Supplies
- S: Suction
- O: Oxygen
- A: Airway equipment (laryngoscope, multiple blades, multiple sizes of ETT, stylet and backup options, syringe, bougie)
- P: Pharmacology (induction agent, paralytic, ongoing sedation, vasopressors)
- M: Monitors
- E: End tidal CO2
Rapid sequence intubation (RSI)
0. Position the patient
1. Push drugs
| |
Dose |
Benefits/side effects |
Use in |
Avoid in |
| Induction |
| Ketamine |
1-2 mg/kg |
Hemodynamic stability
Rapid onset, long duration
Analgesia + sedation (dissociative) |
↓ BP, sepsis, asthma
(causes ↑ BP, ↑ ICP, bronchodilation) |
Cardiac ischemia (e.g. aortic dissection)
Shock where they may be tipped over the edge |
| Etomidate |
0.2-0.3 mg/kg |
Hemodynamic stability
Rapid onset |
↓ BP |
Septic patients (may cause adrenal suppression; inhibits 11-beta-hydroxylase) |
| Propofol |
1-2 mg/kg (but less in many cases) |
Hypotension (vasodilation; negative inotrope)
Propofol infusion syndrome (dose dependent) can → renal failure
Rapid on/off, amnesia + sedation but no analgesic
|
|
|
| Versed |
|
Hypotension (but not a negative inotrope)
Has amnestic properties
|
Cardiac compromise |
|
| Paralytics |
| Succinylcholine* |
1 mg/kg (total body weight dosing) |
Depolarizing neuromuscular blocker
Rapid onset, short-acting (effects last 5-10 min) |
|
hyperkalemia (will ↑ K by about 0.5; more so in quadriplegics, within 24 hrs of burn injury (increased # of neuromuscular junctions)), crush injury/compartment syndrome
Malignant hyperthermia - defect in Ca metabolism → muscle contraction → fever, tachy, rigidity. Tx with dantrolene
|
| Rocuronium |
0.6 mg/kg (lean body weight?)
Can double if need faster RSI |
Non-depolarizing neuromuscular blocker
Renal + hepatic clearance |
|
|
| Atr/cisatracurium |
|
Metabolized by plasma esterase/Hoffman degradation (not hepatic/renal), so OK for ESRD
Histamine release (atr>cis) → hypotension
|
|
|
- Induction agents may cause hemodynamic instability - for patients in shock - use lower dose, titrate up if necessary
- Halve induction dose; double paralytic dose
- post-induction sedations: propofol (short on/short off), or fentanyl/versed if not HDS; glycopyrrolate to dry up secretions
- Important - paralysis must wear off before sedation!!!
- *Succinylcholine Phase I/II block
- Phase I Block (Depolarizing Phase): Succinylcholine binds receptor → depolarizes the membrane; causes an initial discharge that produces fasciculations followed by a flaccid paralysis. Because succinylcholine is metabolized slowly, the membrane becomes unresponsive to further impulses.
- Phase II Block (Desensitizing phase): Eventually, the membrane repolarizes, however remains unresponsive because it is desensitized. During later phase II, desensitizing agents are susceptible to reversal by ACh esterase inhibitors.
- Giving repeated doses of succ (e.g. repeated attempts at intubation) leads to phase II block, at which point you lose the short-acting properties and it ends up acting like rocuronium and takes 3-4 hrs to wear off
2. Wait for drugs to work
- Patient is now apneic, but don't give breaths as they have no airway muscle tone and high risk for aspiration
3. Intubate
4. Success!
- If failure, try again with something changed - person intubating, patient position, diff tube size, ± bougie, ± video laryngoscopy
- No more than 2-3 attempts before proceeding to LMA
- If cannot place LMA, and cannot bag valve mask to keep sats up, then surgical airway
Cricothyroidotomy
author:
admin |
last edited: Jan. 21, 2019, 10:56 p.m. | pk: 118
| unpublished
Jasmine Swanniker