Rapid Sequence

Intubation
John Bradley, MD
Metropolitan Hospital

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 Lessons from Skydiving
Levitan RM. Patient safety in emergency airway management and rapid sequence
intubation: metaphorical lessons from skydiving. Ann Emerg Med. 2003;42:81-87.

• Redundancy of safety (primary and backup chute)

• Planned stepwise approach to deploy 1ary chute
Simple, fast, easy backup chute deployment
• Attention to monitoring: exit plane at correct
altitude, altimeter determines when to deploy
backup chute
• Equipment vigilance

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 Overview
Rapid Sequence Intubation

Airway Assessment
The Difficult Airway
The Failed Airway
Airway Options
Your Approach

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 Rapid Sequence Intubation (RSI)
• Definition
• Assumptions
• Goals
• Indications
• Contraindications
• Alternatives
• Procedure
– Steps
– Pharmacology
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 RSI Definition
• The administration of a potent induction
agent followed immediately by a rapid
acting neuromuscular blocker (NMB) to
render unconsciousness and motor
paralysis for tracheal intubation

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RSI Assumptions

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 RSI Assumptions
• Intubation is indicated
• The stomach is full
• Intubation is anticipated to be successful
• If intubation fails, ventilation is expected to
be successful

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 RSI Goals
• Optimize intubation conditions

• Minimize aspiration risk by avoiding

positive pressure ventilation until after
intubation is accomplished

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Indications for Tracheal Intubation

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 Indications for Tracheal Intubation

Inability to maintain an airway

Inability to maintain adequate oxygenation
and ventilation
Anticipated airway obstruction /
Special situations

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RSI Contraindications

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 RSI Contraindications

• Tracheal / laryngeal injury / disruption

• S/P Laryngectomy
• Massive facial trauma
• Anticipated difficult airway

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 RSI Alternatives
• Awake oral intubation with local
anesthesia and sedation
• Blind nasotracheal intubation (BNTI)

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 RSI
The 7 Ps

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 RSI
The 7 Ps
• Preparation
• Preoxygenation
• Pretreatment
• Paralysis with induction
• Protection with positioning
• Placement with proof
• Post-intubation management

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 RSI Timeline
Time Action
Zero - 10 min Preparation
Zero - 5 min Preoxygenation
Zero - 3 min Pretreatment
Zero Paralysis with induction
Zero + 20-30 sec Protection with positioning
Zero + 45-60 sec Placement with proof
Zero + 60-90 sec Post-intubation management

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 RSI Compressed Timeline
• Concurrent preparation and preoxygenation
• Accelerated (2 min)
– Shorten preoxygenation to 30 sec with 8 vital
capacity breaths (VC) method
– Shorten pretreatment interval from 3 min to 2
min
• Immediate
– Eliminate pretreatment
– Preoxygenate with 8 VC breaths

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 Preparation
• Patient
– Discussion, airway assessment, IV access
– Positioning
• Equipment
– Airway, monitoring, failed airway
– Blade type and size, ETT size
– OP airway, placement confirmation device
– Cuff integrity and stylet, laryngoscope fxn
• Personnel
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 Airway Assessment (LEMON)
• Look externally
• Evaluate 3-3-2
• Mallampati
• Obstruction
• Neck
• (Pediatrics)

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 Look Externally
• Difficult BVM Ventilation ?
• Difficult Laryngoscopy / Intubation ?
• Difficult Surgical Airway ?

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 Difficult BVM Ventilation
(BONES)
• Beard
• Obesity
• No teeth
• (Elderly)
• (Snores)
• Severe facial burns / angioedema / trauma
– Unstable midface and/or mandible

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Difficult Laryngoscopy / Intubation

• (Severe facial burns / angioedema / trauma)

• Buck teeth
• Jay Leno
• Micronathia
• Down’s syndrome
• FLK

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 Difficult Surgical Airway
(SHORT)
• Surgery
• Hematoma or infection
• Obesity
• Radiation
• Tumor (including goiter)

• Anatomic variability
• Females

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 Evaluate
(3-3-2 Rule)
• 3 finger breadths between upper lower teeth
– Ability to visualize
• 3 finger breadths between the mandible and hyoid
bone
– < 3: suggests anterior larynx
– Greater: axes malalignment
• 2 finger breadths between thyroid cartilage notch
and the mandible or floor of the mouth
– Cephalad larynx

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 Mallampati Classification
I Tonsillar pillars and fauces visible
II Upper portion of pillars and uvula visible
III Base of uvula / soft palate visible
IV Only tongue and hard palate visible

