Rapid sequence intubation: Difference between revisions

Revision as of 08:33, 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
  - 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

Source

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

@@ Line 76: / Line 76: @@
 *** 1.5 mg/kg - better to overdose than to underdose
 *** 2mg/kg - neonates/infants
-* Contraindications
+*** Contraindications
-* Stroke less than 6 months old, MS, muscular dystrophies
+*** Stroke less than 6 months old, MS, muscular dystrophies
-* ECG changes c/w hyperkalemia
+*** ECG changes c/w hyperkalemia
-* OK to use in crush injury, acute stroke as long as within 3 days of occurrence
+*** OK to use in crush injury, acute stroke as long as within 3 days of occurrence
-* Rocuronium
+*** Rocuronium
 ) Protection and positioning:
@@ Line 90: / Line 87: @@
 sniffing position
 ) Pass Tube
@@ Line 98: / Line 93: @@
 Cola-complication: need CO2 detection for at least 6 ventilations
 ) 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 ==
 /1/09 Pani (Adapted from Harwood Nuss/Chp 1), UpToDate
 [[Category:Airway/Resus]]