Rapid sequence intubation

Agents

Premed

1. Atropine
   1. 0.02 mg/kg
   2. prevent bradycardia & dries secretions give in < 5 y/o or < 20 kg
   3. (possibly 5-10y , but def not if >10y)
2. Lidocaine
   1. 1.5 mg/kg
   2. lowers ICP

Induction

1. Etomidate 0.2 to 0.4 mg/kg
   1. Onset - 1 min
   2. Dur - 30-60 min
2. Versed 0.2 mg/kg (max 5 mg)
   1. Onset - 1 to 2 min
   2. Dur - 30-60 min
3. Propofol 1 to 2.o mg/kg
   1. Dur - 10-15 min

Paralytics

1. Succinylcholine
   1. 1.5 mg/kg (>10 y/o)
   2. 2.0 mg/kg (< 10 y/o)
   3. 4mg/kg IM if no line
   4. 30-60 s, 10-15 min
2. Vecuronium
   1. 0.3 mg/kg (intubate)
   2. 0.1mg/kg (paralyze)
   3. 60-90 s, 90 min
3. Rocuronium
   1. 1.0 mg/kg (intubate)
   2. 0.6mg/kg (paralyze)
   3. 30-60 s, 25-60 min
4. Pancuronium
   1. 0.1 mg/kg
   2. 2-5 min, 45-90 min
   3. Onset - 30-60 s

Ron Wall's 7 Ps of RSI

1. Preparation
   1. SOAPME (Suction, oxygen, airway, pharmacology, monitoring, equipment)
2. Preoxygenate
   1. Nitrogen wash-out
      1. 100% NRB for 3-5min or 8 vital capacity breaths (BVM) w/ high-flow O2
3. Pretreatment
   1. Incr ICP: Fentanyl 3-5mcg/kg (+- Lidocaine 1.5mg/kg (some think drop in MAP not worth it)
   2. Ischemic heart dz/dissection: Fentanyl 3-5mcg/kg
   3. Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex)
      1. Peds (age <10): Atropine .01-.02mg/kg (max 0.5)
4. Paralysis with induction
   1. INDUCTION
      1. Etomidate (0.3mg/kg)
         1. Especially good for hypotensive/trauma patients
            1. Hemodynamically neutral, decreases ICP
         2. Lowers seizure threshold in patients with known seizure disorder
         3. Does not blunt sympathetic reaction to intubation (no analgesic effect)
         4. Adrenal suppression is irrelevant with one-time dose
      2. Ketamine (1.5mg/kg)
         1. Agent of choice for asthmatics
         2. Sympathomimetic
            1. Avoid in pt with incr. ICP AND HTN
            2. Consider in pt with incr. ICP AND hypotension
      3. Midazolam (0.2 mg/kg)
         1. Consider in pt with CHF (nitro-life effect --> decr. vent filling pressure)
         2. Consider in pt in status epilepticus (anti-seizure effect)
         3. May decrease MAP, especially if pt hypovolemic
      4. Propofol (1.5 to 3 mg/kg)
         1. Consider in pt with bronchospasm
         2. Causes decrease in MAP, CPP
   2. PARALYSIS
      1. Succinylcholine
         1. Dosing
         2. 1.5 mg/kg - better to overdose than to underdose
         3. 2mg/kg - neonates/infants
      2. Contraindications
         1. Stroke less than 6 months old, MS, muscular dystrophies
         2. ECG changes c/w hyperkalemia
         3. OK to use in crush injury, acute stroke as long as within 3 days of occurrence
      3. Rocuronium
5. Protection and positioning:
   1. cricoid pressure until placement confirmed
   2. sniffing position
6. Pass Tube
   1. End-tidal CO2 detection is primary means of ETT placement confirmation
   2. Cola-complication: need CO2 detection for at least 6 ventilations
7. Postintubation management
   1. CXR
   2. Long-active sedative (Midazolam 0.5mg/kg, Fentanyl 3mcg/kg)
   3. Resp Arrest pts: consider esophageal detector device to confirm placement

See Also

Air/Resus: Airway (RSI)

Air/Resus: Intubation

Source

7/1/09 Pani (Adapted from Harwood Nuss/Chp 1), UpToDate