Rapid Sequence Induction

When anaesthetising patients for emergency surgery, anaesthetists use a process called a "rapid sequence induction". The objective is to secure the airway rapidly and prevent soiling of the lungs with gastric contents. We call this "the full stomach". This indicates that for some reason, the stomach is considered full of material; the patient need not have eaten recently. Reasons for having a "full stomach"

1. Recent meal 2. Delayed gastric emptying: trauma, acute abdomen, morphine. 3. Incompetant lower oesophageal sphincter: obesity, hiatus hernia, pregnancy

The patient goes asleep with the aid of an intravenous induction agent: thiopentone or propofol. These cause hypnosis and amnesia. To rapidly intubate the larynx, it is important to have a high degree of muscle relaxation very quickly. The drug used for this is suxamethonium. This acts by causing every muscle in the body to contract, and subsequently relax. The result of this is the sudden release of a lot of potassium into the bloodstream. Suxamethonium is contraindicated if there is hyperkalaemia, as it may cause cardiac arrest. Because it causes such widespread muscle contraction (rather like "cramping"), patients usually complain of muscle pains the next day. It is not conventional to premedicate patients undergoing rapid sequence induction or to administer sedatives such as midazolam or fentanyl prior to the administration of anaesthesia. The reason for this is that if you are unable to intubate the patient, then the anaesthetic agents will wear off and the patient will wake up within 5 mins, thus not putting the airway at risk. We avoid manually ventilating patients undergoing rapid sequence induction, as this inflates the stomach and encourages regurgitation. The procedure of rapid sequence induction:

1. Preparation: Drugs: thiopentone, suxamethonium, atropine, ephedrine. Endotracheal tubes: a variety of sizes available and cut and checked (to make sure that the cuff is intact -ie. Not punctures) Laryngoscopes 2 functioning laryngoscopes with a variety of blades. Suction on and under the pillow. A Gum elastic bougie to railroad the ETT is there is difficulty in placing the ett. An intravenous cannula, with a free-flowing drip

2. Monitoring: Blood pressure, ECG, pulse oximetery, end tidal CO2 (if available). 3. Assistant: This person must be familiar with the RSI process and be able to apply cricoid pressure. The cricoid carthilage is the ring felt below the larynx. If this is displaced posteriorly, because it is circular shaped and solid, it compresses and closes the oesophagus (which lies behind it). This prevents passive regurgitation of gastric contents. 4. Induction: The patient is preoxygenated for a full three minutes, to wash all of the nitrogen out of the lungs and create a resevoir of O2. Thiopentone is administered, cricoid pressure is applied, followed by suxamethonium.

The patient is asleep when the eyelash reflex is lost, and relaxed when fasciculation stops. The patient is intubated, the cuff inflated and the tube secured. Cricoid pressure is not released until the anaesthetist is happy that the tube is correctly placed. This is established by listening for bilateral breath sounds, observing uniform bilateral chest movement and an etCO2 trace (if available).

5. Anaesthesia

When the anaesthetist is happy that the airway is intact, he administers the remainder of the anaesthetic agents - fentanyl, nitrous oxide and the volatile agent which maintains anaesthesia (e.g. isoflurane). A non depolarising neuromuscular blocker may be added now to maintain muscle relaxation for the duration. 6. Emergence At the completion of surgery, the anaesthetic agent is turned off, 100% oxygen is administered, neuromuscular blockade is reversed and the patient is permitted to emerge from anaesthesia. The risk of aspiration of gastric contents is as high now as at the beginning. The airway is carefully cleaned with suction and the ett remains in situ until the patient is fully awake, lying on their side and is able to remove the tube themselves. Sellick Maneuver by Peter Bonadonna The Sellick Maneuver is performed by applying gentle pressure to the anterior neck (in a posterior direction) at the level of the Cricoid Cartilage. The Maneuver is most often used to help align the airway structures during endotracheal intubation. The real value of this procedure is often misunderstood and therefore, is often underutilized. The REAL value of the Sellick Maneuver is to provide a means to prevent gastric insufflation and vomiting during ventilations in an unprotected airway. BLS and ALS medics can direct a member of the resuscitation team to provide this maneuver early and continually until a properly placed endotracheal tube has been inserted. Remember that aspiration pneumonitis has a high mortality rate and proper use of this method can minimize its occurance. Study the images below. The Cricoid Cartilage is the only structure in the airway that completely encircles the air path. Because of this, it is the strongest part of the airway. Notice that gentle pressure on the anterior neck at the level of the Cricoid will pinch the soft esophagus between the spine and the Cricoid Cartilage. This effectivly increases the esophageal opening pressure, making it harder for air to enter the stomach. In the event that the stomach is already distended, this may reduce the chance of vomiting. Care should be taken to prevent excessive pressure which could collapse or injure the airway. In addition to this, efforts should be made to avoid "wide pressure" which could press and block off carotid and jugular vessels (C and J in the above photo).

