Rapid sequence intubation

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:

  • 0.02 mg/kg, minimum dose 0.1 mg[1]
  • May prevent bradycardia

Relative indications:

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

Lidocaine

  • 1.5 mg/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 inc ICP/BP, i.e. ICH, aortic dissection)
  • Should be the last agent given

Induction

Etomidate

Dosing:

  • 0.2-0.4 mg/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[2][3][4]

Versed

  • Dose: 0.2-0.3 mg/kg (max 5 mg)
  • Onset - 1 to 2 min
  • Duration - 30-60 min

Propofol

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

Ketamine

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

Paralytics

Succinylcholine

Dosing:

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

Rocuronium

Dosing:

  • 1.2 mg/kg (intubation RSI dose)
  • O0.6 mg/kg (for repeat paralysis)
  • Onset - 60s
  • Duration- 25-60 min

Vecuronium

Dose:

  • 0.3 mg/kg (intubation RSI dose)
  • 0.1mg/kg (for repeat paralaysisparalyze)
  • Onset - 60-90 s
  • Duration - 90 min


7 Ps

Preparation

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

Preoxygenation

  • Nitrogen wash-out
    • 100% NRB for 3-5min or 8 VC breaths (BVM) w/ 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 dz/dissection: Fentanyl 3-5mcg/kg
  • Incr ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it))
  • Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex)
  • Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1 mg, max 0.5 mg)
    • 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 sz 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
      • Available in IM form
      • Sympathomimetic
        • Avoid in pt with incr. ICP AND HTN
        • Consider in pt with incr. ICP AND hypotension or normal BP
    • 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
      • Decreases MAP, CPP
  • PARALYSIS
    • Succinylcholine
      • 1.5 mg/kg - better to overdose than to underdose
      • 2mg/kg - neonates/infants
    • Contraindications
      • Stroke <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
      • 1-1.2mg/kg

5. 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

External Links

References

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