Rapid sequence intubation: Difference between revisions
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''See [[critical care quick reference]] for medication dosages by age and weight.'' | ''See [[critical care quick reference]] for pre-calculated medication dosages by age and weight.'' | ||
==Background== | ==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. | 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. | ||
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==Premedication== | ==Premedication== | ||
===[[Atropine]]=== | ===[[Atropine]]=== | ||
''There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations'' | ''There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations<ref>Fleming B, McCollough M; Henderson SO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. Can J Emerg Med 2005;7(2):114-7</ref>'' | ||
Dosing: | Dosing: | ||
*0. | *0.02mg/kg, no minimum dose (prior minimum 0.1mg no longer recommended)<ref> AHA 2015 guidelines comparison [http://www.sca-aware.org/sites/default/files/comparison_chart_2015_aha_guidelines_for_cpr_and_ecc.pdf full text]</ref> | ||
*May prevent bradycardia | *May prevent bradycardia | ||
Relative indications: | Relative indications: | ||
*Intubation in child < 1 yr old | *Intubation in child < 1 yr old | ||
*Prior to a second dose of succinylcholine | *Prior to a second dose of succinylcholine | ||
===[[Lidocaine]]=== | ===[[Lidocaine]]=== | ||
*1. | *1.5mg/kg | ||
*May lower ICP, but need 5-10 minutes prior to RSI | *May lower ICP, but need 5-10 minutes prior to RSI | ||
===[[Fentanyl]]=== | ===[[Fentanyl]]=== | ||
*3 mcg/kg | *3 mcg/kg | ||
*Blunts sympathetic response to intubation (pretreat if concern for | *Blunts sympathetic response to intubation (pretreat if concern for increased ICP/BP, i.e. ICH, aortic dissection) | ||
*Should be the last agent given | *Should be the last agent given | ||
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===[[Etomidate]]=== | ===[[Etomidate]]=== | ||
Dosing: | Dosing: | ||
*0.2-0. | *0.2-0.4mg/kg | ||
*Onset - 1 min | *Onset - 1 min | ||
*Duration - 30-60 min | *Duration - 30-60 min | ||
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===[[Versed]]=== | ===[[Versed]]=== | ||
*Dose: 0.2-0. | *Dose: 0.2-0.3mg/kg | ||
*Onset - 1 to 2 min | *Onset - 1 to 2 min | ||
*Duration - 30-60 min | *Duration - 30-60 min | ||
===[[Propofol]]=== | ===[[Propofol]]=== | ||
*Dose: 1- | *Dose: 1-3mg/kg | ||
*Duration - 10-15 min | *Duration - 10-15 min | ||
===[[Ketamine]]=== | ===[[Ketamine]]=== | ||
*Dose: 1- | *Dose: 1-2mg/kg IV or 3-4mg/kg IM | ||
*Duration - 30 min | *Duration - 30 min | ||
==Paralytics== | ==[[Neuromuscular blocking agents|Paralytics]]== | ||
===[[Succinylcholine]]=== | ===[[Succinylcholine]]=== | ||
Dosing: | Dosing: | ||
*1. | *1.5mg/kg IV (>10 y/o) | ||
*2. | *2.0mg/kg IV (<10 y/o) | ||
*4mg/kg IM | *4mg/kg IM | ||
**Onset: IV- 45s, IM - 2-3 min | **Onset: IV- 45s, IM - 2-3 min | ||
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===[[Rocuronium]]=== | ===[[Rocuronium]]=== | ||
Dosing: | Dosing: | ||
*1. | *1.2mg/kg (intubation RSI dose) | ||
* | *0.6mg/kg (for repeat paralysis) | ||
*Onset - 60s | *Onset - 60s | ||
*Duration- 25-60 min | *Duration- 25-60 min | ||
===Vecuronium=== | ===[[Vecuronium]]=== | ||
Dose: | Dose: | ||
*0.1mg/kg | |||
*0.1mg/kg | *Onset - 60-90 seconds | ||
*Onset - 60-90 | *Duration - 65 minutes (95% complete recovery) | ||
*Duration - | *agent of choice for prolonged paralysis | ||
==Trauma RSI== | |||
*Consider decreasing induction agent dosage for hemodynamic compromise | |||
*Paralytic dosage stays the same | |||
*Fentanyl with ketamine and rocuronium may blunt hypertensive response to tracheal manipulation as compared to traditional etomidate and succinylcholine RSI<ref>Lyon RM et al. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015; 19(1): 134. Published online 2015 Apr 1. doi: 10.1186/s13054-015-0872-2.</ref> | |||
