Indications

• A – airway protection and patency

• B – respiratory failure (hypercapnic or hypoxic), increase FRC, decrease WOB, secretion management/ pulmonary toilet, to facilitate bronchoscopy

• C – minimise oxygen consumption and optimize oxygen delivery (e.g. sepsis)

• D – unresponsive to pain, terminate seizure, prevent secondary brain injury

• E — temperature control (e.g. serotonin syndrome)

• F — For humanitarian reasons (e.g. procedures) and for safety during transport (e.g. psychosis)

The decision to perform RSI in the ‘out of theatre’ setting involves weighing the pros and cons:

FOR RSI

• Lack of airway protection despite patency (swallow, gag, cough, positioning , and tone)hypoxia

• hypoventilation

• need for neuroprotection (e.g. target PaCO2 35-40 mmHg)

• impending obstruction (e.g. airway burn, penetrating neck injury)

• prolonged transfer

• combativeness

• humane reasons (e.g. major trauma requiring multiple interventions)

• cervical spine injury (diaphragmatic paralysis)

AGAINST RSI

• urgent need to OT and theatre is available anatomically or pathologically difficult airway (e.g. congenital deformity, laryngeal fracture)

• close proximity to OT

• paediatric cases (especially <5 years of age)

• hostile environment

• poorly functioning team

• lack of requisite skills among team

• emergency surgical airway is not possible (e.g. neck trauma, tumour)

Factors that make emergency intubation difficult

RSI is useful if the following are present

• The dynamically deteriorating clinical situation, i.e., there is a real “need for speed”

• Non-cooperative patient

• Respiratory and ventilatory compromise

• Impaired oxygenation

• Full stomach (increased risk of regurgitation, vomiting, aspiration)

• Extremely short safe apnea times

• Secretions, blood, vomitus, and distorted anatomy

Remembered as the 9Ps:

• Plan

• Preparation (drugs, equipment, people, place)

• Protect the cervical spine

• Positioning (some do this after paralysis and induction)

• Preoxygenation

• Pretreatment (optional; e.g. atropine, fentanyl and lignocaine)

• Paralysis and Induction

• Placement with proof

• Postintubation management

• The intubator will position themselves at the airway and pre-oxygenate the patient using the prepared airway circuit firmly applying the face-mask

• The team will rapidly run through either the RSI checklist

• Intubator or a delegated clinician will challenge

• Support clinician will respond

• The chosen induction agent(s) and muscle relaxants will be administered by the doctor or a delegated clinician

• Upon onset of apnoea the intubator may gently ventilate the patient using an oropharyngeal airway (or iGel device if it was already in situ) until they attempt laryngoscopy - waiting at least 60 seconds after the administration of rocuronium

• A laryngoscope is used to pass a bougie through the cords, over which an appropriately sized endotracheal tube is 'rail-roaded' into position

• Apnoeic time during laryngoscopy should not exceed 30 seconds - the support clinician should announce the time elapsed at 20 seconds and again at 30 seconds

• Connect the prepared airway circuit and confirm successful intubation using waveform capnography.

• In the event that intubation is not successful on first attempt, the failed intubation algorithm should be followed (See Appendix 3)

The airway team should be a minimum of 3 people:

• airway proceduralist

• airway assistant

• drug administrator

The team leader may perform one of the above roles if necessary, but should ideally be a separate stand alone role.

Other roles include:

• person to perform MILS if indicated

• person to perform cricoid pressure (if deemed necessary)

• scribe

• Suction — at least one working suction, place it between mattress and bed

• Oxygen — NRBM and BVM attached to 15 LPM of O2, preferably with nasal prongs for apneic oxygenation

• Airways — 7.5 ET tube with stylet fits most adults, 7.0 for smaller females, 8.0 for larger males, test balloon by filling with 10 cc of air with a syringe — Stylet – placed inside ET tube for rigidity, bend it 30 degrees starting at proximal end of cuff (i.e. straight to cuff, then 30 degree bend) — Blade – Mac 3 or 4 for adults – curved blade — Miller 3 or 4 for adults – straight blade — Handle – attach blade and make sure light source works — Backups – ALWAYS have a surgical cric kit available! — have video laryngoscope, LMA and bougie at bedside

• Pre-oxygenate – 15 LPM NRBM

• Monitoring equipment/Medications — Cardiac monitor, pulse ox, BP cuff opposite arm with IV — Medications drawn up and ready to be given

• End Tidal CO2

Induction Agents

Ketamine

• Dose: 1.5 mg/kg IV (4mg/kg IM)

• Onset: 60-90 sec

• Duration: 10-20 min

• Use: any RSI, especially if hemodynamically unstable (OK in TBI, does not increase ICP despite traditional dogma) or if reactive airways disease (causes bronchodilation)

