Rapid sequence intubation: Difference between revisions
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==Intubating Agents== | ==Intubating Agents== | ||
'''Sux''' | |||
Sux | |||
1.5mg/kg | 1.5mg/kg | ||
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Roc | '''Roc''' | ||
1mg/kg to intubate | 1mg/kg to intubate | ||
| Line 20: | Line 19: | ||
Premeds | '''Premeds''' | ||
Atropine .01-.02 mg/kg | Atropine .01-.02 mg/kg | ||
| Line 26: | Line 25: | ||
Lido 1.5mg/kg | Lido 1.5mg/kg | ||
Etomidate 0.3mg/kg | Etomidate 0.3mg/kg | ||
Vecuronium | Vecuronium | ||
| Line 38: | Line 35: | ||
paralyze 0.1mg/kg | paralyze 0.1mg/kg | ||
==Ron Wall's 7 Ps of RSI== | ==Ron Wall's 7 Ps of RSI== | ||
| Line 46: | Line 42: | ||
* Preparation | * Preparation | ||
* SOAPME (Suction, oxygen, airway, pharmacology, monitoring, equipment) | ** SOAPME (Suction, oxygen, airway, pharmacology, monitoring, equipment) | ||
* Preoxygenate | * Preoxygenate | ||
* Nitrogen wash-out | ** Nitrogen wash-out | ||
* 100% NRB for 3-5min or 8 vital capacity breaths (BVM) w/ high-flow O2 | ** 100% NRB for 3-5min or 8 vital capacity breaths (BVM) w/ high-flow O2 | ||
* Pretreatment | * Pretreatment | ||
* Incr ICP: Fentanyl 3-5mcg/kg (+- Lidocaine 1.5mg/kg (some think drop in MAP not worth it) | ** 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 | ** Ischemic heart dz/dissection: Fentanyl 3-5mcg/kg | ||
* Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex) | * Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex) | ||
* Peds (age <10): Atropine .01-.02mg/kg (max 0.5) | ** Peds (age <10): Atropine .01-.02mg/kg (max 0.5) | ||
* Paralysis with induction | * Paralysis with induction | ||
* INDUCTION | ** INDUCTION | ||
* Etomidate (0.3mg/kg) | *** Etomidate (0.3mg/kg) | ||
* Especially good for hypotensive/trauma patients | *** Especially good for hypotensive/trauma patients | ||
* Hemodynamically neutral, decreases ICP | *** Hemodynamically neutral, decreases ICP | ||
* Lowers seizure threshold in patients with known seizure disorder | *** Lowers seizure threshold in patients with known seizure disorder | ||
* Does not blunt sympathetic reaction to intubation (no analgesic effect) | *** Does not blunt sympathetic reaction to intubation (no analgesic effect) | ||
* Adrenal suppression is irrelevant with one-time dose | *** Adrenal suppression is irrelevant with one-time dose | ||
* Ketamine (1.5mg/kg) | *** Ketamine (1.5mg/kg) | ||
* Agent of choice for asthmatics | *** Agent of choice for asthmatics | ||
* Sympathomimetic | *** Sympathomimetic | ||
* Avoid in pt with incr. ICP AND HTN | *** Avoid in pt with incr. ICP AND HTN | ||
* Consider in pt with incr. ICP AND hypotension | *** Consider in pt with incr. ICP AND hypotension | ||
* Midazolam (0.2 mg/kg) | *** Midazolam (0.2 mg/kg) | ||
* Consider in pt with CHF (nitro-life effect --> decr. vent filling pressure) | *** Consider in pt with CHF (nitro-life effect --> decr. vent filling pressure) | ||
* Consider in pt in status epilepticus (anti-seizure effect) | *** Consider in pt in status epilepticus (anti-seizure effect) | ||
* May decrease MAP, especially if pt hypovolemic | *** May decrease MAP, especially if pt hypovolemic | ||
* Propofol (1.5 to 3 mg/kg) | *** Propofol (1.5 to 3 mg/kg) | ||
* Consider in pt with bronchospasm | *** Consider in pt with bronchospasm | ||
* Causes decrease in MAP, CPP | *** Causes decrease in MAP, CPP | ||
* PARALYSIS | ** PARALYSIS | ||
* Succinylcholine | *** Succinylcholine | ||
* Dosing | *** Dosing | ||
* 1.5 mg/kg - better to overdose than to underdose | *** 1.5 mg/kg - better to overdose than to underdose | ||
* 2mg/kg - neonates/infants | *** 2mg/kg - neonates/infants | ||
* Contraindications | * Contraindications | ||
* Stroke less than 6 months old, MS, muscular dystrophies | * Stroke less than 6 months old, MS, muscular dystrophies | ||
Revision as of 08:32, 2 March 2011
Intubating Agents
Sux
1.5mg/kg
2mg/kg kids
4mg/kg IM if no line
Roc
1mg/kg to intubate
0.6mg/kg to paralyze
Premeds
Atropine .01-.02 mg/kg
Lido 1.5mg/kg
Etomidate 0.3mg/kg
Vecuronium
intubate 0.3mg/kg
paralyze 0.1mg/kg
Ron Wall's 7 Ps of RSI
- Preparation
- SOAPME (Suction, oxygen, airway, pharmacology, monitoring, equipment)
- Preoxygenate
- Nitrogen wash-out
- 100% NRB for 3-5min or 8 vital capacity breaths (BVM) w/ high-flow O2
- 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)
- Paralysis with induction
- INDUCTION
- Etomidate (0.3mg/kg)
- Especially good for hypotensive/trauma patients
- Hemodynamically neutral, decreases ICP
- Lowers seizure threshold in patients with known seizure disorder
- Does not blunt sympathetic reaction to intubation (no analgesic effect)
- Adrenal suppression is 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
- Causes decrease in MAP, CPP
- PARALYSIS
- Succinylcholine
- Dosing
- 1.5 mg/kg - better to overdose than to underdose
- 2mg/kg - neonates/infants
- INDUCTION
- Contraindications
- Stroke less than 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:
cricoid pressure until placement confirmed
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-active sedative (Midazolam 0.5mg/kg, Fentanyl 3mcg/kg)
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