Paucis Verbis card: Rapid Sequence Intubation

2017-08-03T00:37:31+00:00

July 16th, 2010 | ALiEM Cards, Tox & Medications |11 Comments

By: Demian Szyld, MD EdM

The key to success in performing procedures is preparation. This is especially true for endotracheal intubations in the Emergency Department where things are chaotic. Strategic planning and anticipation of obstacles during rapid sequence intubation (RSI) are key principles to avoiding complications.

PV Card: Rapid Sequence Intubation

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Bio
Latest Posts

Demian Szyld, MD EdM

ALiEM Guest Contributor
Associate Medical Director
New York Simulation Center for the Health Sciences
New York University Langone Medical Center and City University of New York

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Michelle Lin, MD

Hey Demian: Nice PV card! Although I’ll probably never use just midazolam only for induction, it’s nice to know the dose is 0.1-0.3 mg/kg. That’s 24 mg in a 80 kg person! That is a hefty dose.
Demian Szyld

Hi Michelle: Most EM Physicians are comfortable with midazolam in anxiolytic and procedural sedation doses (.02-.05 mg/kg). The induction dose of midazolam though is indeed quite large (almost 10X).

It is because of the hypotension associated with the appropriate dose necessary to sedate someone sufficiently for intubation that this is not among our go-to drugs in the ED, where the patients who require intubation are frequently hypovolemic and have less cardiovascular and catecholamine reserve.

On the other hand, I think it is useful and important to know about the dosing of other induction medications for at least 2 reasons:

1) Drug shortages: In 2009 some hospitals saw a temporary shortage in Etomidate supply and starting in October 2009 there has been a nationwide shortage of Propofol. According to a perspective article from FDA officials published ahead of print in the NEJM http://content.nejm.org/cgi/content/full/NEJMp1005849v1 total and sterile injection drug shortages are on the rise since 2005 and have potential to impact clinical practice and patient care. They site various reasons including production lines and financial pressures and incentives.

2) Granted, Ketamine is reportedly the most widely used anesthetic in the world and a very cardiovascularly stable induction medication, nonetheless it is possible that some of our colleagues and trainees may find themselves working in environments where midazolam might be one of the few available options for example some pre-hospital systems or when traveling abroad.

Does anyone routinely use medications other than Etomidate for induction in rapid sequence intubation in EMS or in the ED?

Demian
WongML

I think there’s a math error on your card.

Vec at a dose of 0.2mg/kg * 80kg = 16mg total, not 160mg.
Michelle Lin, MD

Aha! Good catch, fix it. Thanks for catching our math.
Matt

Great reference card! I also use etomidate routinely however I like propofol or ketamine as a back up. My problem with midazolam is even when you feel the patient is sedated you often fall short evidenced by a surge in the heartrate with DL. 0.3mg/kg is a scary dose to give but as you say likely necessary to avoid this.
Chris Nickson

Hi all,

Nice memory aid.

Etomidate is not available in Australia – to be honest, i don’t think it is missed. Is that is sacrilegious in the States? But a good RSI is more about the amount of a drug you give rather than which drug, in my opinion. It’s good to know the max doses you can go up to, but as one of my former ICU bosses liked to say, the basic RSI is: ‘Sux-tube-apology’ Then add in some drugs to smooth the ride – maybe just a whiff of fentanyl and midazolam in septic shock. Maybe swap Sux for Roc these days…
Chris
PS. For fentanyl, in the 80kg column the dose shouldn’t be /kg.
Michelle Lin, MD

Chris: Nice catch on the typo! Fixed.

As for the no-etomidate issue, it is indeed a bit sacrilegious in the States. It is interesting that there is such a disparity in our practices. Not saying that one approach is wrong — it’s just fascinating. I definitely use midazolam generously post-intubation to promote some retrograde amnesia of the intubation procedure especially in the case of “sux-tube-apology” approach.
Michelle Lin, MD

Matt: Good call on having propofol as a backup. It’s perfect because you can then place them on a drip for post-intubation sedation.

Also, I’m glad I’m not the only one who is frightened by a 0.3 mg/kg dosing of midazolam (and I don’t easily get frightened).
Demian Szyld

Thank you everyone for the interesting discussion and the typo corrections!

I just got an email from the Pharmacy at my hospital alerting to more medication shortages: “The shortages have been the result of pharmaceutical manufacturers not being able to supply the medications. There can be multiple reasons for this; production problems; lack of raw material; production not able to keep up with demand, product recalls, FDA interactions; etc…”

On the list are 17 medications, most of which I use or a fairly regular basis including IV antibiotics, diuretics, and code cart medications.

Fortunately Etomidate and Propofol are not on the list today, but rectal tylenol and Epinephrine are.

Matt: thank you for sharing with us your observations on heart rate.

Chris: I can’t imagine and don’t hope for a world without etomidate, but it would not surprise me if at some point ketmaine and propofol or a combination of the two drugs becomes

I personally do not advocate RSI with Midazolam given its side effect profile and the usual availability of other meds. I also don’t recommend homeopathic doses of sedatives in RSI, even when dealing with intoxicated, obtunded and head injured patients.

One question that came up for us recently was on the use of a push dose Phenylephrine to help with post intubation hypotension (in addition to NS bolus). Does anyone have any experience with it? Doses? Strategies? Pre-RSI, post-hypotension?

Demian
precordialthump

Demain,
Minimal experience of using phenylephrine personally, though I’m aware of it being used byanesthetists (the old joke of an IM dose in the backside on the way to recovery…)

In Australia we tend to use metaraminol (a pure alpha-agonist) for short-term buffing of a low BP post-induction. Effects of a 1 mg IV bolus last up to about 20 minutes (sometimes a lot less).
http://lifeinthefastlane.com/book/critical-care-drugs/metaraminol/

Chris
Demian Szyld

Hi Chris: Thanks for chiming in! I also think of phenylephrine as a short acting alpha-agonist with duration in the 20 minute range. I don’t know metraminol but it seems to be quite similar. Thanks for sharing, Demian