**Etomidate does not have analgesic properties | |||
**However, etomidate and succinylcholine produces less hypotension | |||
*Hemodynamically stable, normotensive, well perfusing | |||
**Option 1: 0.3 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine | |||
**Option 2: 2 mcg/kg fentanyl PLUS 2 mg/kg ketamine PLUS 1 mg/kg rocuronium | |||
*Hypotensive or poorly perfusing | |||
**Option 1: 0.15 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine | |||
**Option 2: 1 mcg/kg fentanyl PLUS 1 mg/kg ketamine PLUS 1 mg/kg rocuronium | |||
==7 Ps== | ==7 Ps== | ||
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===Preoxygenation=== | ===Preoxygenation=== | ||
*Nitrogen wash-out | *Nitrogen wash-out | ||
**100% NRB for 3-5min or 8 VC breaths (BVM) | **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 | **[[Apneic oxygenation]] with NC at 6L/min while setting up and increase to 15L/min once patient is sedated | ||
===Pretreatment=== | ===Pretreatment=== | ||
*Ischemic heart | *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 | *Reactive Airway disease: [[Lidocaine]] 1.5mg/kg (suppresses cough reflex) | ||
*Peds (age <1): Atropine 0.01-.02mg/kg (min 0. | *Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1mg, max 0.5mg) | ||
**Controversial | **Controversial | ||
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***Especially good for hypotensive/trauma patients | ***Especially good for hypotensive/trauma patients | ||
***Hemodynamically neutral, lowers ICP | ***Hemodynamically neutral, lowers ICP | ||
***Lowers seizure threshold in patients with known | ***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 likely irrelevant with one-time dose | ***Adrenal suppression is likely irrelevant with one-time dose | ||
**[[Ketamine]] (1-4mg/kg) | **[[Ketamine]] (1-4mg/kg) | ||
***Agent of choice for asthmatics | ***Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock) | ||
***Available in IM form | ***Available in IM form | ||
***Sympathomimetic | ***Sympathomimetic | ||
****Avoid in patient with | ****Avoid in patient with significant HTN | ||
****Consider in | ****Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP | ||
**Midazolam (0. | **Midazolam (0.2mg/kg) | ||
***Consider in patient with CHF (nitro-life effect | ***Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure) | ||
***Consider in patient in status epilepticus (anti-seizure effect) | ***Consider in patient in status epilepticus (anti-seizure effect) | ||
***May decrease MAP, especially if patient hypovolemic | ***May decrease MAP, especially if patient hypovolemic | ||
**[[Propofol]] (1.5 to | **[[Propofol]] (1.5 to 3mg/kg) | ||
***Consider in patient with bronchospasm | ***Consider in patient with bronchospasm | ||
***Decreases MAP, CPP | ***Decreases MAP, CPP | ||
*PARALYSIS | *PARALYSIS | ||
**[[Succinylcholine]] | **[[Succinylcholine]] | ||
***1. | ***1.5mg/kg - better to overdose than to underdose | ||
***2mg/kg - neonates/infants | ***2mg/kg - neonates/infants | ||
**Contraindications | **Contraindications | ||
***Stroke <6 months old, MS, muscular dystrophies | ***Stroke <6 months old, MS, muscular dystrophies | ||
***ECG changes | ***[[ECG]] changes consistent with 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]] | ||
***1-1.2mg/kg | ***1-1.2mg/kg | ||
**Consider not paralyzing in these situations | **Consider not paralyzing in these situations | ||
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===Protection and positioning=== | ===Protection and positioning=== | ||
*Sniffing position | *Sniffing position | ||
*in cervical spine immobilization, use bimanual laryngoscopy and consider adjuncts such as video laryngoscopy if minimal blood in oropharynx | |||
