Rapid Sequence Induction

1. Precautions
   1. High risk procedure
   2. Must be able to completely control airway and ventilation after use
2. Indications
   1. Preparation for intubating a conscious patient
3. Alternatives
   1. Consider Nasotracheal intubation of a conscious patient
4. Protocol: (Mnemonic: 7P)
   1. Preparation
      1. Telemetry
      2. Oxygen Saturation monitoring
      3. Capnography (if available)
      4. Video laryngoscope, Glidescope or other similar device
      5. Endotracheal Tube (including a size smaller than anticipated)
   2. Pre-oxygenation
      1. Standard pre-oxygenation
      2. Rapid pre-oxygenation (if alert)
   3. Pretreatment: ABC Mnemonic
      1. Asthma or COPD
         1. Lidocaine 1.5 mg/kg (120 mg for 80 kg adult)
      2. Brain (prevention of Intracranial Pressure increase)
         1. Lidocaine 1.5 mg/kg and
         2. Fentanyl 3 mcg/kg (250 mcg for 80 kg adult) given slowly over 1-2 minutes
      3. Cardiovascular disease
         1. Fentanyl 3 mcg/kg
   4. Paralysis with induction
      1. Sedation agents
         1. Etomidate 0.2 to 0.3 mg/kg (24 mg for an 80 kg adult) or
            1. Agent of choice in most cases
         2. Ketamine 1.5 mg/kg (120 mg for an 80 kg adult)
            1. Preferred agent in Asthma
      2. Paralysis agents
         1. Succinylcholine 1.5 mg/kg (120 mg for an 80 kg adult) or
            1. Contraindicated for Hyperkalemia risk
         2. Rocuronium 1 mg/kg (80 mg for 80 kg adult)
            1. Agent of choice in children (and in adults if Succinylcholine contraindicated)
   5. Positioning
      1. Typical: Flex-Extend (sniffing)
      2. Alternatives
         1. Flex-Flex
         2. Extend-Extend
         3. Fixed (trauma)
      3. Adjuncts
         1. Sellick's Maneuver
   6. Placement with Proof
      1. End-Tidal CO2 Detector
      2. Chest auscultation
   7. Post-intubation Management
      1. Secure ET Tube
      2. Chest XRay
      3. Manage Low Blood Pressure
         1. IV Fluid bolus
      4. Mechanical Ventilation
      5. Sedation
5. Preparations
   1. Sedatives
      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 (children - recent use in combination with Propafol)
   2. Paralytics
      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
6. 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
7. References
   1. Walker L. A. (1993) Emerg Med Rep, 14(15):127-32