Rapid sequenceintubation venotheni ed
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This document provides guidance on intubation procedures to minimize the risk of gastric aspiration. It recommends inducing unconsciousness and paralysis prior to intubation without mechanical ventilation. It outlines the LEMON assessment method for evaluating difficult airways and provides checklists for equipment, staffing, patient positioning and monitoring. Drug options for induction and paralysis are presented along with dosages, onset times and durations. The full procedure from preparation to confirmation of tube placement is described.
Rapid sequenceintubation venotheni ed
- 2. The induction of a state of unconsciousness with complete neuromuscular paralysis to achieve intubation without interposed mechanical ventilation in efforts to facilitate the procedure and minimize risks of gastric aspiration Assumptions made : - patient not fasted - patient not known / assessed to be difficult intubation Decreased Aspiration !
- 7. Evaluate › LEMON Equipment Check – Mask – bag valve device, magills forcep, endotracheal tubes,laryngoscope, lubricants, different sizes of blades, airways, suction catheter, stylet, stetoscope, syringe, cricothyrotomy tray, Positioning Drug Selection – sedatives, paralysing agent IV’s, monitor – ECG, vitals, SpO2, Staff Anticipate alternative airway maneuver / difficult airway Anticipate difficult bag mask ventilation Anticipate vomitting - immediate suction with large bore Yankauer sucker - lateral / recovery position
- 9. LEMON assessment of difficult airway › L-look externally › E-evaluate ‘2-3’ rule › M-Mallampati score & grade of laryngeal view : Mallampati :- oropharygeal visualisation Cormack – Lehane : laryngoscope grading system › O-Obstruction › N-Neck mobility – sniffing morning air position
- 11. Mask Seal : bushy beard, crusted blood on the face, disruption of lower facial continuity, Obesity, Obstruction : obesity, pregnancy, angioedema,upper airway abscess, Age : > 55yrs old No teeth : consider leaving dentures in Sleep apnea, stiff lung : COPD, ARDS, asthma Can I Bag this patient ? Maybe Maybe not
- 13. Cormack – Lehane : laryngoscope grading system
- 15. 100% O2 for 5 minutes of 5 vital capacity breaths can theoretically permit 3-5 minutes of apnea before desaturation to less than 90% occurs “nitrogen wash-out” Avoid bagging the patient if adequately preoxygenated Well fitted mask
- 17. Goal is to blunt the patient’s physiologic responses to intubation Minimizes bradycardia, hypoxemia, cough/gag reflex, increases in intracranial, intraocular, and intragastric pressures Given 3 minutes prior to intubation
- 18. Lidocaine Opioid Atropine Defasciculating doses “priming”
- 22. Induction agent ( Dosage) Onset Full recovery ( duration ) Advantages Disadvantages Side Effect / caution Special uses Midazolam (0.1mg / kg ) 30-60s 0.5 – 2hrs Amnestic sedative Hypotension Suppresses respiration, cvs Etomidate (0.3mg / kg) 15 – 30sec 15 – 30min Cerebroprotective Heamodynamic stability Rapid onset, short duration Nausea, vomiting, pain on injection, myoclonic movements Hiccups Adrenal suppression Head injury Hypotensive patient Ketamine (2mg / kg) 15 – 30sec 15 – 30min Releases cathecholamines Analgesic amnestic Raised ICP Raised ICP Bronchospastic patient Hypotensive patient WITHOUT head injury Heamodynamically instability due to cardiac tamponade or myocardial disease Propofol (0.5 – 2.5mg / kg) 10 - 20sec 10-15min Decrease ICP Rapid onset Hypotension Bradycardia
- 24. Neuromuscular Blocking Agents Chemical paralysis facilitates intubation by allowing visualization of the vocal cords and optimizing intubating condition Only CONTRAINDICATION is anticipated difficult airway › Mallampati Class › Thyromental Distance
- 26. Onset : 45 sec, duration 8-10 min Dose: (adults :1.5 mg/kg IV, Children 2.0 mg/kg IV - Rapid onset, - Eliminated independently of renal excretion
- 27. Muscle fasiculations › Increase ICP/IOP › Causes muscle pain › Minimized by “priming” dose of NMB Hyperkalemia › Burns, crush injuries, spinal cord injuries, neuromuscular disorders, chronic renal failure Bradycardia › Most common in children <10 years due to higher vagal tone Malignant hyperthermia › From excessive calcium influx through open channels › Genetic predisposition › Rapid temperature, rhabdomyolysis, muscle rigidity, Trismus (Masseter spasm) › Children, - Unknown cause › Treat with a nondepolarizing NMB
- 28. Has the shortest onset of the nondepolarizing agents (1-3 min) Duration 30-45 min Tachycardia can occur Dose: 0.6-1.2 mg/kg
- 29. 45 seconds ONSET 1 minute 9 minutes DURATION 45 minutes 1 mg/kg1-2.5 mg/kg
- 31. Sellick’s Manoeuvre / application of cricoid pressure – initiated immediately upon obseration of patient losing consciousness Positioned for laryngoscopy
- 34. Tube placement confirmed with : - end tidal CO2 monitoring Clinical parameters: SpO2 monitoring, tube condensation Cricoid pressure released after confirmation of correct tube placement, endotracheal tube secured
- 36. Secure tube Continuous pulse oximetry Reassess vital signs frequently Obtain chest x-ray, ABG Restrain patient Consider long term sedation
- 38. 1. Emergency Medicine, Shirley Ooi 2. Current Emergency medicine, Lange. 3. Guideline For Resuscitation training, NCORT 4. Medscape