II. Precautions
- High risk procedure
- Must be able to completely control airway and ventilation after use
- Use a checklist!
III. Indications
- Preparation for intubating a conscious patient
IV. Protocol
- Walls protocol describes all steps in Endotracheal Intubation
- This page focuses on pharmacologic strategies in RSI (steps 3, 4 and 7)
- Endotracheal Intubation Preparation describes a safety checklist for readying for intubation
- Endotracheal Intubation Preoxygenation - prevent Hypoxia during intubation (including Apneic Oxygenation)
- Endotracheal Intubation describes techniques for maximal laryngeal visualization and ET insertion, confirmation
- Mnemonic: 7Ps (Walls)
- Preparation - step 1
- See Endotracheal Intubation Preparation
- Includes SOAP-ME Mnemonic
- See Endotracheal Tube
- Includes size and length selection of Endotracheal Tubes
- See Direct Laryngoscope
- Includes sizes of Miller Blade and Macintosh Blade
- See Video Laryngoscope
- Includes Video Laryngoscopy devices such as Glidescope, C-MAC, MacGrath
- Preoxygenation - step 2
- See Endotracheal Intubation Preoxygenation (includes Apneic Oxygenation)
- Significantly extends duration of safe apnea during intubation
- Pretreatment -step 3
- Rarely indicated in 2013
- See below
- Paralysis with Induction - step 4
- See below
- Positioning - step 5
- Placement with Proof - step 6
- Postintubation Management - step 7
- See Endotracheal Intubation
- Also see post-intubation agents described below
- Preparation - step 1
- Alternatives
- See Extraglottic Device
- Includes Laryngeal Mask Airway or LMA
- Consider as emergency device in case of Endotracheal Intubation failure
- See Nasotracheal Intubation
- May be considered in anticipated difficult airway of a conscious patient
- See Extraglottic Device
V. Protocol: Pretreatment - step 3 (not indicated in most cases)
- ABC Mnemonic (not indicated in most cases)
- Pretreatment (Fentanyl, Lidocaine, Atropine) is now rarely indicated (in 2013)
- Indications are listed below for completeness, but are not generally recommended
- No evidence of benefit for any of these agents
-
Asthma or COPD
- Lidocaine 1.5 mg/kg (120 mg for 80 kg adult)
- Brain (prevention of Intracranial Pressure increase with intubation)
- Fentanyl 4-5 mcg/kg (320 mcg for 80 kg adult) given slowly over 1-2 minutes
- More than twice the Analgesic dose
- Lidocaine 1.5 mg/kg (no longer recommended)
- Multiple studies show no benefit for neurologic outcome
- Lin (2012) Am J Emerg Med 30(9): 1782-7 +PMID:22633717 [PubMed]
- Robinson (2001) Emerg Med J 18(6): 453-7 +PMID:11696494 [PubMed]
- Fentanyl 4-5 mcg/kg (320 mcg for 80 kg adult) given slowly over 1-2 minutes
- Cardiovascular disease (Ischemic Heart Disease, aortic aneurysm, Aortic Dissection)
- Fentanyl 3 mcg/kg
- Children under age 12 months (optional for ages 1 to 5 years)
- Greatest predictive factor for Bradycardia on intubation is Hypoxia
- Apneic Oxygenation (Nasal Cannula delivered High Flow Oxygen throughout intubation)
- Prolongs safe intubation time (see above)
- Atropine 0.02 mg/kg
- Atropine has historically been used to prevent Bradycardia when intubating children
- Not routinely recommended for any age
- Consider Atropine ready at the time of intubation in case of Symptomatic Bradycardia
- If Atropine used in cases of suspected Non-accidental Trauma
- Consider performing Retinal Exam immediately after RSI with Atropine
- Avoid Atropine to dry secretions with Ketamine (results in thicker secretions)
- Greatest predictive factor for Bradycardia on intubation is Hypoxia
-
Hypotension
- Avoid intubating a severely hypotensive patient (outside of crash airway without RSI)
- RSI, NIPPV and Endotracheal Intubation may all significantly lower Blood Pressure further
- Transition from negative pressure ventilation (diaphragm) to intubation decreases Preload
- Peri-Intubation Hypotension is ominous, and may herald imminent Cardiac Arrest
- Risk factors for Peri-Intubation Hypotension
- Advanced age
- Neuromuscular Blockers
- COPD
- Sepsis
- Hypoxemia
- Morbidly obese or cacchexia
- Pre-intubation Blood Pressure <140 mmHg
