Rapid sequence intubation: Difference between revisions

(38 intermediate revisions by 8 users not shown)
Line 1: Line 1:
''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.
Line 5: Line 5:
==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:
*0.02 mg/kg, minimum dose 0.1 mg<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>
*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]]===
*1.5 mg/kg
*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 inc ICP/BP, i.e. ICH, aortic dissection)
*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


Line 24: Line 25:
===[[Etomidate]]===
===[[Etomidate]]===
Dosing:
Dosing:
*0.2-0.4 mg/kg
*0.2-0.4mg/kg
*Onset - 1 min
*Onset - 1 min
*Duration - 30-60 min
*Duration - 30-60 min
Line 31: Line 32:


===[[Versed]]===
===[[Versed]]===
*Dose: 0.2-0.3 mg/kg
*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: 1-3 mg/kg
*Dose: 1-3mg/kg
*Duration - 10-15 min
*Duration - 10-15 min
===[[Ketamine]]===
===[[Ketamine]]===
*Dose: 1-2 mg/kg IV or 3-4 mg/kg IM
*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:
*1.5 mg/kg IV (>10 y/o)
*1.5mg/kg IV (>10 y/o)
*2.0 mg/kg IV (<10 y/o)
*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
Line 52: Line 53:
===[[Rocuronium]]===
===[[Rocuronium]]===
Dosing:
Dosing:
*1.2 mg/kg (intubation RSI dose)
*1.2mg/kg (intubation RSI dose)
*O0.6 mg/kg (for repeat paralysis)
*0.6mg/kg (for repeat paralysis)
*Onset - 60s
*Onset - 60s
*Duration- 25-60 min
*Duration- 25-60 min


===Vecuronium===
===[[Vecuronium]]===
Dose:
Dose:
*0.3 mg/kg (intubation RSI dose)
*0.1mg/kg
*0.1mg/kg (for repeat paralaysisparalyze)
*Onset - 60-90 seconds
*Onset - 60-90 s
*Duration - 65 minutes (95% complete recovery)
*Duration - 90 min
*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==
Line 70: Line 83:
===Preoxygenation===
===Preoxygenation===
*Nitrogen wash-out
*Nitrogen wash-out
**100% NRB for 3-5min or 8 VC breaths (BVM) w/ high-flow O2
**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 disease/dissection: Fentanyl 3-5mcg/kg
*Ischemic heart disease/dissection: Fentanyl 3-5mcg/kg
*Incr ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it))
*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)
*Reactive Airway disease: [[Lidocaine]] 1.5mg/kg (suppresses cough reflex)
*Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1 mg, max 0.5 mg)
*Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1mg, max 0.5mg)
**Controversial
**Controversial


Line 89: Line 102:
***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 incr. ICP AND HTN  
****Avoid in patient with significant HTN  
****Consider in patient with incr. ICP AND hypotension or normal BP
****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 (0.2 mg/kg)
**Midazolam (0.2mg/kg)
***Consider in patient with CHF (nitro-life effect --> decr. vent filling pressure)
***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 3 mg/kg)
**[[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]]
***1.5 mg/kg - better to overdose than to underdose
***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 c/w hyperkalemia  
***[[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
Line 118: Line 131:
===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===
Line 125: Line 139:


===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==
*[[Intubation]]
*[[Delayed sequence intubation]]
*[[Vasopressors]]
*[[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
  • 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
  • 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
    • 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)

See Also

Airway Pages

External Links

References

  1. 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
  2. AHA 2015 guidelines comparison full text
  3. Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.
  4. Dmello D et al. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138(6):1327-1332.
  5. 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
  6. 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.