I. See Also
- Advanced Airway
- Endotracheal Intubation Preparation
- Endotracheal Intubation
- Endotracheal Intubation Preoxygenation (and Apneic Oxygenation)
- Post-Intubation Sedation and Analgesia
- Endotracheal Tube
- Direct Laryngoscope
- Video Laryngoscope
- Endotracheal Intubation
- Extraglottic Device (e.g. Laryngeal Mask Airway or LMA)
- Tactile Orotracheal Intubation (Digital Intubation)
- Nasotracheal Intubation
- Cricothyrotomy
- Needle Cricothyrotomy
II. Precautions
- High risk procedure
- Must be able to completely control airway and ventilation after use
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 describes techniques for preventing Hypoxia during intubation (including Apneic Oxygenation)
- Endotracheal Intubation describes techniques for maximal laryngeal visualization and Endotracheal Tube insertion and 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)
- Cardiovascular disease
- 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
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
- Consider half dose of induction agents
- Indicated in Hypotension
- Can never over-dose paralytics
-
Sedation without paralysis (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
- Sedation without paralysis may lead to inadequate muscle relaxation for intubation
- Etomidate is short acting and may not allow for adequate intubation attempt without paralysis
- Propofol is longer acting, but risks Hypotension
- 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
- Sedation without paralysis may lead to inadequate muscle relaxation for intubation
- 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)
- 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)
- Preferred agent in Asthma, Angioedema (and possibly Sepsis)
- Ketamine is not associated with apnea, regardless of dose
- 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)
- Preferred agent in Asthma, Angioedema (and possibly Sepsis)
- 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 for 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 mg/kg (80 mg for 80 kg adult)
- Agent of choice in children (and in adults if Succinylcholine contraindicated)
- Duration of paralysis: 45 minutes
- Sugammadex tightly binds Rocuronium and Vecuronium to reverse paralysis (not available in U.S.)
- 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 (or Vecuronium) 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
IX. Resources
- FPnotebook: Virtually Resuscitated RSI
- Rapid Sequence with Rocuronium and Ketamine Video (Sacchetti)
X. References
- Majoewsky (2012) EM: RAP-C3 2(5): 3-4
- Levitan (2013) Practical Airway Management Course, Baltimore
- Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 24-35
- Walker L. A. (1993) Emerg Med Rep, 14(15):127-32 [PubMed]