- Temporize airway and breathing management (Nasal Airway, bipap) during stabilization
- Consider awake intubation
- Consider Arterial Line for Blood Pressure monitoring
- Place before radial pulses are lost
- Arterial Lines remain reliable even in Hypotension and Tachycardia (contrast with Blood Pressure cuffs)
- Consider Inferior Vena Cava Ultrasound for Volume Status
- Fluid responsiveness may be assessed with Passive Leg Raise Maneuver combined with IVC Ultrasound
- IVC <1.5 cm on Ultrasound immediately after intubation, is associated with Hypovolemia
- Optimize systolic Blood Pressure prior to RSI
- Use agents less likely to lower Blood Pressure
- Avoid Propofol as Sedative (induction agent) for emergency intubation
- Ketamine in 0.25 to 0.5 mg/kg boluses until dissociation
- Etomidate 0.3 mg/kg IV
- No RSI agents are needed in Cardiac Arrest (crash airway)
- Fluid Resuscitation
- Standard bolus of crystalloid in a peri-intubation hemodynamically Unstable Patient is 20 cc/kg IV
- Even in CHF, 250 to 500 ml crystalloid bolus is tolerated to stabilize BP for intubation
- Vasopressors
- Phenylephrine
- Norepinephrine
- Peri-intubation Norepinephrine is associated with increased mortality in-hospital and 90 day
- Smischney (2015) BMC Res Notes 8:445 [PubMed]
- Use agents less likely to lower Blood Pressure
- Avoid intubating a severely hypotensive patient (outside of crash airway without RSI)
VI. Protocol: Paralysis with induction - step 4
- Sedation with paralysis (standard, recommended protocol)
- Can never over-dose paralytics
- Best to over-estimate than under-estimate dose (e.g. 2 mg/kg of Succinylcholine or Rocuronium)
- Low Cardiac Output may reduce effect and delay onset of action (overcome by higher dose)
- Re-dose fully in reliable IV if suspected infiltration of first dose via a poorly placed IV
- Consider half dose of induction agents
- Indicated in Hypotension (and use Etomidate or Ketamine)
- Can never over-dose paralytics
- Sedation without paralysis (facilitated intubation, use only with caution in difficult airway)
- See Difficult Airway for other ways to approach a patient with risk of failed airway
- Precaution: May significantly Handicap intubation technique
- RSI with sedation only (without paralytic) is not recommended
- Risk for adverse outcome (multiple intubation attempts, airway injury, aspiration, death)
- Bozeman (2006) Prehosp Emerg Care 10(1): 8-13 [PubMed]
- Sedation without paralysis may lead to inadequate Muscle relaxation for intubation
- Etomidate is short acting
- May not allow for adequate intubation attempt without paralysis
- Propofol is longer acting, but risks Hypotension
- Etomidate is short acting
- Risk of Emesis and aspiration
- Consider pretreatment with Ondansetron to suppress Gag Reflex
- Full dose paralytics are recommended for even the lowest GCS scores (outside of crash airway)
- Avoid half-dose paralytics or defasciculating dose
- RSI with sedation only (without paralytic) is not recommended
- Indications
- Patients who are not resisting stabilization measures AND
- Difficult Airway (with risk of a unsupportable patient if intubation unsuccessful)
- Otherwise complete paralysis for 8 minutes (Succinylcholine) to 45 minutes (Rocuronium)
- A patient aware, "locked-in", paralyzed without sedation or Analgesic is torture
- Avoid, unless the only alternative is death
- Alternatives
- Technique
- Prepare Paralytic Agent for injection (even if not immediately injected)
- Consider pretreatment with Ondansetron to suppress Gag Reflex
- Administer sedation (e.g. Etomidate) at standard dosing
- Dissociative Awake Intubation with Ketamine 1-2 mg/kg
- Consider adding Etomidate 0.1 mg/kg to suppress Gag Reflex
- References
- Braude in Herbert (2013) EM:Rap 13(11): 14
- Weingart in Majoewsky (2012) EM:Rap 12(2): 8
- Sedation agents
- Etomidate 0.2 to 0.3 mg/kg (24 mg for an 80 kg adult) or
- Agent of choice in most cases (most hemodynamically stable agent)
- Preferred in Hemorrhagic CVA with increased Blood Pressure
- Causes adrenal suppression (which may impact survival in Sepsis)
