Rapid sequence intubation: Difference between revisions

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==Intubating Agents==
==Intubating Agents==
===Sux===
#1.5mg/kg
#2mg/kg kids
#4mg/kg IM if no line


'''Sux'''
===Roc===
#1mg/kg to intubate
#0.6mg/kg to paralyze


1.5mg/kg
===Premeds===
 
#Atropine .01-.02 mg/kg
2mg/kg kids
#Lido 1.5mg/kg
 
#Etomidate 0.3mg/kg
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


===Vecuronium===
#intubate 0.3mg/kg
#paralyze  0.1mg/kg


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

Revision as of 13:54, 12 March 2011

Intubating Agents

Sux

  1. 1.5mg/kg
  2. 2mg/kg kids
  3. 4mg/kg IM if no line

Roc

  1. 1mg/kg to intubate
  2. 0.6mg/kg to paralyze

Premeds

  1. Atropine .01-.02 mg/kg
  2. Lido 1.5mg/kg
  3. Etomidate 0.3mg/kg

Vecuronium

  1. intubate 0.3mg/kg
  2. paralyze 0.1mg/kg

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
  4. Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex)
    1. Peds (age <10): Atropine .01-.02mg/kg (max 0.5)
  5. 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
  6. Protection and positioning:
    1. cricoid pressure until placement confirmed
    2. sniffing position
  7. 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
  8. 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

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