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 Rapid Sequence Intubation

o Preparation
 Check monitors, IVs (2>1), equipment to see if they’re working
 Patient’s external canal meatus should be level with sternal notch
 Do this by placing bed linens to create a ramp under patient’s head
o Preoxygenation
 3 minutes on 100% O2 nonrebreather mask or 6 vital capacity breaths
o Premedication – blunts adverse effect of laryngoscopy
 Only if PREMED:
 Pediatric – use ATROPINE 0.02 mg/kg
 Reactive Airway Disease (asthma) – use LIDOCAINE 1.5 mg/kg
 Elevated ICP (strokes) – use LIDOCAINE
 MI – use FENTANYL 3 ug/kg
 Elevated blood pressure
 Dissection - FENTANYL
 Give pretreatment 3 minutes before induction medications
o Paralysis with Induction
 Induction meds first, then immediately give paralytic meds
 Etomidate MC used
 Use KETAMINE if CAD (causes tachycardia and thus demand
 For paralytics, choose between succinylcholine and nondepolarizing agents
 If crush injury (forearm fracture or diffuse bruising), use
VECURONIUM, ROCURONIUM (nondepolarizing agents)
o To reverse nondepolarizing agents, once you see partial
motor activity regained, give ATROPINE 1st (0.01 mg/kg IV),
then EDROPHONIUM (0.5-1 mg/kg IV)
 Avoid succinylcholine for anything that may cause HYPERkalemia
o ALS, MS, muscular dystrophy, myasthenia gravis
o Stroke, spinal cord injury
o Major burns
o Sepsis > 5 days (esp. abdominal)
o Malignant hyperthermia history
o Caution with ESRD
o Placement of Tube (intubate)
o Postintubation
 Confirm tube with ETCO2 and auscultation
 ETCO2 confirms placement, NOT position and cannot r/o main stem
 ETCO2 is most sensitive after SIX manual breaths
 False negative ETCO2 can occur with massive PE, MI, or severe
pulmonary edema
 Sedate with BENZOS or PROPOFOL to minimize agitation
 OPIATES to control pain and blunt sympathetic response to intubation