: Zero plus 45 seconds Post Intubation Management: zero plus 1 minute