Rapid Sequence Induction The trachea can be intubated by the methods already described above. Rapid sequence induction (RSI) is the use of pharmacologic agents to aid in establishing a definitive airway. Its use is common in the hospital setting. It is intended for those patients who are considered at risk of aspiration of stomach contents, the so - called full stomach patients; as an effort to decrease the potential occurrence of pulmonary aspiration. In the prehospital setting, any patient should be considered a full stomach and thus, at risk of aspiration. RSI has been made popular from its use in the operating room by anesthesiologists where the normal sequence of putting a patient to sleep is done in a more rapid fashion. But what exactly is meant by rapid sequence induction? Before we describe the technique some terms need to be defined: Induction = the use of pharmacologic agents, whether it be intravenous solutions or inhaled gases, that act on the brain to quickly move from consciousness to unconsciousness; to create a plane or level of anesthesia. Preoxygenation = the application of oxygen to the patient prior to attempting intubation. Premedication = the administration of medications prior to the induction of anesthesia; usually chosen with a particular purpose in mind. Cricoid Pressure = the use of gentle, continuos downward pressure on the cricoid cartilage of the larynx; intended to aid in protection from aspiration by compressing the larynx against the posteriorly located esophagus. Neuromuscular Relaxing Agents = drugs that produce a chemical paralysis of skeletal muscle. It must always be remembered that these agents only paralyze skeletal muscle, they offer no benefit of sedation or analgesia. Also called paralytic agents, neuromuscular blockers, skeletal muscle relaxants.

a.) Technique Normally, in non-emergent situations, the patient is given an induction agent which rapidly produces unconsciousness and apnea. At this point, there is a period of assisted ventilation and oxygenation via bag - mask ventilation to establish the presence of a patent airway as well as to determine the ability to oxygenate. This is performed before the administration of the neuromuscular relaxing agent (NMR). Once the presence of an airway is established and ventilation can be easily performed, the paralytic is given and intubation of the trachea follows shortly after. The difference in the performance of RSI is the exclusion of assisted ventilation once the patient is induced. The induction agent is immediately followed by administering the paralytic agent, thus the name rapid sequence induction. Preoxygenation is done prior to administering any agents and cricoid pressure is applied until airway establishment has been confirmed. A sample sequence follows:

All equipment is available and functional (laryngoscopes, ETT, suction, # 11 scalpel, pulse oximeter/end tidal CO2 monitor, ECG and BP monitor). IV access is established. Preoxygenation with non -rebreather mask or AMBU bag - valve assisted ventilations with the application of cricoid pressure. Premedications, if any, are administered. The induction agent is administered. The paralytic agent is given immediately following induction. Laryngoscopy and intubation is performed. Endotracheal tube placement is confirmed (listening for bilateral equal breath sounds, absence of breath sounds over the stomach, esophageal detector, presence of end tidal CO2, observing symmetrical chest expansion). Cricoid pressure is then released. Tube is secured. Patient is ventilated with additional paralysis and sedation as needed.

b) Indications Any patient at risk of aspiration, this includes the following;

patients with full stomach (any emergent case or trauma patient) pregnant patients patients with known reflux, hiatal hernia, or delayed gastric emptying

