Pulmonology Book

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Rapid Sequence InductionAka: Rapid Sequence Intubation

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  1. Warnings
    1. High risk procedure
    2. Must be able to control airway after use
  2. Indications
    1. Preparation for intubating a conscious patient
  3. Alternatives
    1. Consider Nasotracheal intubation of a conscious patient
  4. Basic RSI Protocol
    1. Preparation and Preoxygenation
    2. Midazolam (Versed) 0.1 mg/kg IVP (5-6 mg)
    3. Apply cricoid pressure
    4. Succinylcholine 1 mg/kg IV (100 mg)
    5. Intubate
  5. RSI Protocol for Children under age 10 years
    1. Preparation and Preoxygenation
    2. Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg)
      1. Prevents vagally stimulated Bradycardia
    3. Midazolam (Versed) 0.1 mg/kg IVP
    4. Apply cricoid pressure
    5. Succinylcholine 2 mg/kg IV
    6. Intubate
  6. RSI protocol for high ICP or penetrating Eye Injuries
    1. Preparation and Preoxygenation
    2. Prevent ICP rise
      1. Lidocaine 1.5-2 mg/kg IV
      2. Vecuronium .01 mg/kg IV (defasciculating dose)
      3. Consider Fentanyl 3 ug/kg IVP
    3. Prevent Vagally stimulated Bradycardia
      1. Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg)
    4. Sedation
      1. Etomidate 0.3 mg/kg IVP OR
      2. Thiopental (Pentothal) 4 mg/kg IVP (IF BP stable)
    5. Apply cricoid pressure
    6. Muscle relaxants/Paralytic Agents
      1. Succinylcholine 1.5 mg/kg IV (2 mg/kg if <10 yo) OR
      2. Vecuronium 0.2 mg/kg IV
    7. Intubate
  7. General RSI Protocol (All Options)
    1. Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg)
      1. Prevents vagally stimulated Bradycardia
    2. Consider Increased Intracranial Pressure management
      1. Lidocaine 1 mg/kg IV (Prevents ICP rise)
      2. Fentanyl 3 ug/kg IVP
    3. Consider Vecuronium 1 mg (defasciculating dose)
    4. Sedation
      1. Preferred medications
        1. Etomidate 0.2-0.3 mg/kg IVP
        2. Midazolam (Versed) 0.1 mg/kg IVP
      2. Other options
        1. Thiopental (Pentothal) 3-5 mg/kg IVP
        2. Ketamine 1-2 mg/kg IV
    5. Muscle relaxants/Paralytic Agents
      1. Succinylcholine 1-1.5 mg/kg IV, 2-4 mg/kg IM
      2. Vecuronium (Norcuron) 0.1 mg/kg IV
      3. Pancuronium (Pavulon) 0.1 mg/kg IV
  8. Special Circumstances
    1. Status Asthmaticus
      1. Use Ketamine as the sedating agent
    2. Congestive Heart Failure
      1. Use Etomidate for Sedation
      2. Use Vecuronium for paralysis
      3. Avoid Thiopental, Succinylcholine
    3. Status Epilepticus
      1. Use Thiopental to sedate (raises Seizure threshold)
    4. Multiple trauma or hemorrhagic shock
      1. Use Etomidate for Sedation
  9. References
    1. Walker L. A. (1993) Emerg Med Rep 14(15):127

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