EMERGENCY ROOM RAPID SEQUENCE INTUBATION

Pre – Oxygenation: 5 minutes non-rebreathing mask at 10 L/min or BVM at 15 L/min. Mask seal should be complete

Pre – Medications: 3 minutes before intubation. Usually optional except atropine in pediatric patient. All doses adult and pediatric.

1. Lidocaine: 1.0 – 1.5 mg/kg over 30 – 60 sec. to blunt intracranial and intraocular pressure spikes.

2. Fentanyl: 2.0 mcg/kg slowly over 3-5 minutes to blunt intracranial and arterial pressure surges.

3. Atropine: 0.02 mg/kg - children <10 years

4. Pancuronium: 0.01 mg/kg (defasciculating dose) or

5. Rocuronium: 0.1 mg/kg (defasciculating dose)

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Induction – Use 1 sedation and 1 paralysis medication IV push. All doses adult and pediatric.

Sedation:

1. Midazolam: 0.1 – 0.3 mg/kg

2. Etomidate: 0.3 mg/kg slowly over 30-60 sec

3. Thiopental: 2-5 mg/kg slowly over 30-60 sec.

4. Ketamine: 2 mg/kg

Paralysis:

1. Succinylcholine: 1-2 mg/kg

2. Rocuronium: 1.0 mg/kg

3. Pancuronium: 0.1 mg/kg

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Tube Placement and Confirmation:

1. OK to remove c-spine collar if in-line stabilization is being provided.

2. Use end-tidal CO₂ detector to confirm placement.

· Failed intubation: Review Airway Algorithms.

· Can ventilate with bag and mask (BMV) – re-attempt optimal intubation – maximum 3 attempts in total.

· Cannot intubate after 3 failed attempts – failed airway - consider placing LMA or combitube and prepare for cricothyrotomy.

· Cannot ventilate with BMV using optimal mask ventilation – failed airway – consider placing an LMA (Laryngeal Mask Airway) or Combitube and prepare for cricothyrotomy.

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Post – Intubation:

1. Pancuronium: 0.05 - 0.1 mg/kg q ½ - 1h prn

2. Midazolam: 1 – 3 mg/hr

3. Morphine: 1 – 5 mg/hr.

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Sources

Adapted from:

1. Interior Health ER Rapid Sequence Induction Worksheet 2003.

2. Bi-International Trauma Anesthetic and Critical Care Seminars 1999

3. Yeung JK, Zed PJ. Review of etomidate for rapid sequence intubation in the emergency department. CJEM 2002; 4(3): 194-198.

4. Thompson J, Irvine H, Dodd G. The occasional rapid sequence intubation. In: Hutten-Czapski P, Magee G, Wootton J, Editors. Manual of Rural Practice. Shawville, Quebec: 2006. p 7-18.

5. Trevisanuto D, Verghese C, Doglioni N, Ferrarese P, Zanardo V. Laryngeal mask airway for inter-hospital transport of neonates. Pediatrics 2005;115:e109–e111. URL: http://pediatrics.aappublications.org/cgi/reprint/peds.2004-1468v1

6. Martin SE, Ochsner MG, Jarman RH, Agudelo WE, Davis FE. Use of the laryngeal mask airway in air transport when intubation fails. J Trauma. 1999 Aug;47(2):352-7.

7. Walls RM, Murphy MF. The failed airway in adults. UpToDate 2008 ver.15.3. [CDROM].

8. Walls RM. Manual of Emergency Airway Management 2004. Lippincot, Williams and Wilkins.

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Atropine

1. Primarily to block vagal stimulation in children.

2. Minimum dose 0.1 mg, max dose 1.0 mg.

3. Onset 1-2 min, duration 4 hours

4. Consider especially with ketamine to reduce secretion and bronchospasm.

Midazolam

1. Onset 2 min. Duration 1-2 hr.

2. Reversal Flumazenil 0.1 mg. increments prn. Onset 1-3 min. Peak 3-5 min. *Will need to repeat the dose, as midazolam can last up to 2 hr.

Etomidate

1. Onset 30-60 sec..

2. Preferred in hemodynamic instability and cardiac ischemia.

3. Preferred in head injury and increased ICP.

4. Contraindicated in sepsis because long-term use can cause adrenal suppression.

5. Can produce myoclonus, hiccups, vomiting.

6. Not yet licensed for use in Canada, but available through the Federal Special Access Program

Thiopental

1. Onset 20-40 sec. Duration 5-10 min.

2. Only in stable normotensive patient

3. Use lidocaine, fentanyl and rocuronium for premedication to blunt intracranial pressure spike in head injury if etomidate not available.

