Rapid sequence intubation

Agents

Premedication

• Atropine
  • 0.02 mg/kg
  • Prevents bradycardia & dries secretions
  • Consider if <5yr or <20kg
• Lidocaine
  • 1.5 mg/kg
  • Lowers ICP

Induction

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

Paralytics

• Succinylcholine
  • 1.5 mg/kg (>10 y/o)
  • 2.0 mg/kg (< 10 y/o)
  • 4mg/kg IM if no line
  • Onset - 30-60 s
  • Dur - 10-15 min
• Vecuronium
  • 0.3 mg/kg (intubate)
  • 0.1mg/kg (paralyze)
  • Onset - 60-90 s
  • Dur - 90 min
• Rocuronium
  • 1.0 mg/kg (intubate)
  • 0.6mg/kg (paralyze)
  • Onset - 30-60 s
  • Dur - 25-60 min

Ron Wall's 7 Ps of RSI

• 1. Preparation
  • SOAPME: (Suction, oxygen, airway, pharmacology, monitoring, equipment)
• 2.Preoxygenate
  • Nitrogen wash-out
    • 100% NRB for 3-5min or 8 VC breaths (BVM) w/ high-flow O2
• 3. Pretreatment
  • Incr ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it)
  • Ischemic heart dz/dissection: Fentanyl 3-5mcg/kg
  • Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex)
  • Peds (age <10): Atropine .01-.02mg/kg (max 0.5)
• 4.Paralysis with induction
  • INDUCTION
    • Etomidate (0.3mg/kg)
      • Especially good for hypotensive/trauma patients
      • Hemodynamically neutral, lowers ICP
      • Lowers seizure threshold in patients with known sz disorder
      • Does NOT blunt sympathetic reaction to intubation (no analgesic effect)
      • Adrenal suppression is likely irrelevant with one-time dose
    • Ketamine (1.5mg/kg)
      • Agent of choice for asthmatics
      • Sympathomimetic
        • Avoid in pt with incr. ICP AND HTN
        • Consider in pt with incr. ICP AND hypotension
    • Midazolam (0.2 mg/kg)
      • Consider in pt with CHF (nitro-life effect --> decr. vent filling pressure)
      • Consider in pt in status epilepticus (anti-seizure effect)
      • May decrease MAP, especially if pt hypovolemic
    • Propofol (1.5 to 3 mg/kg)
      • Consider in pt with bronchospasm
      • Decreases MAP, CPP
  • PARALYSIS
    • Succinylcholine
      • 1.5 mg/kg - better to overdose than to underdose
      • 2mg/kg - neonates/infants
    • Contraindications
      • Stroke <6 months old, MS, muscular dystrophies
      • ECG changes c/w hyperkalemia
      • OK to use in crush injury, acute stroke as long as within 3 days of occurrence
    • Rocuronium
  • 5.Protection and positioning:
    • Sniffing position
• 6. Pass Tube
  • End-tidal CO2 detection is primary means of ETT placement confirmation
  • Cola-complication: need CO2 detection for at least 6 ventilations
• 7. Postintubation management
  • CXR
  • Long-acting sedative (Midazolam 0.05mg/kg, Fentanyl 3mcg/kg)

See Also

Airway (RSI) Intubation

Source

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