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Rapid Sequence Intubation: Medications, Dosages, and Recommendations

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Rapid Sequence Intubation: Medications, Dosages, and Recommendations Rapid Sequence Intubation: Medications, dosages, and recommendations Timeline of Rapid Sequence Intubation S Zero Minus Zero Minus Zero Minus Zero Zero plus 20- Zero plus 10 Minutes 5 Minutes 3 Minutes 30 seconds 45 seconds 7. Post- intubation management 1. Preparation 2. Preoxygenation 3. 4. Paralysis/ 5. Positioning 6. Placement Pretreatment Induction with proof 1. Preparation – Assemble all necessary equipment, drug, etc. 2. Preoxygenation – Replace the nitrogen in the patient’s functional reserve with oxygen – “nitrogen wash out – oxygen wash in” 3. Pretreatment – Ancillary medications are administered to mitigate the adverse physiologic consequences of intubation 4. Paralysis with induction – Administer sedative induction agent via IV push, followed immediately by administration of paralytic via IV push 5. Positioning – Position patient for optimal laryngoscopy; Sellick’s maneuver, if desired, is applied now 6. Placement with proof – Assess mandible for flaccidity; perform intubation, confirm placement 7. Post-intubation management – Long-term sedation/analgesia/paralysis as indicated Pre-treatment – agents should be given 3 minutes prior to intubation (can be given in any order) Drug Dose Indication Other notes Lidocaine 100 mg Head injury, traumatic Lidocaine will help brain injury, unknown protect the patient mechanism of injury, from increases in elevated ICP intracranial pressure caused by intubation Fentanyl 2-3 mcg/kg Elevated ICP, Fentanyl helps decrease cardiovascular disease catecholamine (ischemic coronary discharge secondary to disease, aneurismal intubation, thus disease, great vessel decreasing the risks rupture or dissection, associated from BP intracranial increases in pts with CV hemorrhage) disease, aortic dissections, etc. Be careful if the patient is already hypotensive Rocuronium 0.1 mg/kg Head injury, traumatic Defasciculation no (defasciculation) (e.g., 7 mg in a 70 kg pt) brain injury, unknown longer routinely mechanism of injury, recommended. May elevated ICP consider if pt. w/head injury to be paralyzed with succinylcholine (SCh). SCh causes transient muscle fasciculation (twitch) which theoretically may increase intracranial pressure. Summary of Induction Agents Agent Usual Onset Duration Indications Adverse Comment Emergency (sec) of Action Effects Induction (min) Dose Thiopental 3 mg/kg IV <30 5-10 Patients with Histamine Not routinely elevated ICP or release used status epilepticus Myocardial who are depression Avoid intra- hemodynamically Venodilation arterial stable Hypotension injection (may cause gangrene) Pregnancy category C Midazolam 0.2-0.3 60-90 15-30 Not routinely Respiratory Not mg/kg IV recommended for depression recommended RSI. Apnea for RSI. May use for post- Paradoxical Patient intubation agitation response may management be extremely variable Etomidate 0.3 mg/kg 10-15 4-10 Used in almost all -Adrenal Communicate IV patients for insufficiency to subsequent emergency RSI. -Pain on providers that May consider injection patient alternative agent if -Myoclonic received patient is septic or activity etomidate if in status epilepticus patient septic Ketamine 1.5 mg/kg 45-60 10-20 Good option for Increased: Not IV patients with BP recommended reactive airway HR in hypertensive disease or who are or hypovolemic, Intraocular normotensive hemorrhaging, or in pressure patients. shock Use caution in patients with cardiovascular disease Propofol 1.5 mg/kg 15-45 5-10 Hemodynamically Hypotension Ultra-short IV stable patients with Myocardial acting reactive airway depression disease or in status Reduced Negative CV epilepticus cerebral effects limits perfusion use for pressure induction in RSI Pain on injection Paralytic Summary – Depolarizing Agent Usual Onset Duration Indications Adverse Comments Emergency (sec) (min) Effects Induction Dose Succinylcholine 1.5 mg/kg IV 45 6-10 Essentially all Hyperkalemia Bradycardia Increase to 2 patients except may occur mg/kg IV in those with: Muscle after repeated myasthenia Malignant fasciculations doses, have gravis hyperthermia atropine ready 4 mg/kg IM Hyperkalemia Elevated IOP in the event it (only in life ->5d after occurs threatening burn, crush, situations) denervation, severe infection Paralytic Summary – Nondepolarizing Agent Usual Onset Duration Indications Adverse Comments Emergency (sec) (min) Effects Induction Dose Rocuronium 1 mg/kg 60-75 40-60 RSI when No, Ensure succinylcholine clinically contingency contraindicated significant plan in place in ADEs the event of failed airway Vecuronium 0.01 mg/kg 120- 45-65 Not recommended No Ensure priming dose 180 for RSI unless a clinically contingency followed 3 nondepolarizing significant plan in place in minutes later agent is indicated ADEs the event of with 0.15 and rocuronium is failed airway mg/kg not available .
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