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^[1]

Atropine 0.02 mg/kg, no minimum dose IV — May prevent bradycardia

Relative indications:

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

Lidocaine

Lidocaine 1.5 mg/kg IV — May lower ICP; need 5-10 min prior to RSI

Fentanyl

Fentanyl 3 mcg/kg IV — Blunts sympathetic response (pretreat if concern for increased ICP/BP); should be the last agent given

Induction

Etomidate

Etomidate 0.2-0.4 mg/kg IV (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^[2]^[3]^[4]

Versed

Versed 0.2-0.3 mg/kg IV (onset 1-2 min, duration 30-60 min)

Propofol

Propofol 1-3 mg/kg IV (duration 10-15 min)

Ketamine

Ketamine 1-2 mg/kg IV (duration 30 min)
Ketamine 3-4 mg/kg IM (duration 30 min)

Paralytics

Succinylcholine

Succinylcholine 1.5 mg/kg IV (onset 45 sec, duration 4-6 min) — Age >10 years
Succinylcholine 2.0 mg/kg IV (onset 45 sec, duration 4-6 min) — Age <10 years
Succinylcholine 4 mg/kg IM (onset 2-3 min, duration 10-30 min)

Rocuronium

Rocuronium 1.2 mg/kg IV (onset 60 sec, duration 25-60 min) — Intubation RSI dose
Rocuronium 0.6 mg/kg IV — For repeat paralysis

Vecuronium

Vecuronium 0.1 mg/kg IV (onset 60-90 sec, duration 65 min) — 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^[5]
- 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 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

Calculators

Ideal Body Weight

Ideal Body Weight / Adjusted Body Weight
Parameter	Value
Sex	1 Male Female
Height (inches) — total inches, e.g. 70 for 5'10"
Actual Weight (kg) — for adjusted BW
Results
Ideal Body Weight (Devine)	kg
Adjusted Body Weight (IBW + 0.4 × [ABW − IBW])	kg

References
Devine BJ. Gentamicin therapy. Drug Intell Clin Pharm. 1974;8:650-655. Male IBW = 50 kg + 2.3 kg per inch over 5 feet. Female IBW = 45.5 kg + 2.3 kg per inch over 5 feet. Adjusted BW = IBW + 0.4 × (Actual BW − IBW). Used for drug dosing in obese patients (e.g., vancomycin, aminoglycosides). Tidal volume dosing: Use IBW for ventilator settings (6–8 mL/kg IBW per ARDSNet protocol).

External Links

References

↑ 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
↑ 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
↑ 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.

[1] 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

[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

[5] 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.

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