• Drawbacks: increased secretions, caution in cardiovascular disease (hypertension, tachycardia), laryngospasm (rare), raised intra-ocular pressure

Thiopentone

• Dose: 3-5 mg/kg IV TBW

• Onset: 30-45 sec

• Duration: 5-10 min

• Use: any RSI if haemodynamically stable, status epilepticus

• Drawbacks: histamine release, myocardial depression, vasodilation, hypotension, must NOT be injected intra-arterially due to risk of distal ischaemia, contra-indicated in porphyria

Propofol

• Propofol 1-2.5 mg/kg IBW + (0.4 x TBW) (others simply use 1.5-2.5 mg/kg x TBW as the general guide)

• Onset: 15-45 seconds

• Duration: 5 – 10 minutes

• Use: Haemodynamically stable patients, reactive airways disease, status epilepticus

• Drawbacks: hypotension, myocardial depression, reduced cerebral perfusion, pain on injection, variable response, very short acting

Fentanyl

• Dose IV 2-10 mcg/kg TBW

• Onset: <60 seconds (maximal at ~5 min)

• Duration: dose dependent (30 minutes for 1-2 mcg/kg, 6h for 100 mcg/kg)

• Use: may be used in a low dose as a sympatholytic premedication (e.g. TBI, SAH, vascular emergencies); may used in a’modified’ RSI approach in low doses or titrated to effect in cardiogenic shock and other hemodynamically unstable conditions

• Drawbacks: respiratory depression, apnea, hypotension, slow onset, nausea and vomiting, muscular rigidity in high induction doses, bradycardia, tissue saturation at high doses

Midazolam

• Dose: 0.3mg/kg IV TBW

• Onset: 60-90 sec

• Duration: 15-30 min

• Use: not usually recommended for RSI, some practitioners use low doses of midazolam and fentanyl for RSI of shocked patients

• Drawbacks: respiratory depression, apnea, hypotension, paradoxical agitation, slow onset, variable response

Etomidate

• 0.3mg/kg IV

• onset: 10-15 seconds

• Use: suitable for most situations including haemodynamically unstable, other than sepsis or seizures

• Drawbacks: adrenal suppression, myoclonus, pain on injection, not available in Australia

Paralytic Agents

Suxamethonium (aka succinylcholine)

• Dose: 1.5 mg/kg IV (2 mg/kg IV if myasthenia gravis) and 4 mg/kg IM (in extremis)

• Onset: 45-60 seconds

• Duration: 6-10 minutes

• Use: widely used unless conra-indicated; ideal if need to extubate rapidly following an elective procedure or to assess neurology in an intubated pateint

• Drawbacks: numerous contra-indications (hyperkalemia, malignant hyperthermia, >5d after burns/ crush injury/ neuromuscular disorder), bradycardia (esp after repeat doses), hyperkalemia, fasciculations, elevated intra-ocular pressure, will not wear off fast enough to prevent harm in CICV situations

Rocuronium

• Dose: 1.2 mg/kg IV IBW

• Onset: 60 seconds

• Use: can be used for any RSI unless contra-indication or require rapid recovery for extubation after elective procedure or neurological assessment; ensures persistent ideal conditions in CICV situation (i.e. immobile patient for cricothyroidotomy) – can be reversed by sugammadex

• Drawbacks: allergy (Rare)

Vecuronium

• Dose: 0.15 mg/kg IV (may be preceded by a 0.01 mg/kg IV priming dose 3 minutes earlier)

• Osent: 120-180 econds

• Duration: 45-60 minutes

• Use: not recommended for RSI, unless no suxamethonium or rocuronium cannot be used – can be reversed by sugammadex

• Drawbacks: allergy (rare), slow onset, long duration

Following successful endotracheal intubation complete the following post-intubation checks:

Airway

• Secure the endotracheal tube with a Thomas tube holder or tube tie taking care to confirm the intended length of the tube at the lips.

• Reconfirm the presence of waveform capnography

Breathing

• Confirm Bilateral air entry and chest movement

• Perform thoracostomies if indicated

• Establish mechanical ventilation as early as practicable

• Declare target SpO2 and ETCO2 values

Circulation

• Confirm presence of central and radial pulse

• Obtain a NIBP reading

• Provide cardiovascular support as required (fluid / vasopressors)

• Consider invasive blood pressure monitoring

Disability

• Prepare maintenance drugs and initiate appropriate sedation.

• Infusions are preferable.

Exposure & Evacuation

• Insert an oesophageal temperature probe if available

• Hypothermia mitigation - blizzard blanket / warm ambulance

• Secure the patient and equipment for transfer