Patient’s mouth open, tongue sticking out

Correlates with laryngoscopy classification, but not
as sensitive in grades 3 and 4…

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 Laryngoscopic Classification
• Grade I Entire glottis visible
• Grade II Arytenoid cartilage and
posterior glottis visible
• Grade III Epiglottis only visible
• Grade IV Tongue or soft palate visible

• Grade III and IV are considered difficult

intubations (about 5% of OR cases)
• Visualization predicts intubation success
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 Obstruction
• Angioedema
• Epiglottis
• Abscess
• Burn
• Trauma
• Tumor

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 Neck
• Possible cervical spine injury
• Rheumatoid arthritis
• Ankylosing spondylitis

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 High Risk Patients
• ASA Class III and higher
• Chronic pulmonary or cardiac disease
• Fever, volume depletion, current URI
• Airway assessment suggestive

• Consider OR, anesthesia consult and/or

awake intubation

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 ETT Size and Depth
• Size
– Females 7.5-8; Males 8-8.5
– Broslow tape, little finger diameter
– 4 + age/4
• Depth
– Females - 21 cm; Males - 23 cm
– Broslow tape, markings on ETT
– ETT size x 3 (cm); age + 10

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 Preoxygenation
• Establish an O2 reservoir in the lungs & body
– Essential to “no bagging” principle of RSI
– Function residual capacity is primary reservoir
– Permits several minutes of apnea without
desaturation
• 100% O2 via nonrebreather for 5 minutes
OR
8 VC breaths with 100% O2 via bag/mask

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Pretreatment (LOAD)

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 Pretreatment (LOAD)
• Mitigate adverse effects of laryngoscopy
• Lidocaine 1.5 mg/kg
– Airway bronchospasm / cough reflex
– Increased ICP
• Opiates (Fentanyl 3-6 mcg/kg)
– Increased ICP, aortic dissection, ruptured
aortic or IC aneurysm, ischemic heart disease
– Blunts reflex sympathetic response to
laryngoscopy
– Not recommended under age 1
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 Pretreatment (LOAD)
• Atropine 0.01-0.02 mg/kg (0.1 to 0.5 mg)
– Children <= 10 yo
– Blunts vagal response to laryngoscopy
• Defasiculation (with succinylcholine)
– Increased ICP
– 1/10th dose of a non-depolarizing NMB
– Not indicated under age 5

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 Paralysis with Induction
• Rapid IV administration of sedation
followed immediately by rapid
administration of a neuromuscular
blocking agent

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 Protection and Positioning
• Sellick’s maneuver
– Firm pressure (10 #)
– Maintain until placement confirmation and cuff
inflation
• Positioning
– Keep the pillow to maximize POGO
– Height of bed, height in bed

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 Placement with Proof
• Test for jaw flaccidity
• Extend head on neck
• Gentle controlled technique
• Blade entry on right, sweep tongue to left
• Lift handle up and away
• Suction prn
• Insert into esophagus, then slowly withdraw
• Visualize vocal cords
• Watch ETT pass through vocal cords
• Check ETT depth
• Never let go of the tube!
• Inflate cuff
• Auscultation
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 Placement with Proof
• Confirm tracheal placement
– Direct visualization plus either
– EtCO2 detector or
– Esophageal detector
• Preferred in cardiopulmonary arrest
• Confirm depth (cords > bronchus)
– Auscultation
– CXR

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 Post-Intubation Management
• Secure ETT
• Reassess VS
• PCXR for depth of placement

• Bradycardia / Hypoxia -> Nontracheal tube

placement until proven otherwise (DOPE)
• Hypertension->inadequate sedation/analgesia
• Hypotension

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 Post-intubation Management
(Hypotension)
• Tension PTX
– High PIP, hard to bag, decreased BS, hypoxia
– Immediate thoracostomy
• Decreased venous return
– High PIPs 2ndary to high intrathoracic pressure
– Fluids, bronchodilators,
– Increase expiratory time, decrease TV

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 Post-intubation Management
(Hypotension)
• Induction agent
– Other causes excluded
– Fluid bolus, consider reversal agent, expectant
• Cardiogenic
– Usually a compromised pt
– Check EKG, exclude other causes
– Fluid bolus (caution), pressors

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 Medications
• Pretreatment drugs (LOAD)
– Lidocaine
– Opiates
– Atropine
– Defasiculation
• Sedation
• Paralysis

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 Sedation
• Midazolam
• Etomidate
• Methohexital / Thiopental
• Ketamine
• Propofol

