RAPID  SEQUENCE  INTUBATION

 

  1. Prepare laryngoscope, pulse ox, Yankaure suction. Place patient's head in sniffing position.
     
  2. Pre-oxygenate patient with 100% O2.
     
  3. Administer Lidocaine 1.5 mg/kg (100 mg). This will block the increase in BP, HR and ICP seen with intubation.
     
  4. Administer sedating agent. This could be any of the following:
    • Thiopental 3-5 mg/kg. Onset of action in 45 sec and duration 10 min. Can cause laryngospasm and  BP.
    • Midazolam 1-5 mg. Onset in 2-3 min and duration 30min -2 hr.
    • Propofol (Diprivan) 1.5-3.0 mg/kg (150 mg). Onset in 30 sec and duration 10 min.  Can  BP but responds quickly with discontinuation of the medication.
    • Ketamine 1-2 mg/kg. Onset in 1 min and duration 20 min. Relaxes smooth muscles and is appropriate for asthma
       
  5. Administer  neuromuscular blockade. This provides muscular relaxation to achieve easy intubation.
     
  6. Two main categories of neuromascular medications are Depolarizing and Nondepolarizing agents.
     
    • The  Depolarizing agent Succinylcholine used when there is no suspicion of ­ K (e.g. 6 hr  after burn, CRF), ­ ICP, glaucoma, hyperthermia, paralytic disease such as myasthenia, spinal cord injury and Guillain-Barre. Dose is 100 mg (1-1.5 mg/kg). Onset in 30-60 sec and duration 10 min.
    • The Nondepolarizing agents take longer to act and have a longer duration of action. Thus when rapid  induction is needed nondepolarizing agents are used only if contraindications to succinylcholine exist. Commonly used are Vecuronium and Pancuronium; both have 2-3 min onset of action and duration of 30 min and 60 min respectively. The dose for both is 0.1 mg/kg (7-10 mg) IV.  "Priming" is used by some physicians prior to administration of succinylcholine. This consist  of administration of a small "defasciculating" amount of Vancuronium 0.01mg/kg in order to prevent fasciculations and the increase in ICP and other side effects of depolarizing agent observed with administration of succinylcholin.
       
  7. Apply cricoid pressure. This is done to prevent regurgitation and aspiration when full stomach is suspected. Also helps visualize vocal cords.
     
  8. Intubate. Confirm tube placement by listening to bilateral BS, CO2 monitor and CXR.
     
  9. Make sure that patient is well sedated if paralyzed.
     
  10. Ventilator setting: CMV, FiO2 - 100%, AC - 8-14 bpm, TV - 800 ml (8-10 ml/kg)

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