Review of Critical Care Medicine

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Archive for June 23rd, 2012

Endotracheal Intubation

Posted by Dr KAMAL DEEP on June 23, 2012

The author wish to acknowledge the excellent guidance of Dr Kapil Chhabra, Consultant, Deptt. of Critical Care Medicine in this topic

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Rapid Sequence Intubation

RSI is the cornerstone of modern emergency airway management and is defined as the virtually simultaneous administration of a potent sedative (induction) agent and an NMBA, usually succinylcholine, for the purpose of endotracheal intubation. This approach provides optimal intubating conditions, while minimizing the risk of aspiration of gastric contents.

Administration of 100% oxygen for 3 minutes of normal, tidal volume breathing in a normal, healthy adult results in the establishment of an adequate oxygen reservoir to permit 8 minutes of apnea before oxygen desaturation to less than 90% occurs.

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Sample Rapid Sequence Intubation Using Etomidate and Succinylcholine
 
Time Step
Zero minus 10 min Preparation
Zero minus 5 min

    Preoxygenation
    100% oxygen for 3 min or eight vital capacity breaths
Zero minus 3 min Pretreatment as indicated “LOAD”
Zero Paralysis with induction  
Etomidate, 0.3 mg/kg
Succinylcholine, 1.5 mg/kg
Zero plus 45 sec Placement  
Sellick’s maneuver
Laryngoscopy and intubation
End-tidal carbon dioxide confirmation
Zero plus 2 min Post-intubation management  
Midazolam 0.1 mg/kg, plus
Pancuronium, 0.1 mg/kg, or
Vecuronium, 0.1 mg/kg
 
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FIGURE 1-7 The LEMON airway assessment method

Table 1-4. Drugs Used to Facilitate Intubation
Drug IV Dose (mg/kg) Onset of Action (sec) Side Effects
Induction drugs
Thiopental 2.5–4.5 20–50 Hypotension
Propofol 1.0–2.5 <60 Pain on injection
Hypotension
Midazolam 0.02–0.20 30–60 Hypotension
Ketamine 0.5–2.0 30–60 Increases in intracranial pressure
Increase in secretions
Emergence reactions
Etomidate 0.2–0.3 20–50 Adrenal insufficiency
Pain on injection
Muscle relaxants
Succinylcholine 1–2 45–60 Hyperkalemia
Increased intragastric pressure
Increased intracranial pressure
Rocuronium 0.6–1.0 60–90 —

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