INTUBATION DR.MANISHA(RSI & DSI).pptx ppt
- 2. RAPID SEQUENCE INTUBATION RAPID SEQUENCE INTUBATION IS THE VIRTUALLY SIMULTANEOUS ADMINISTRATION OF A SEDATIVE AND A NEUROMUSCULAR BLOCKING (PARALYTIC)AGENT TO RENDER A PATIENT RAPIDLY UNCONSCIOUS AND FLACCID IN ORDER TO FACILITATE EMERGENT ENDOTRACHEAL INTUBATION TO MINIMIZE THE RISK OF ASPIRATION
- 3. DELAYED SEQUENCE INTUBATION A TECHNIQUE FOR PATIENTS REQUIRING EMERGENT AIRWAY MANAGEMENT BUT WHO ARE RESISTENT TO PRE INTUBATION PREPARATIONS BECAUSE OF ALTERED MENTAL STATUS
- 5. ADVANTAGES OF RSI FACILITATES AND EXPEDITES ENDOTRACHEAL INTUBATON (INCREASED SUCCESS RATE) (DECREASED TIME TO INTUBATE) MINIMIMIZES TRAUMA DURING LARYNGOSCOPY MINIMIZES HYPOXIA MINIMIZES HYPERCAPNIA MINIMIZES RISK OF ASPIRATION MINIMIZES HEMODYNAMIC EFFECTS OF INTUBATION
- 6. INDICATIONS: INABILITY TO MAINTAIN AIRWAY PATENCY. ACUTE RESPIRATORY FAILURE DUE TO POOR OXYGENATION OR VENTILATION PERSISTENT HYPOXIA ACUTE UPPER GASTROINTESTINAL BLEED WITH A HIGH RISK OF ASPIRATION LOW GCS (8/15) IMPENDING AIRWAY OBSTRUCTION FACIAL FRACTURES NO ORAL EXCESSIVE ORAL BLEEDING FACIAL BURNS INHALATION INJURY EXPANDING RETROPHARYNGEAL HEMATOMA EXCESSIVE WORK OF BREATHING REFRACTORY SHOCK
- 7. CONTRAINDICATIONS: • COMPLETE UPPER AIRWAY OBSTRUCTION • LOSS OF FACIAL OR OROPHARYNGEAL LANDMARKS, WHICH WILL REQUIRE A SURGICAL AIRWAY TO BE PLACED. • RELATIVE CONTRAINDICATION: PROCEDURAL FAILURE DUE TO INJURIES TO THE AIRWAY, ANATOMIC ABNORMALITIES, • THESE RELATIVE CONTRAINDICATIONS CAN BE EVALUATED BY L.E.M.O.N. AND CORMACK LEHANE GRADING SYSTEM
- 10. LEMON GRADING:
- 11. SEVEN ‘‘ P’’ OF RSI PREPARATION PREOXYGENATION PRETREATMENT PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT WITH PROOF POST INTUBATION MANAGEMENT
- 12. PREPARATION :(10 MINS BEFORE INTUBATION) CHECK ENDOTRACHEAL TUBE STYLET BLADES SUCTION BVM CARDIAC MONITORING ETCO2 ONE(PREFERABLY TWO) IV LINES DRUGS DIFFICULT AIRWAY KIT INCLUDING CRIC KIT PATIENT POSITIONING
- 13. PREOXYGENATION:(5 MINUTES) ADMINSTRATION OF 100% OF OXYGEN 3 MINUTES OF NORMAL TIDAL VOLUME BREATHING IN HEALTHY ADULTS WITH PERMISIBLE 6-8 MINUTES OF SAFE APENIC PERIOD PREOXYGENATION IS ALSO ESSENTIAL STEP IN NON BAGGING APPROACH IN RSI DESATURATION IN OBESE PATIENTS CAN BE REDUCED BY HEAD UP POSITION AND BY CONTINUING SUPPLEMENTAL OXYGEN AFTER PARALYSIS AND INSERTION OF SCOPE TILL ETT IS PLACED CONSTANT DIFFUSION OF ALVEOLAR OXYGEN INTO THE PULMONARY CIRCULATION CREATES A NATURAL DOWNWARD GRADIENT WITH PASSIVE OXYGEN FROM UPPER AIRWAY INTO LUNG GASEOUS PORTIONS.
