Rapid sequence intubation

See critical care quick reference for medication dosages by age and weight.

Background

Rapid sequence intubation (RSI) is an airway management technique that produces immediate anesthesia via an induction agent as well as rapid paralysis via a neuromuscular blocking agent.

Premedication

Atropine

There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations

Dosing:

• 0.02mg/kg, minimum dose 0.1mg
• May prevent bradycardia

Relative indications:

• Intubation in child < 1 yr old
• Prior to a second dose of succinylcholine

Lidocaine

• 1.5mg/kg
• May lower ICP, but need 5-10 minutes prior to RSI

Fentanyl

• 3 mcg/kg
• Blunts sympathetic response to intubation (pretreat if concern for increased ICP/BP, i.e. ICH, aortic dissection)
• Should be the last agent given

Induction

Etomidate

Dosing:

• 0.2-0.4mg/kg
• Onset - 1 min
• Duration - 30-60 min

Special Considerations:

• There is concern for adrenal suppression exists regarding etomidate dosing although clinically significant outcomes from transient depression has not been demonstrated. Effects may be greater for pediatric patients

Versed

• Dose: 0.2-0.3mg/kg
• Onset - 1 to 2 min
• Duration - 30-60 min

Propofol

• Dose: 1-3mg/kg
• Duration - 10-15 min

Ketamine

• Dose: 1-2mg/kg IV or 3-4mg/kg IM
• Duration - 30 min

Paralytics

Succinylcholine

Dosing:

• 1.5mg/kg IV (>10 y/o)
• 2.0mg/kg IV (<10 y/o)
• 4mg/kg IM
  • Onset: IV- 45s, IM - 2-3 min
  • Duration: IV - 4-6min, IM - 10-30min

Rocuronium

Dosing:

• 1.2mg/kg (intubation RSI dose)
• 0.6mg/kg (for repeat paralysis)
• Onset - 60s
• Duration- 25-60 min

Vecuronium

Dose:

• 0.1mg/kg
• Onset - 60-90 seconds
• Duration - 65 minutes (95% complete recovery)

7 Ps

Preparation

• SOAPME: (Suction, oxygen, airway, pharmacology, monitoring, equipment)

Preoxygenation

• Nitrogen wash-out
  • 100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2
  • Apneic oxygenation with NC at 6L/min while setting up and increase to 15L/min once patient is sedated

Pretreatment

• Ischemic heart disease/dissection: Fentanyl 3-5mcg/kg
• Increased ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it))
• Reactive Airway disease: Lidocaine 1.5mg/kg (suppresses cough reflex)
• Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1mg, max 0.5mg)
  • Controversial

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 seizure disorder
    • Does NOT blunt sympathetic reaction to intubation (no analgesic effect)
    • Adrenal suppression is likely irrelevant with one-time dose
  • Ketamine (1-4mg/kg)
    • Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock)
    • Available in IM form
    • Sympathomimetic
      • Avoid in patient with increased ICP AND hypertension
      • Evidence for clinically significant rise in ICP equivocal at best. Consider in patients with increased ICP AND low or normal BP
  • Midazolam (0.2mg/kg)
    • Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
    • Consider in patient in status epilepticus (anti-seizure effect)
    • May decrease MAP, especially if patient hypovolemic
  • Propofol (1.5 to 3mg/kg)
    • Consider in patient with bronchospasm
    • Decreases MAP, CPP
• PARALYSIS
  • Succinylcholine
    • 1.5mg/kg - better to overdose than to underdose
    • 2mg/kg - neonates/infants
  • Contraindications
    • Stroke <6 months old, MS, muscular dystrophies
    • ECG changes consistent with hyperkalemia
    • OK to use in crush injury, acute stroke as long as within 3 days of occurrence
  • Rocuronium
    • 1-1.2mg/kg
  • Consider not paralyzing in these situations
    • Expanding neck hematoma, to keep integrity of strap muscles
    • Unable to BVM due to facial hair, micrognathia
    • Unable to move to cricothyroidotomy (angioedema, goiter, anterior neck mass)

Protection and positioning

• Sniffing position

Pass Tube

• Intubation
• End-tidal CO2 detection is primary means of ETT placement confirmation
• Cola-complication: need CO2 detection for at least 6 ventilations

Postintubation management

• CXR
• Sedation
  • Benzos
    • Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
    • Midazolam 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
  • Propofol
    • 5-80mcg/kg/min (titrate q10min)
• Analgesia
  • Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
• Paralysis (if needed)
  • Vecuronium 10mg, then 7mg/hr

See Also

• Intubation
• Delayed sequence intubation
• Vasopressors
• Critical care quick reference
• EBQ:Comparison of Succinylcholine and Rocuronium for RSI

External Links

• Adventures in RSI - Pediatric Emergency Playbook