c) Contraindications The true contraindication to RSI is any patient who you may not be able to intubate or perform a cricothyroidotomy. Contrary to belief, the presence or suspicion of cervical spine injury (CSI) is not a contraindication of RSI. d) Cervical Spine Injury (CSI) The presence or suspicion of cervical spine injury is not a contraindication to performance of RSI. The technique can be performed safely if the proper patients at risk of such injury are identified and if the appropriate precautions are taken. When a patient at risk of CSI is in need of airway management and RSI is to be performed, an extra person is needed to stabilize the neck in the following fashion. Manual in-line axial stabilization (MIAS) is used to add protection against creating or causing further damage to the spinal cord. This is accomplished with the help of another provider who stabilizes the neck in a neutral position. By using both hands, the mastoid processes are grasped and the head and neck are maintained in a neutral position. To perform MIAS, three providers are needed; one for cricoid pressure, one for laryngoscopy and intubation, and another for MIAS. It is important to realize that the intention of MIAS is to provide stabilization and not traction of the cervical spine. Traction may cause distraction of any ligamentous injury and further damage an already compromised spinal cord. e) Failed Intubation In the event that an intubation attempt has failed, a backup plan should be ready. If the patient has been induced and given paralytics then this could be a true emergency. If this scenario occurs, it is important to maintain oxygenation via bag-valve ventilation with the constant use of cricoid pressure. Another attempt at laryngoscopy and intubation may be made if mask ventilation is possible and oxygenation, as measured by pulse oximetry, is adequate. A sample algorithm follows:

Cannot intubate Maintain cricoid and MIAS (if c-spine injury suspected) Bag-valve ventilation with 100% oxygen Reposition patient, attempt to optimize view, use GEB Reattempt laryngoscopy and intubation If unable to reintubate, but can bag-valve ventilate, maintain cricoid pressure and continue with bag-valve ventilation.

** If unable to bag-valve ventilate, go to surgical airway or airway adjunct (LMA, Combitube) if protocol allows Rapid Sequence Induction Rapid Sequence Intubation Book Chapter Page

I.

Warnings A. High risk procedure B. Must be able to control airway after use

II.

Indications A. Preparation for intubating a conscious patient

III.

Alternatives A. Consider Nasotracheal intubation of a conscious patient

IV.

Basic RSI Protocol A. B. C. D. E. Preparation and Preoxygenation Midazolam (Versed) 0.1 mg/kg IVP (5-6 mg) Apply cricoid pressure Succinylcholine 1 mg/kg IV (100 mg) Intubate

V.

RSI Protocol for Children under age 10 years A. B. Preparation and Preoxygenation Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg) 1. C. D. E. F. Prevents vagally stimulated Bradycardia

Midazolam (Versed) 0.1 mg/kg IVP Apply cricoid pressure Succinylcholine 2 mg/kg IV Intubate

VI.

RSI protocol for high ICP or penetrating Eye Injuries A. B. Preparation and Preoxygenation Prevent ICP rise 1. 2. 3. C. Lidocaine 1.5-2 mg/kg IV Vecuronium .01 mg/kg IV (defasciculating dose) Consider Fentanyl 3 ug/kg IVP

Prevent Vagally stimulated Bradycardia

1. D.

Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg)

Sedation 1. 2. Etomidate 0.3 mg/kg IVP OR Thiopental (Pentothal) 4 mg/kg IVP (IF BP stable)

E. F.

Apply cricoid pressure Muscle relaxants/Paralytic Agents 1. 2. Succinylcholine 1.5 mg/kg IV (2 mg/kg if <10 yo) OR Vecuronium 0.2 mg/kg IV

G. VII.

Intubate

General RSI Protocol (All Options) A. Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg) 1. B. Prevents vagally stimulated Bradycardia

Consider Increased Intracranial Pressure management 1. 2. Lidocaine 1 mg/kg IV (Prevents ICP rise) Fentanyl 3 ug/kg IVP

C. D.

Consider Vecuronium 1 mg (defasciculating dose) Sedation 1. Preferred medications a. b. 2. Etomidate 0.2-0.3 mg/kg IVP Midazolam (Versed) 0.1 mg/kg IVP

Other options a. b. Thiopental (Pentothal) 3-5 mg/kg IVP Ketamine 1-2 mg/kg IV

E.

Muscle relaxants/Paralytic Agents 1. 2. 3. Succinylcholine 1-1.5 mg/kg IV, 2-4 mg/kg IM Vecuronium (Norcuron) 0.1 mg/kg IV Pancuronium (Pavulon) 0.1 mg/kg IV

VIII.

Special Circumstances

A.

Status Asthmaticus 1. Use Ketamine as the sedating agent

B.

Congestive Heart Failure 1. 2. 3. Use Etomidate for Sedation Use Vecuronium for paralysis Avoid Thiopental, Succinylcholine

C.

Status Epilepticus 1. Use Thiopental to sedate (raises Seizure threshold)

D.

Multiple trauma or hemorrhagic shock 1. Use Etomidate for Sedation