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Intubating in the ED - RSI, DSI and Beyond...

A talk for residents managing critical patients. Material based on current practices and literature, may not reflect your local standard of care. Be sure to use standard references for all procedures and medication dosing.
by

David Marcus

on 6 September 2017

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Transcript of Intubating in the ED - RSI, DSI and Beyond...

http://vimeo.com/18057952
David Marcus, MD
Combined Residency in Emergency and Internal Medicine
LIJ Medical Center, New Hyde Park, NY
July 11th, 2012
Intubating in the ED - RSI, DSI and Beyond...
Goals
RSI vs DSI
Pharma Review
Oxygen Management
Traditional General Sedation + Intubation vs. Rapid Sequence Intubation vs. Delayed Sequence Intubation
(Anesthesiologists do it slower) (ED Docs do it faster) (Intensivists make it last)
Let's talk about our options for a second:
Example #1
Example #2
Example #3
75 yr old M, obtunded, impending respiratory failure in setting of septic shock.
42 yr old F with ESRD p/w AMS and massive intracranial hemorrhage
43 yr old M, severe asthma, RR 16, maximal O2 sat = 79%
RSI:
Preox/Denitrogenation
Premedication
Sedation + Paralysis
Intubation
Maintenance
No pauses!!!
Why RSI?
Increased first pass success
Decreased risk of aspiration
Decreased risk of stomach insufflation
Decreased mortality
Premedicate? Sedate? Paralyze? Maintain?
Lidocaine - 1.5 mg/kg (100-150 mg)
Indications:
Theoretical prevention of ICP bump during intubation in patients sensitive to increased ICP. If used, must be given 3-5 minutes prior to pharyngeal manipulation.
Contraindications:
Hypotension, Allergy, Bradydysrrhythmias
Fentanyl - 1-3 mcg/kg (70-300 MICROgrams)
Indications:
Same as Lidocaine premedication, also, ischemic heart disease, AAA, aortic dissection
Contraindications:
?resp depression
Etomidate - 0.3 mg/kg (20-30 mg)
Onset:
15-30 seconds Duration 5-10 minutes
Indications:
Induction. Benign hemodynamic profile.
Contraindications:
May increase seizure activity, Controversial in sepsis - transient adrenal suppression, and association between adrenal suppression and mortality (no causative relationship found...)
Propofol - 2-2.5 mg/kg (< 55 yrs old = 140-250 mg);
1-1.5 mg/kg > 55 yrs old = 70-150 mg)
Onset:
15-45 seconds, Duration: 5-10 minutes
Indications:
Induction of hemodynamically stable or in Status Epilepticus; Bronchodilator
Contraindications:
Hypotension, egg or soy allergy
Midazolam (Versed) - 0.1 mg/kg (7-10 mg)
Onset:
60-90 seconds, Duration: 15-30 minutes
Indications:
Induction if other agents contraindicated/unavailable
Contraindications:
Hypotension, myocardial depression
Ketamine - 2 mg/kg (140-200 mg)
Onset 45-60 seconds, Duration 10-20 minutes
Indications:
Induction. Bronchodilator. Increases HR and MAP (may be useful alternative to Etomidate in septic shock)
Contraindications:
Caution in normo/hypertensive patients, ischemic heart disease. (Elevated ICP?) Fear of emergence reactions in adults, may combine with Midazolam or Propofol.
Fentanyl - 1-3 mcg/kg (70-300 MICROgrams)
Indications:
Induction. Relatively minimal hemodynamic effects.
Contraindications:
?resp depression
Succinylcholine - 1.5 mg/kg IV (100-150 mg); 4 mg/kg IM (300-400 mg)
Onset:
45 seconds, Duration: 6-8 minutes
Indications:
1st line paralytic. Fast on, Fast off.
Contraindications:
Many, due to risk of hyperkalemia. Falling out of favor?
Hyperkalemia with ECG changes
Burn > 72 hrs
Rhabdomyolysis
Should not be given in renal failure, though no evidence of adverse outcomes in this population (may be given if no other agents available).
Risk of Bradycardia (not preventable by Atropine, but Atropine responsive).
Sepsis > 5 days
Muscular dystrophy or other denervating neuromuscular disease
Stroke > 72 hrs.
History of Malignant Hyperthermia (personal or family)
IF Malignant Hyperthermia ---> DANTROLENE - 1 MG/KG IV
Rocuronium - 1.2 mg/kg (70-100 mg)
Onset:
45 seconds, Duration 45-60 minutes
Indications:
1st line paralytic for many. Equally effective as Sux. Several studies have demonstrated longer safe apnea times.
Contraindications:
Allergy. Prolonged duration of action.
Reversal: Sugammadex
- If in Europe... Also effective for Vec and Pancuronium (though less so)
Vecuronium - 0.1 mg/kg (7-10 mg)
Onset:
75-90 seconds, Duration 60-75 minutes
Indications:
Other agents unavailable.
Contraindications:
Allergy. Prolonged duration of action.
Propofol gtt - 0.1-0.2 mg/kg/min (< 55 yrs old = 7-20 mg/min);
0.05-0.1 mg/kg/min (> 55/debilitated = 3-10 mg/min)
Indications:
Maintenance, analgesia, anxiolysis.
Contraindications:
Hypotension, myocardial depression. Over time, accumulates in fatty tissues/redistribution.
Fentanyl gtt - 1-3 mcg/kg/hr (70-300 mcg/hr)
Indications:
Maintenance, analgesia, anxiolysis.
Contraindications:
Respiratory suppression. Hemodynamic effects.
Midazolam (Versed) gtt - 0.05 - 0.1 mg/kg/hr (3.5 - 10 mg/hr)
Indications:
Maintenance, anxiolysis
Contraindications:
Hypotension, BDZ contraindication
s,
prolonged effect
Ketamine gtt - 0.1-0.5 mg/min
Indications:
Maintenance, dissociation with maintenance of reflexes in lower doses.
Contraindications:
Elevated BP/ICP.
The Vigilant Provider
Monitors, and responds to:
Sedation
BP
Saturation
Patient/Vent Discordance
The Vigilant Provider
Panta rhei
All things are flowing...
Don't let your patient desat!
Sat < 70%:
Dysrrhythmia
Hemodynamic collapse
Hypoxic brain injury
Death
TALKING ABOUT OXYGEN MANAGEMENT
Pre-induction
The Apneic Period
Post-Intubation
Prexoygenation: Give it more than 100%!
Aim for 100% O2 Sat
Denitrogenate lungs
Denitrogenate blood
Preferred technique:
Seated or head elevated position (> 20 deg.), Reverse Trendelenburg as alternative.
"Partial Non-Rebreather" mask to maximal O2 flow for 3 minutes "regular" breathing or 8 maximal inhalations/exhalations
Achieve O2 Sat > 95%!
Alternative:
BVM connected to O2 for preox. -
ONLY