- Consider Ketamine as an alternative induction agent in Sepsis
- Not Clinically Significant if used in single dose as induction agent for intubation
- Avoid in Sepsis for any longer use than brief
- Ketamine 1.5 mg/kg (120 mg for an 80 kg adult)
- Do not exceed 1.5 mg/kg in shock cases
- Preferred agent in copd, Asthma, Angioedema (and possibly Sepsis)
- Ketamine is not associated with apnea, regardless of dose
- Ketamine also has Bronchodilator properties (ideal for COPD, Asthma)
- Not contraindicated in Closed Head Injury (previously thought to increase Intracranial Pressure)
- Appears to be neuroprotective by increasing Cerebral Perfusion Pressure
- Does not lower Seizure threshold
- Consider administration with Zofran (due to associated Vomiting)
- Not contraindicated in Coronary Artery Disease, Congestive Heart Failure or Hypertension
- Avoid concurrent Atropine to dry secretions (worsens increased airway secretions by thickening them)
- Propofol (Diprivan)
- Consider for Status Epilepticus
- Contraindicated in hypotensive patients
- Thiopental (Pentothal)
- Older agent, rarely used in U.S. in 2013
- Consider for Status Epilepticus (Fast-acting anti-epileptic)
- Consider Increased Intracranial Pressure (Fastest lowering of ICP of any induction agent)
- Contraindicated in hypotensive patients or porphyria
- Risk of skin necrosis if infiltrates (highly alkalotic agent with pH 10)
- Midazolam (Versed)
- Considered a poor agent for RSI
- Rarely given at adequate doses (a typical adult dose for RSI is an astounding 8-10 mg)
- Could be considered in Status Epilepticus
- Risk of Hypotension
- Risk of Agitation in the elderly and those with liver disease
- Etomidate 0.2 to 0.3 mg/kg (24 mg for an 80 kg adult) or
- Paralysis agents
- Succinylcholine 1.5 mg/kg (120 mg for an 80 kg adult) or
- Contraindicated if Hyperkalemia risk (see Succinylcholine)
- Duration or paralysis: 8 minutes
- Wait at least one minute for defasciculation prior to intubating (risk of Emesis)
- Some prefer in anticipated difficult airway (due to much shorter duration)
- Oxygen Saturation drops more quickly with Succinylcholine due to oxygen utilization for paralysis
- Rocuronium 1 to 1.2 mg/kg (80-96 mg for 80 kg adult)
- Agent of choice in children (and in adults if Succinylcholine contraindicated)
- Many recommend Rocuronium for all intubations as the safest option in undifferentiated ED presentations
- Inadequate sedation and analgesia is common following Rocuronium
- Err on the side of more aggressive sedation and analgesia while patient paralyzed
- Korinek (2014) Eur J Emerg Med 21(3): 206-11 +PMID:23510899 [PubMed]
- Duration of paralysis: 45 minutes
- Sugammadex tightly binds Rocuronium and Vecuronium to reverse paralysis
- Some prefer in difficult airway due to longer duration of action
- Positive Pressure Ventilation may be easier with paralysis
- Longer duration allows for repeat attempt without re-dosing in case of failed intubation
- Succinylcholine 1.5 mg/kg (120 mg for an 80 kg adult) or
VII. Protocol: Post-intubation Management - step 7
VIII. Management: Special Circumstances
-
Status Asthmaticus
- Sedation: Ketamine
-
Congestive Heart Failure
- Sedation: Etomidate
-
Status Epilepticus
- Sedation: Thiopental, Midazolam, Propofol
- Multiple Trauma or Hemorrhagic Shock
- Sedation: Etomidate
-
Shock
- Use lower induction agent doses (e.g. half dose)
- Use increased paralytic doses
- Rocuronium 2 mg/kg
- Succinylcholine 3-4 mg/kg
- References
- Orman and Hayes in Herbert (2017) EM:Rap 17(1): 10
- Heier (2000) Anesth Analg 90(1): 175-9 +PMID:10625000 [PubMed]
IX. Resources
- FPnotebook: Virtually Resuscitated RSI
- Rapid Sequence with Rocuronium and Ketamine Video (Sacchetti)
- RSI Calculator (slide-rule bedside calculator for RSI drugs)
X. References
- Herbert (2012) EM: RAP-C3 2(5): 3-4
- Swaminathan and Weingart in Herbert (2019) EM:Rap 19(5): 11-12
- Levitan (2013) Practical Airway Management Course, Baltimore
- McClain, Lawner and Butler (2019) Crit Dec Emerg Med 33(12): 19-27
- Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 24-35
- Walker L. A. (1993) Emerg Med Rep, 14(15):127-32 [PubMed]