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
- Etomidate (0.3mg/kg)
- 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
- Succinylcholine
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)
- Benzos
- 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
- ↑ 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