===Pass Tube=== | ===Pass Tube=== | ||
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===Postintubation management=== | ===Postintubation management=== | ||
*CXR | *[[CXR]] | ||
*Non-violent restraints | |||
*Sedation | *Sedation | ||
**Benzos | **[[Benzos]] | ||
***Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr) | ***[[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) | ***[[Midazolam]] 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr) | ||
**Propofol | **[[Propofol]] | ||
***5-80mcg/kg/min (titrate q10min) | ***5-80mcg/kg/min (titrate q10min) | ||
*Analgesia | *[[Analgesia]] | ||
**Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min) | **[[Fentanyl]] 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min) | ||
*Paralysis (if needed) | *Paralysis (if needed) | ||
**Vecuronium 10mg, then 7mg/hr | **[[Vecuronium]] 10mg, then 7mg/hr | ||
==See Also== | ==See Also== | ||
*[[Critical care quick reference]] | *[[Critical care quick reference]] | ||
*[[EBQ:Comparison of Succinylcholine and Rocuronium for RSI]] | |||
{{Related Difficult Airway Pages}} | |||
==External Links== | ==External Links== |
Revision as of 04:56, 26 October 2019
See critical care quick reference for pre-calculated 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[1]
Dosing:
- 0.02mg/kg, no minimum dose (prior minimum 0.1mg no longer recommended)[2]
- 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[3][4][5]
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)
- agent of choice for prolonged paralysis
Trauma RSI
- Consider decreasing induction agent dosage for hemodynamic compromise
- Paralytic dosage stays the same
- Fentanyl with ketamine and rocuronium may blunt hypertensive response to tracheal manipulation as compared to traditional etomidate and succinylcholine RSI[6]
- Etomidate does not have analgesic properties
- However, etomidate and succinylcholine produces less hypotension
- Hemodynamically stable, normotensive, well perfusing
- Option 1: 0.3 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
- Option 2: 2 mcg/kg fentanyl PLUS 2 mg/kg ketamine PLUS 1 mg/kg rocuronium
- Hypotensive or poorly perfusing
- Option 1: 0.15 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
- Option 2: 1 mcg/kg fentanyl PLUS 1 mg/kg ketamine PLUS 1 mg/kg rocuronium
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 significant HTN
- Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured 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
- Etomidate (0.3mg/kg)
- 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)
- Succinylcholine
Protection and positioning
- Sniffing position
- in cervical spine immobilization, use bimanual laryngoscopy and consider adjuncts such as video laryngoscopy if minimal blood in oropharynx
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
- Non-violent restraints
- Sedation
- Analgesia
- Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
- Paralysis (if needed)
- Vecuronium 10mg, then 7mg/hr
See Also
Airway Pages
- Pre-intubation
- Induction
- Intubation
- Surgical airways
- Post-intubation
External Links
References
- ↑ Fleming B, McCollough M; Henderson SO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. Can J Emerg Med 2005;7(2):114-7
- ↑ AHA 2015 guidelines comparison full text
- ↑ Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.
- ↑ Dmello D et al. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138(6):1327-1332.
- ↑ Scherzer D et al. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. J Pediatr Pharmacol Ther JPPT Off J PPAG. 2012;17(2):142-149. doi:10.5863/1551-6776-17.2.142
- ↑ Lyon RM et al. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015; 19(1): 134. Published online 2015 Apr 1. doi: 10.1186/s13054-015-0872-2.