IF
sealing to face and
actively
assisting patient!
If O2 sat < 90% despite the "preferred technique":
Attempt NIPPV
: BiPAP/CPAP or BVM+PEEP Valve!
Outcomes mixed, mostly increasing safe apnea time
NO evidence of hemodynamic risk
NO increased risk of gastric insufflation (keep pressures < 25 cmH2O)
Consider this step also if Sat < 95%
Safe apnea?
Keep O2 mask on patient until introducing blade!
Up to 8 minutes in healthy individuals
20-30 seconds in critically ill
Immediate
desaturation in ill patients who could not be preoxygenated
Apenic Oxygenation
CO2
O2 (x10!)
Net negative pressure can maintain PaO2 > 100 mmHg for up to 100 (!!!) minutes
(not in the ED population)
Apneic Oxygenation can add
MINUTES
to your safe apnea time
Practice Safe Apnea
NODESAT: Nasal Oxygenation During Efforts Securing A Tube (Levitan)
O2 via nasal cannula at 15 LPM through apneic period
NOT affected by open mouth
May add nasal trumpets as needed
Bagging while apneic?
Not a great idea
Keep pressures to a minimum (< 25 cmH2O)
Do, gently, only if hypoxemic or severe metabolic acidosis
Consider for high-risk of desaturation
Practicing Safe Apnea - Positioning
IDEAL POSITION: FACE PARALLEL TO CEILING
External auditory meatus to sternal notch
Head elevated relative to body
Head-tilt/Chin lift or Jaw thrust
May need to ramp patient's back!
Practicing Safe Apnea - Do You Cricoid?
(...but honey, everyone else does!)
Lateral esophageal displacement
Makes ventilation more difficult
May not be a great idea
Consider Thyroid cartilage manipulation, i.e. Bimanual Laryngoscopy instead
BVM with PEEP valve (5-15 cmH2O)
Keep nasal cannula on until tube confirmed
100% FiO2 and decrease as tolerated
DSI
Your Acute Pulmonary Edema patient weighs 350 lbs!
Air hunger doesn't begin to describe this guy!!
He's tearing off the NRB!!!
O2 sat is 75%!!!!!
Delayed Sequence Intubation
(Think of it as PROCEDURAL SEDATION for PREOXYGENATION)
1) Moderate sedation (avoiding respiratory suppression)
2) Preoxygenation CPAP (or NRB)
3) Maintain Sat > 95% for 3 minutes
4) RSI, if still warranted
Pharmacology
Ketamine - 1-2 mg/kg (70-200 mg) SLOW IV Push
Pro: Onset within 30 sec. No respiratory depression, maintain reflexes
Con: Increased BP, ICP, Sympathetic tone
Dexmedetomidine (Precedex) - 1 MICROgram/kg (70-100 MICROgram) over 10 minutes
Pro: No respiratory depression, maintain reflexes, Alpha2 agonist, not sympathomimetic.
Con: 3-5 minute onset, 10 minute infusion, (cost?), hypotension
Wrapping Up
Meds:
Choose carefully, dose appropriately, consider different meds
Consider Roc instead of Sux
Consider alternatives to Etomidate in sepsis

