Rapid sequence intubation: Difference between revisions
(Created page with "==Intubating Agents== Sux 1.5mg/kg 2mg/kg kids 4mg/kg IM if no line Roc 1mg/kg to intubate 0.6mg/kg to paralyze Premeds Atropine .01-.02 mg/kg Lido 1.5mg/kg ...") |
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==Ron Wall's 7 Ps of RSI== | ==Ron Wall's 7 Ps of RSI== | ||
* Preparation | |||
* SOAPME (Suction, oxygen, airway, pharmacology, monitoring, equipment) | |||
* Preoxygenate | |||
* Nitrogen wash-out | |||
* 100% NRB for 3-5min or 8 vital capacity breaths (BVM) w/ high-flow O2 | |||
* Pretreatment | |||
* Incr ICP: Fentanyl 3-5mcg/kg (+- Lidocaine 1.5mg/kg (some think drop in MAP not worth it) | |||
* Ischemic heart dz/dissection: Fentanyl 3-5mcg/kg | |||
* Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex) | |||
* Peds (age <10): Atropine .01-.02mg/kg (max 0.5) | |||
* Paralysis with induction | |||
* INDUCTION | |||
* Etomidate (0.3mg/kg) | |||
* Especially good for hypotensive/trauma patients | |||
* Hemodynamically neutral, decreases ICP | |||
* Lowers seizure threshold in patients with known seizure disorder | |||
* Does not blunt sympathetic reaction to intubation (no analgesic effect) | |||
* Adrenal suppression is irrelevant with one-time dose | |||
* Ketamine (1.5mg/kg) | |||
* Agent of choice for asthmatics | |||
* Sympathomimetic | |||
* Avoid in pt with incr. ICP AND HTN | |||
* Consider in pt with incr. ICP AND hypotension | |||
* 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 | |||
* Causes decrease in MAP, CPP | |||
* PARALYSIS | |||
* Succinylcholine | |||
* Dosing | |||
* 1.5 mg/kg - better to overdose than to underdose | |||
* 2mg/kg - neonates/infants | |||
* Contraindications | |||
* Stroke less than 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 | |||
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7/1/09 Pani (Adapted from Harwood Nuss/Chp 1) | 7/1/09 Pani (Adapted from Harwood Nuss/Chp 1), UpToDate | ||
Revision as of 23:42, 1 March 2011
Intubating Agents
Sux
1.5mg/kg
2mg/kg kids
4mg/kg IM if no line
Roc
1mg/kg to intubate
0.6mg/kg to paralyze
Premeds
Atropine .01-.02 mg/kg
Lido 1.5mg/kg
Etomidate 0.3mg/kg
Vecuronium
intubate 0.3mg/kg
paralyze 0.1mg/kg
Ron Wall's 7 Ps of RSI
- Preparation
- SOAPME (Suction, oxygen, airway, pharmacology, monitoring, equipment)
- Preoxygenate
- Nitrogen wash-out
- 100% NRB for 3-5min or 8 vital capacity breaths (BVM) w/ high-flow O2
- Pretreatment
- Incr ICP: Fentanyl 3-5mcg/kg (+- Lidocaine 1.5mg/kg (some think drop in MAP not worth it)
- Ischemic heart dz/dissection: Fentanyl 3-5mcg/kg
- Reactive Airway Dz: Lidocaine 1.5mg/kg (suppresses cough reflex)
- Peds (age <10): Atropine .01-.02mg/kg (max 0.5)
- Paralysis with induction
- INDUCTION
- Etomidate (0.3mg/kg)
- Especially good for hypotensive/trauma patients
- Hemodynamically neutral, decreases ICP
- Lowers seizure threshold in patients with known seizure disorder
- Does not blunt sympathetic reaction to intubation (no analgesic effect)
- Adrenal suppression is irrelevant with one-time dose
- Ketamine (1.5mg/kg)
- Agent of choice for asthmatics
- Sympathomimetic
- Avoid in pt with incr. ICP AND HTN
- Consider in pt with incr. ICP AND hypotension
- 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
- Causes decrease in MAP, CPP
- PARALYSIS
- Succinylcholine
- Dosing
- 1.5 mg/kg - better to overdose than to underdose
- 2mg/kg - neonates/infants
- Contraindications
- Stroke less than 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
5) Protection and positioning:
cricoid pressure until placement confirmed
sniffing position
6) Pass Tube
End-tidal CO2 detection is primary means of ETT placement confirmation
Cola-complication: need CO2 detection for at least 6 ventilations
7) Postintubation management
CXR
Long-active sedative (Midazolam 0.5mg/kg, Fentanyl 3mcg/kg)
Resp Arrest pts: consider esophageal detector device to confirm placement
See Also
Air/Resus: Airway (RSI)
Air/Resus: Intubation
Source
7/1/09 Pani (Adapted from Harwood Nuss/Chp 1), UpToDate