- 14. PRETREATMENT:(3MINUTES) • DRUING THIS PHASE ,DRUGS ARE ADMINISTRED 3 MINUTES BEFORE THE ADMINISTRATION OF MUSCLE RLEXANTS AND AN INDUCTION AGENT TO MITIGATE THE ADVERSE PHYSIOLOGIC EFFFECTS OF LARYNGOSCOPY AND INTUBATION . • PRE TREATMENT APPROACH DOWN TO THE BARE ESSENTIALS WITH A FOCUS ON OPTIMISING PATIENT’S PHYSIOLOGY PRIOR TO ANY INTUBATION ATTEMPT . • INTUBATION IS INTENSLY STIMULATING AND RESULTS IN A SYMPATHETIC DISCHARGE DISCHARGE OR REFLEX SYMPATHETIC RESPONSE TO LARYNGOSCOPY (RSRl)
- 15. • IF A PATIENT SUFFERING FROM HYPERTENSIVE EMERGENCY , SYMPATHOLYSIS FENTANYL (3 MCG /KG IV) • ADMINISTER 3 MIN BEFORE RSI CAN OPTIMISE THE PATIENT HEMODYNAMICS BY ATTENUATING SPIKES IN BP AND SHEER FORCES . • PATIENT WITH REACTIVE AIRWAY DISEASE CAN EXHIBIT WORSENING PULMONARY MECHANISM AFTER INTUBATION AS A RESULT OF BRONCHOSPASM .
- 16. CONTROVERSISES • CONTROVERSIES EXIST REGARDING WHETHER LIDOCAINE (1.5 MG/KG IV ) CONFERS ANY ADDITIONAL BENEFITS BEYOND ALBUTEROL AND SHOULD BE CONSIDERED OPTIMAL AND BEST . • ASTHMA PATIENT BEING INTUBATED IN ED FOR STATUS ASTHMATICUS WILL HAVE RECEIVED ALBUTEROL BEFORE INTUBATION . • UNLIKELY IN THIS PATIENT LIDOCAINE HAS ADDITIVE , PROTECTIVE EFFECT . • LIDOCAINE HAS A VANISHING ROLE IN AIRWAY MANAGEMENT AND MAY DISSAPEAR IN NEAR FUTURE .
- 17. REACTIVE AIRWAY DISEASE ALBUTEROL 2.5 MG BY NEB. IF TIME DOES NOT PERMIT ALBUTEROL NEB . GIVE LIDOCAINE 1.5 MG/KG REFENCE FROM :TEXTBOOK ROSEN’S(10TH EDITION)
- 18. PARALYSIS WITH INDUCTION: HEAD INJURY OR STROKE: GOAL IS TO MAINTAIN ADEQUATE CEREBRAL PERFUSION AND MAINTAIN ARTERIAL PRESSURE.
