01 RSI

RSI
7P’s:
1. Preparation T-10 mins
2. Preoxygenation T -5 mins
3. Pretreatment T-3 mins
4. Paralysis with Induction T 0
5. Protection and Positioning T + 20 secs
6. Placement and Proof T+ 45 secs
7. Postintubation management T + 90 secs


Preparation T-10 minutes
- check equipments (laryngoscope, bag, capnograph, Oesophageal detector) including adjuncts (bougie, LMA), cric set
- LEMON

Preoxygenation T -5 mins
- objective is to washout lungs and even tissues with oxygen
- tight fitting, don't bag
- 8 vital capacity breaths (ask patient to take 8 deep breaths)

Pretreatment = new evidence questions routine use of pretreatment
- Lidocaine, Opioids, Atropine, Defasciculating agents LOAD
- Lidocaine to decrease tight brains (ICP) and tight lungs (bronchocospasm) = not proven
- Opiods/Fentanyl: Blunt hemodynamic response, decrease pain = beware of hypotension and apnea (dose is 3 ug/kg)
- Atropine: prevent bradycardia; evidence is mounting that questions routine use
1. all children <8 dose =" 0.01-0.02" style="font-weight: bold;">Paralysis with induction, given simultaneously (or induction first, then just paralytic in few seconds)
Induction: Etomidate, Thiopental, Ketamine, Propofol, Midaz
Paralytics: depolarizing = Sux, Non-depolarizing = Roc, Vecu

Sux still the best, fastest in, fastest out
onset: Sux 45 secs, Roc 1 minute
duration: Sux 9 minutes, Roc 45 minutes
sux: 1-2.5mg/kg, roc 1mg/kg

Sux really sucks if
1. Hyperkalemia: renal failure, rhabdomyolysis
2. Receptor upregulation: potential to increase K
subacute burns >1 day
subacute denervating disorder (unknown evolving neuro condition)
= can still give acute condition like stroke
hx of malignant hyperthermia

Induction:
- etomidate 0.3mg/kg is agent of choice
- rest gives hypotension except ketamine (some like it for asthma)

T+20seconds protection and positioning
- Sellick maneuver (cricoid pressure): occludes esophagus, prevents passive regurgitation; slight pressure only, if vomits, let go, else iatrogenic Boorhave's
- BURP (backward upward rightward maneuver): pressure on thyroid higher up for better cord visualization
- ELM external laryngeal manipulation
- C spine in line immobilization

T + 45 seconds: Placement and proof

T + 90 secs: Post intubation management
- confirm, secure, check cxr/abg
- gold standard confirmatory: wave form capnography
- seeing the tube pass thru the cords = not enough
- capnograph: false (+) and (-)