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 Neuromuscular Blocking Agents
• Noncompetitive depolarizer
– Succinylcholine (Anectine)
• Competitive nondepolarizer
Benzylisoquinolinium group
– Atracurium (Tracrium), cisatracurium (Nimbex),
mivacurium (Mivacron)
Aminosteroid group
– Pancuronium (Pavulon), vecuronium (Norcuron),
rocuronium (Zemuron)
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 Succinylcholine (SCh) (Anectine)

• Rapid onset (45 seconds) and short

duration of action (<= 10 minutes)
• Mechanism of action
• Metabolism
• Sequence of action
• Dosing

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SCh Adverse Effects

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 SCh Adverse Effects
• Malignant hyperthermia
• Masseter spasm
• Hyperkalemia
• Increased ICP / Increased IOP
– Fasciculations
• Bradycardia (peds)
• Prolonged NMB
• Hypotension (histamine release, (-) inotrope)

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SCh Contraindications

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 SCh Contraindications
• Personal or FH of malignant hyperthermia

• Known or suspected hyperkalemia

• > 24 hours post-burn (>10% BSA, 1-2 yrs)
• > 1 week post crush injury (60-90 days)
• > 1 week post SCI or CVA (6 months)
• Neuromuscular disease (indefinite)
– MS, ALS, muscular dystrophy

• Anticipated difficult airway

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 Competitive, Nondepolarizing NMB

• Most commonly utilized post-intubation

• No CIs other than the difficult airway
• Disadvantage is longer onset and duration
• Metabolism variable
• Higher dose reduces time to paralysis but
prolongs time to recovery

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 Competitive, Nondepolarizing NMB

• Aminosteroid group dose not cause

histamine release
• Reversible with AChesterase inhibitor
– Requires 40% spontaneous recovery
• Consider administering sedation shortly
after administering vecuronium or
pancuronium for RSI

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 Competitive, Nondepolarizing NMB

• Rapacurium off the market

• Rocuronium (0.6-1.2 mg/kg)
• Mivacurium (0.15 mg/kg)
• Vecuronium (0.3 mg/kg)
• Pancuronium (0.1 mg/kg)

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 Awake Oral Intubation
• Upper airway distortion is anticipated
• Prepare the patient
• Anesthetize the airway
– Lidocaine 4% 4 cc / neosynephrine 0.5% 1cc OR
– Lidocaine 2% w/EPI 5cc / Lidocaine 2% Plain 5 cc
– Via nebulizer for 10 minutes OR
– Lidocaine spray
• Sedation (Midazolam or Etomidate +/- Fentanyl)
– Onset 3-5 minutes
• Perform laryngoscopy
• Immediate intubation / consider RSI / surgical airway
– Can the epiglottis be visualized?
– Is an abnormal glottis anticipated?

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 Pediatrics
• Relatively large tongue / more oral secretions
• High tracheal opening (C1 > C4,5 adult)
• Large occiput
• Cricoid ring is narrowest portion
• Large tonsils and adenoids and greater angle
between epiglottis and larygeal opening
• Minimal cricothyroid membrane until age ¾
• Small relative FRC
• Basal oxygen consumption twice the adult rate
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 Pediatrics
• Appropriately sized equipment (Broslow)
• Positioning
– Avoid hyperextension
– May need to elevate shoulders
• Effective BVM
– C-grip / good seal
– Squeeze, release, release
– Tidal volume
– Cricoid pressure

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 Pediatrics
• Atropine < age 10
• Avoid fentanyl < age, use cautiously
• Lower barbituate dose per kg
• No defasciculation < age 5 / 20 kg
• Succinylcholine dose
• Straight blade
• Uncuffed ETT < age 8

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 Pediatrics
• No BNTI < age 10
• Adult EtCO2 detector > 15 kg
• Securing the tube
• Place NGT or OGT early
• Orotracheal intubation for better security
• No surgical cricothyroidotomy < age 10

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 The Second Attempt
• Learn from your first attempt (experience)
• Blade type or size (Use Mac as a Miller)
• ETT size
• Sellick’s technique / stylet
• BURP
• Reposition the head and neck
• Chest pressure looking for air bubble
• Monitor VS, interposed BVM ventilation
• Find the epiglottis
• Call for help

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 The Bottom Line
• The Broslow Tape / Cart
• Get the trachea intubated efficiently
• Have a plan
• Have a back-up plan
• Call for help early
• Airway assessment is an integral part of
RSI and procedural sedation
• Practice, practice, practice

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 Resources
• Manual of Emergency Airway
Management by Ron Walls et al

• Airway Courses

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