Rapid sequence intubation

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

See Also

Air/Resus: Airway (RSI)

Air/Resus: Intubation

Source

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