- 19. ETOMIDATE: (0.3MG/KG) EXCELLENT SEDATION AND DOES NOT CAUSE HYPOTENSION
- 20. KETAMINE: (1-2MG/KG) USESED IN (SEPTIC SHOCK,BRONCHOSAPSM ,AND HYPOTENSION) HEAD INJURY AVOID IN CEREBRAL HEMORRHAGE
- 21. STATUS EPILEPTICUS MIDAZOLOM (0.2-0.3MG/KG) CAN CAUSE HYPOTENSION,USE ETOMIDATE IF PATIENT HAS HEMODYNAMIC COMPROMISE
- 22. BRONCHOSAPASM: HEMODYNAMICALLY STABLE: USE KETAMINE,PROPOFOL,ETOMIDATE,MIDAZOLOM HEMODYNAMICALLY UNSTABLE:KETAMINE OR ETOMIDATE
- 23. CARDIOVASCULAR: ETOMIDATE PREFERRED IN CAD AND AORTIC DISSECTION USE FENTANYL AS A PRETREATMENT
- 24. SHOCK: • ETOMIDATE OR KETAMINE • IF REFRACTORY SEPTIC SHOCK WITH ETOMIDATE GIVE HYDROCORTISONE
- 25. NEURO MUSCULAR BLOCKING AGENT DEPOLARISING AGENT: SUCCINYLCHOLINE (1.5MG/KG) BIND TO ACH RECPTOR PRODUCES FASICULATION AND PARALYSIS RAPID ONSET(45-60 SEC) OFFSET(6-10 MINS) NON DEPOLARIZING: ROCURONIUM,VECRONIUM ROCURONIUM SHORT ONSET (45-60 SEC) (1MG/KG) VECURONIUM (0.15MG/KG) ONSET ABOUT( 90SEC)
- 27. RAMP POSITION : • HORIZONTAL ALINGMENT BETWEEN STERNAL NOTCH AND EXTERNAL AUDITORY MEATUS • USE: • PROVIDES SUPERIOR LARYNGEAL VIEW COMPAREED TO OTHER POSITIONING • IMPROVES GLOTTIS VIEW IN OBESE PATIENTS • MODIFIED RAMP • POSITIONING WITH SPECIAL PILLOW ( HASANIN PILLOW)
- 28. SNIFFING POSITION: • A COMBINATION OF FLEXION OF THE NECK AND EXTENSION OF HEAD (30 to 35 degree) • PROVIDE A SUPERIOR GLOTTIC VISUALIZATION, DURING DIRECT LARYNGOSCOPY, ENHANCING THE EASE OF INTUBATION. • Axis of sniffing : LA = LARYNGEAL AXIS; MA = MOUTH AXIS; PA = PHARYNGEAL AXIS
- 30. SELLICKS’MANEUVER: LOCATE THE CRICOID CARTILAGE BY PALPATING THE THYROID CARTILAGE AND FEEL THE DEPRESSION JUST BELOW IT(CIRCOTHYROID MEMBRANE) USING YOUR THUMB AND INDEX FINGER OF ONE HAND,APPLY PRESSURE TO ANTERIOR AND LATERAL ASPECTS OF THE CRICOID CARTILAGE JUST NEXT TO THE MID LINE
- 35. PLACEMENT WITH PROOF:(45 SECONDS) • FLACCID IS ACHIEVED AND LARYNGOSCOPY IS PERFOMED • CONFIRMATION OF PROPER ENDOTRACHEAL TUBE PLACEMENT IN CRUCIAL • END TIDAL DETERMINATION (ETCO2) • VISUALIZATION OF ETT THROUGH THE CORDS • MISTINGOF THE TUBE WITH VENTILATION • 5 POINT ASCULTATION (SOUND INSUFFICIENT MEANS TO CONFIRM TRACHEAL PLACEMENT)
- 37. POST INTUBATION MANAGEMENT:(2MINUTE S) PROVIDE ADEQUATE LONG TERM SEDATION ,ANALGESICS AND PARALYTIC AGENT IF REQUIRED MECHANICAL VENTILATION IS INITIATED POST PROCEDURAL CHEST XRAY IS OBTAINED TO CONFIRM DEPTH OF TUBE PLACEMENT AND TO EVALUATE FOE EVIDENCE OF BAROTRAUMA AS ACONSEQUENCE OF POSITIVE PRESSURE VENTILATION. REASSES ABG REASSES VITALS PROPERLY PLACED ENDOTRACHEAL TUBE IS SECURED
- 38. RECENT RESEARCHES - (International anaesthesia research society ) • EFFICACY OF THE BURP MANEUVER DURING A DIFFICULT LARYNGOSCOPY – • BRUP MANEUVER IMPROVED VISUALIZATION OF THE LARNYX MORE EFFECTIVELY THAN SIMPLE BACK PRESSURE ON LARNYX . ITS SHOULD BE INCLUDED IN ROUTINE METHODS FOR VISUALIZATION OF LARNYX.
- 39. REFERENCE : • TINTINALLI’S BOOK OF EMERGENCY MEDICINE - 9th edition • ROSENS BOOK OF EMERGENCY EDITION -10TH edition • INTERNATIONAL ANESTHESIA RESEARCH SOCIETY
- 40. THANK YOU