RSI and Preoxygenation:
Low risk for desat = Sat > 95% for at least 3 minutes on 100% NRB
High risk = Sat < 95% despite NRB for 3 minutes
If sat < 90%, and for some high risk, try NIPPV for preox.
Always use Nasal Cannula@15LPM, and PEEP valve on BVM

Delayed Sequence Intubation:
For hypoxemic or high risk patient who cannot tolerate preoxygenation
Ketamine 1-2 mg/kg IV slow push (70-200 mg)
or
Dexmedetomidine 1mcg/kg over 10 minutes
Then, CPAP (or NRB) for 3 full minutes at Sat > 95%, then RSI

Post-Intubation Care:
ED Docs undersedate, don't torture your intubated patients

(Weingart)
http://emcrit.org/podcasts/post-intubation-sedation/
Dexmedetomidine (Precedex) - 1 MICROgram/kg (70-100 MICROgram) over 10 minutes, then 0.7-0.7 MICROgram/kg/hr (approved for up to 24 hours)
Pro: No respiratory depression, maintain reflexes, Alpha2 agonist, not sympathomimetic.
Con: 3-5 minute onset, 10 minute infusion, (cost?), hypotension
The famous awake intubation video, residents beware...
Resources
References
Ahn, J, Bryant, A.
Focus On: Rapid Sequence Intubation Pharmacology.
http://www.acep.org/Clinical---Practice-Management/Focus-On--Rapid-Sequence-Intubation-Pharmacology/ Accessed online: July 7, 2012.
Emergency Medicine Residents' Association (EMRA) Resuscitation Medication Card (pictured). 2011.
Mallon et al.
Rocuronium vs. succinylcholine in the emergency department: a critical appraisal.
J Emerg Med. 2009 Aug;37(2):183-8.
Strayer, R.
Rocuronium vs. Succinylcholine Revisited
. Letter to the Editor. DOI: http://dx.doi.org/10.1016/j.jemermed.2009.08.070
Weingart, S.
Preoxygenation, Reoxygenation and Deoxygenation
. http://emcrit.org/preoxygenation/
Weingart, S, Levitan, R.
Preoxygenation and prevention of desaturation during emergency airway management.
Ann Emerg Med. 2012 Mar;59(3):165-75.e1.
EM/CC Resource:
www.emcrit.org (Dr. Scott Weingart)
All things EM:
http://lifeinthefastlane.com/
Post intubation sedation
: http://emcrit.org/podcasts/post-intubation-sedation/
DSI:
http://emcrit.org/podcasts/dsi/
All you ever wanted to know about AW/O2 mgm't
: LITFL Own the Airway: http://lifeinthefastlane.com/2011/02/own-the-airway/
For Med-Students/Intubation/AW Mgm't:
http://shortcoatsinem.blogspot.com/2012/05/medical-student-perspective-web.html
Full transcript