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What is it?
It is a virtually simultaneous administration of a potent sedative and a neuromuscular blocking agent for the purpose of intubation
Purpose
Routine: To introduce anesthesia and neuromuscular blockade in preparation for intubation Emergency: To produce neuromuscular blockade to facilitate placement of an endotracheal tube in those patients in which the airway could not otherwise be managed.
Adults and children Full or partially conscious Seizures resulting in status epilepticus unresponsive to benzodiazepines. Hypoxic and Combative, unable to intubate by regular means Trauma with seizures or trismus
Advantages
Indications
Inadequate oxygenation Inadequate ventilation Inability to maintain a patent airway Protection of the lower airway Treatment of elevated ICP Impending airway collapse Control of the patient Head injuries Drug overdose Status epilepticus
Brief History Equipment Preparation Preoxygenation Premedication Sedation Cricoid Pressure Muscle Relaxation Intubation Verification of Tube Placement Tube Security
Brief History
ABCs have been checked if a decision to intubate has been made History of present illness or injury Inspection of head and airway
Difficult airway???
Difficult Airways-MEDICTUBES
Mouth, mandible Excessive weight Deformity Incisors C-spine Thyromental distance Uvula Burns Emesis Stridor
Mouth, Mandible
Measure the width of the mouth opening. Anything less than three (3) fingers width can complicate laryngoscopy. Mandible should be without deformity or dislocation.
Excessive Weight
Overweight, pregnant or no-neck patients can also be very complicated. Complete repositioning of the patient may be required in order to visualize the airway
Deformity
Incisors
C-Spine, Trauma
Patients with cervical immobilization in place have mis-aligned airway structures, landmarks and pathways. These patients must remain immobile with cervical spine secured without manipulation when attempting intubation.
Thyromental Distance
Distance from chin to thyroid cartilage. Anything less than three (3) fingers width suggests difficult intubation.
Uvula
Mallampati Signs. Ideally, you should be able to see the entire oropharynx, including the uvula. Any airways with a partial or complete concealment of this structure may prove difficult to intubate.
Burns
Emesis
Stridor
Suction Oxygen Airway (laryngoscope, ET tubes, stylet, BVM, tube holder) Pharmacology (mix, draw-up and label) Monitoring Equipment (ECG, SaO2, etCO2)
Preoxygenation
2- 5 minutes of 100% Oxygen before initiation of sedation and neuromuscular blockade BVM only if necessary
Premedication
Atropine *
in children only
Lidocaine
Defasciculating Agent
Atropine
Bradycardia may be caused by hypoxia, succinylcholine or vagal stimulation during laryngoscopy or vagal stimulation Atropine reduces vagal tone Atropine decreases secretions *Atropine may be indicated before a second dose of succinylcholine in adolescents and adults Adult: 0.6 0.8 mg IV, Pediatric: 0.02 mg/kg
Lidocaine
Is believed to blunt the increased ICP response to intubation It is required in all cases of suspected head trauma Dosage: 1.5 mg/kg IVP
Sedation
Administered to eliminate the sensation of paralysis and decrease sympathetic tone Remember that paralytics do NOT alter consciousness. They do not work on the central nervous system. Your patient is aware of everything that is going on!
Sedation Options
Sedative selection must be made on an individual patient basis with consideration of hypovolemia, hypotension, increased ICP, age and underlying medical conditions Sedatives should never be withheld from the patient about to undergo paralysis! There are ethical considerations as well.
