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
• 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

• Dose: 0.2-0.4 mg/kg
• Onset - 1 min
• Duration - 30-60 min

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

• Intubation
• Delayed sequence intubation
• Critical care quick reference