Rapid sequence intubation

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

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

7/1/09 Pani (Adapted from Harwood Nuss/Chp 1), UpToDate