Ketamine

1. Onset 30-60 sec. Duration 15 min.

2. Increases pulse and BP (PCP derivative).

3. Use in hemodynamic instability.

4. Agent of choice in asthma

5. Not for use in head injury/increased ICP

6. Occasional laryngospasm, apnoea, vomiting and emergence delerium.

7. Airway reflexes well preserved.

8. Increased salivation. Use atropine in children.

Fentanyl

1. Onset 30-60 sec. Peak 3-5 min. Duration 30-60 min

2. Reversal Naloxone 0.04 – 0.1 mg. prn. Duration 20-60 min. Remember to re-dose if multiple doses of Fentanyl given.

Succinylcholine

1. Onset 45 sec. Duration 10 min.

2. Dose may be repeated if necessary

3. May increase vagal tone. Use atropine in children.

4. Not used with increased ICP, muscle disease, cocaine, open eye, burns

Rocuronium

1. Non-depolarizer

2. Onset 45-60 sec. Duration 40-60 min.

3. Use in head injury as paralytic, or give defasciculating dose prior to succinylcholine.

Pancuronium

1. Non-depolarizer, longer duration of action.

2. Lasts 60-90 min.

3. For longer term paralysis if necessary.

Morphine

1. Use for longer term sedation.

2. Reversal Naloxone 0.04 – 0.1 mg. prn. Onset <2 min. Peak 5-15 min. Duration 20-60 min. Repeat doses will need to be given.

Optimal Intubation

1. Ideally 3 attempts at intubation should be maximum. Additional attempts will increase supraglottic and glottic trauma leading to swelling and more problems.

2. The most experienced person should make the last attempt.

3. There should be adequate paralysis.

4. Positioning of the patient should be optimal.

5. Pressure should be applied to the thyroid cartilage (not the cricoid, which is compressed to prevent aspiration).

6. Different blades can be tried. The Miller blade will allow lifting of the epiglottis.

7. Different devices can be used in experienced hands, such as the lighted stylet, intubating LMA, gum elastic bougie or fibreoptics.

Optimal mask ventilation

1. Two people to apply mask. One implements jaw thrust and one applies mask seal.

2. Adequately sized oropharyngeal airway.

3. Nasal vasoconstrictor, lubrication and 2 adequately sized nasopharyngeal airways.

4. Should maintain oxygen saturation of 90% or more

5. Watch for inflation of stomach.

Failed airway

1. Cannot intubate and cannot ventilate

2. Attempt LMA or Combitube while preparing for cricothyrotomy

3. If ventilation is possible with oxygen saturation of 90% or more, consider attempting an alternative method of intubation such as a lighted stylet, gum elastic bougie, glidescope or fibreoptics.

4. Otherwise proceed to cricothyrotomy.

5. If you cannot make yourself do a cricothyrotomy and have no help, and if a supraglottic airway (LMA or Combitube) is in place and functioning well, transport with suboptimal airway protection must be considered. There is increasing experience in pediatric transport using the LMA [5], and some evidence now exists for safe use in adult transport [6].

6. Under age 12, the surgical airway of choice is needle cricothyrotomy with transtracheal jet ventilation. This is a temporary measure, not always allowing for adequate CO2 exchange. Again, the LMA alternative can be considered for transport.

7. Review Airway Algorithms.

Cricothyrotomy

1. Expect difficulty if:

· History of neck surgery

· Presence of hematoma

· Obesity

· Radiation to neck

· Trauma to neck

2. Procedure (“No-drop” technique). This requires at least one assistant.

· Define anatomy. The cricoid is just below the thyroid cartilage.

· Prepare the skin and infiltrate with 1% lidocaine if time permits or patient is aware. Some lidocaine directly intratracheal can be helpful with cough in patients with an intact reflex.

· Immobilize the laryngeal cartilage with thumb and 3^rd finger of non-dominant hand. Do not let go.

· Make a 2 cm. vertical incision over the cricothyroid membrane.

· Directly identify the membrane with the index finger of the non-dominant hand.

· Make a horizontal 1 cm. incision through the lower (less vascular) portion of the membrane.

· Have your assistant grasp the lower aspect of the thyroid cartilage with the tracheal hook. Again, do not let go.

· Spread the incision vertically with the trousseau dilator.

· Insert a #4 tracheostomy tube vertically directing the curve caudad.

· Confirm placement by expired CO2 testing, sounding with a nasogastric tube if necessary, and check for subcutaneous emphysema.