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RAPID SEQUENCE INTUBATION

These pages are excerpted from the Trauma Resident Handbook, Rhode Island Hospital Department of Surgery, Division of Trauma - updated 2001. The policies herein are intended to serve as guidelines only. Individual circumstances need to be considered as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated routinely.

  1. Assemble staff, i.e., ED attending, nurse, respiratory therapist.
  2. Continuous monitoring of BP (rapid cycling), EKG, pulse oximetry
  3. Consult Anesthesiologist if airway problem is anticipated (i.e., short neck, facial trauma, high suspicion of C-spine fracture)
  4. Prepare and assemble equipment:
    · Tonsil tip/Yankauer suction
    · ETT-appropriate suction catheter
    · 2 suction systems at head range of ETT sizes and stylet
    · Consider cuffed ETT even in infants
    · Laryngoscope and light
    · Bag-valve mask and range of mask sizes
    · Oral airway (emergency only)
    · Syringe (ETT)
    · Tape
    · End-tidal CO2 device (capnograph or easy cap).
  5. Evaluate airway: Facial, cervical, laryngeal trauma/congenital anomolies. Consult anesthesiologist and/or surgeon (cricothyroidotomy) prn.
  6. Pre-oxygenate patient with 100% O2. Assess chest rise. If patient is not breathing spontaneously: cricoid pressure and bag mask ventilation
  7. Evaluate and establish intravenous access.
  8. Have Atropine available (to reverse bradycardia)
  9. Maintain in-line c-spine immobilization.
  10. Sedation and miscle relaxation: Administer in rapid succession one drug from each category:

Category

Drug

Dose

Comments


Vagolytic
  • Atropine
0.02 mg/kg IV
 
  • Min. dose 0.1 mg
  • Consider if <8 y.o., to block laryngos-
    copy induced bradycardia

Intracranial Antihypertensive
  • Lidocaine
1 mg/kg IV push
  • Give when icnreased ICP is known/suspected

Sedative
  • Midazolam . .................... ..
  • Etomidate.. ....... ........... .....
  • Ketamine ............. ....
  • Thiopental . .
.......
0.1 mg/kg IV
 
0.3 mg/kg IV
 
1-2 mg/kg IV
 
 
1-2 mg/kg IV
  • Less CV effects than thiopental
  • Decreases ICP, no CV effects
  • Bronchodilator, but increases ICP, BP, HR
  • Decreases ICP but may decrease BP and HR

Paralytic
  • Rocuronium
 
 
  • Succinylcholine
 
 
 
 
 
1 mg/kg IV
 
 
 
 
0.3 mg/kg IV
 
 
 
 
 
 
  • May have slower onset of action (30-90 vs 30-60 sec) and is longer acting (28-60 vs 3-12 min) than succ.
  • Contraidications: glaucoma, penetrating eye injuries, neuromuscular disease, FHx mailgnant hyperthermia or psuedocholinesterase deficiency, severe burns, crush injuries, hyperkalemia

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