Sedatives
While benzodiazepines are mostly given in the field, you may also need to be familiar with these other sedatives: Thiopental (Pentothal) Midazolam (Versed) Lorazepam (Ativan) Fentanyl (Sublimaze) Ketamine (Ketalar) Etomidate (Amidate) Propofol (Diprivan)
Thiopental (Pentothal)
Short-acting barbiturate Produces rapid, deep sedation but not analgesia Excellent choice for sedation of patients with head injury because:
attenuates the ICP response to intubation reduces the cerebral metabolic rate and oxygen consumption acts as a free radical scavenger to decrease brain damage by toxic metabolites in the injured brain
Adverse Effects:
respiratory depression and apnea decreased cardiac output hypotension anaphylaxis bronchospasm
Midazolam (Versed)
Benzodiazepine Provides sedation, amnesia and anticonvulsant properties No analgesia Advantages over other benzodiazepines
faster onset than Ativan or Valium shorter duration than Ativan or Valium
Adverse effects:
cardiovascular depression respiratory depression broad dosing range and need for titration
Fentanyl (Sublimaze)
Short-acting narcotic Often used in combination with a benzodiazepine The dose for induction is variable and much higher than for premedication
Adverse Effects:
cardiovascular depression at high doses skeletal and thoracic muscle rigidity
Ketamine (Ketalar)
A dissociative anesthetic agent Also a phencyclidine derivative Causes analgesia, amnesia, dissociation from the environment, maintenance of reflexes, cardiorespiratory stability
Adverse Effects:
increases ICP increases blood pressure increases airway secretions increases intraocular pressure increases intragastric pressure causes hallucinations known as emergence reactions
Etomidate (Amidate)
Rapid-onset Short-acting Sedative-hypnotic agent Not approved for children under 10 years Reduces cardiorespiratory depression Minimizes increased ICP during intubation
Adverse Effects:
transient reduction in plasma cortisol levels transient reduction in aldosterone levels
Propofol (Diprivan)
Relatively new anesthetic induction and sedative agent Rapid onset Short duration of action Cerebroprotective effects similar to thiopental Recommended for ages 3 and over
Adverse Effects:
can decrease mean arterial pressure
Prehospital Choice
There is literature that demonstrates that approximately 30% of prehospital RSI could be avoided by using Highdose Versed Dose 0.1 mg/kg (max dose is 10 mg) Often, the patient will sedate enough to be intubated without requiring RSI. If unsuccessful, proceed to paralytics.
Cricoid Pressure
Sellecks Maneuver prevents passive regurgitation during intubation Place digital pressure over the cricoid cartilage to occlude the esophagus Cricoid pressure is released after the patient has been successfully intubated
Muscle Relaxation
Neuromuscular Blockade allows for easier intubation and ventilation A muscle relaxant is given in rapid sequence with a sedative before intubation is attempted
Depolarizing
(noncompetitive and nonreversible) produces a brief period of excitation resulting in fasciculations followed by a brief period of neuromuscular blockade
Nondepolarizing
(competitive and reversible) slower onset than depolarizing agent no fasciculations
Neuromuscular Blockade
Before Paralysis
Clinical endpoint should be established at the start Know exactly why the patient is being paralyzed How will we know when we have met goals of care?
To facilitate intubation Agitation so severe that patient is at risk of injury despite appropriate sedation Severe hypoxemia, to reduce oxygen consumption by muscle movement Increased ICP Seizures, trismus
To facilitate procedures and diagnostic tests such as CT scans and MRIs, when patients must remain still
When patients with seizures are paralyzed, it is critical to remember that just because you cant see motor activity, it doesnt mean the seizures are stopped in the brain!
Muscle receives impulse from nerve or nerve group Muscle and nerve do not touch Synapse at the neuromuscular or myoneural junction
Axon contains neurotransmitter Muscle has special receptors Between nerve and muscle, neurotransmitter is acetylcholine
Acetylcholine triggers cholinergic receptors on muscle cells Muscle contracts Acetylcholinesteras e removes neurotransmitter
Classifying NMBs
Depolarizing mimic acetylcholine sustained depolarization at synapse prevents repolarization muscle fiber refractory
Classifying NMBs
Depolarizing succinylcholine
Classifying NMBs
Succinylcholine (Anectine)
Adverse Effects:
increased ICP increased intraocular pressure increased intragastric pressure hyperthermia muscarinic stimulation of the SA node causing bradycardia especially in children release of potassium
Contraindications:
patients with burns more that 24 hours old massive muscle injury patients with upper motor neuron diseases such as Muscular Dystrophy penetrating globe injury history of malignant hyperthermia other agents are preferable in children
Rocuronium (Zemuron)
Nondepolarizing agent Relatively new agent Rapid onset Vagolytic properties Studies with Succinylcholine have shown no difference in time to action No fasiculations at onset of paralysis
Vecuronium (Norcuron)
Nondepolarizing agent Slower onset Longer duration Minimal cardiovascular effects Produces no histamine release
Neostigmine Pyridostigmine Edrophonium Administer Atropine before reversing a nondepolarizing agent to abort the muscarinic effects
Intubation
Verification of Placement
Auscultation of bilateral breath sounds Equal chest rise, misting in tube Absence of epigastric air movement Use one other method besides auscultation
End-Tidal CO2 monitoring Esophageal Detector Device
Security of ET Tube
Chart the depth of the ET tube at the patients lip Use tape or an approved ET tube holder to secure the ET tube at the correct depth Re-evaluate tube placement by checking the depth of the ET tube and auscultating breath sounds at regular intervals
Summary