Ver el código de «Rapid sequence intubation»

''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<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:
*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 
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 - 3–8 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<ref>Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.</ref><ref> Dmello D et al. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138(6):1327-1332.</ref><ref>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</ref>

===[[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

==[[Neuromuscular blocking agents|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<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==
===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 [[bougie]] or [[Video Laryngoscopy|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 
*Head of bed to 30° elevation
*Check ABG 30 minutes post-intubation
*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==
*[[Critical care quick reference]]
*[[EBQ:Comparison of Succinylcholine and Rocuronium for RSI]]

{{Related Difficult Airway Pages}}

==External Links==
*[http://pemplaybook.org/podcast/adventures-in-rsi/ Adventures in RSI - Pediatric Emergency Playbook]
*[https://www.merckmanuals.com/professional/critical-care-medicine/respiratory-arrest/drugs-to-aid-intubation?query=rapid%20sequence%20intubation Merk Manual - Drugs to Aid Intubation]
*[https://emcrit.org/pulmcrit/rapid-sequence-intubation-and-procedurization/ EMCrit - Rapid Sequence Intubation and Procedurization]

==References==
<references/>

[[Category:Critical Care]]
[[Category:Procedures]]
[[Category:Pharmacology]]