Rapid Sequence Induction HOWTO?

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Aprz

The New Beach Medic
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Brown (he's in a retirement home) and I were talking about rapid sequence induction.. I remember he used to talk about it all the time, and I forgot a lot about it since I've read my airway chapter in my paramedic textbook. He disagreed with my book. I wanted to hear how do you guys do it, what do you think is wrong with how my book described.

1. Prepare your equipment.

2. Consider atropine (dose: 0.5 mg for adult, 0.1-0.2 mg/kg for pediatrics) for bradycardia, especially in kids. Succinylcholine is like an acetylcholine receptor agonist and can cause bradycardia I guess. Lidocaine (1.0-1.5 mg/kg any age) for increase intracranial pressure (ICP) or arrhythmias because intubating can increase ICP or cause arrythmias (personally, I thought it usually stimulated the vagus (X) nerve and caused bradycardia, which is one reason why you shouldn't suction for too long). Consider a sedative like midazolam (dose: adult 2-5 mg, didn't recommend for pediatrics) so the patient doesn't remember being intubated and paralyzed.

3. Preoxygenate the patient as best as you can. If you can't prior to induction, you may have to do it as you do the procedure itself.

4. Administer 10% of the initial dose of a nondepolarizing agent like vecuronium bromide (initial dose: 0.1 mg/kg) or pancuronium bromide (initial dose: 0.06-0.01 mg/kg) to cause weakness, not paralysis.

5. Administer succinylcholine (dose: 1.5-2.0 mg/kg), a depolarizing agent, to cause paralysis.

The book said that you wanted to cause weakness, not complete paralysis, so the patient can still breath on their own. Then succinylcholine because it has a short half life, and it will cause paralysis, but if you bail on intubating, you don't have to have to bag for that long.

6. Intubate.

7. After confirming that you've successfully intubated the patient, administer the remaining initial dose of the nondepolarizing agent.

8. Maintain. Readminister vecuronium bromide (0.01-0.015 mg/kg) every 20-45 minutes) or pancuronium bromide (0.01 mg/kg) every 20-60 minutes. Midazolam (2-5 mg) every 2-3 minutes. <_<

Does that sound right? What would you do differently?

I don't know of any county nearby that allows rapid sequence induction. I just wanna know it. Posting this for my sake also just to remember the dose, ordering, and reason. In paramedic school, rapid sequence induction, or they said intubation, covered it by saying "RSI, you'll never do that", and moved on. I personally don't believe they know how to do it either.
 
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Aprz said:
Brown (he's in a retirement home) and I were talking about rapid sequence induction.. I remember he used to talk about it all the time, and I forgot a lot about it since I've read my airway chapter in my paramedic textbook. He disagreed with my book. I wanted to hear how do you guys do it, what do you think is wrong with how my book described.

1. Prepare your equipment.

2. Consider atropine (dose: 0.5 mg for adult, 0.1-0.2 mg/kg for pediatrics) for bradycardia, especially in kids. Succinylcholine is like an acetylcholine receptor agonist and can cause bradycardia I guess. Lidocaine (1.0-1.5 mg/kg any age) for increase intracranial pressure (ICP) or arrhythmias because intubating can increase ICP or cause arrythmias (personally, I thought it usually stimulated the vagus (X) nerve and caused bradycardia, which is one reason why you shouldn't suction for too long). Consider a sedative like midazolam (dose: adult 2-5 mg, didn't recommend for pediatrics) so the patient doesn't remember being intubated and paralyzed.

3. Preoxygenate the patient as best as you can. If you can't prior to induction, you may have to do it as you do the procedure itself.

4. Administer 10% of the initial dose of a nondepolarizing agent like vecuronium bromide (initial dose: 0.1 mg/kg) or pancuronium bromide (initial dose: 0.06-0.01 mg/kg) to cause weakness, not paralysis.

5. Administer succinylcholine (dose: 1.5-2.0 mg/kg), a depolarizing agent, to cause paralysis.

Waste of time and extra drugs. Pick one and use it.

The book said that you wanted to cause weakness, not complete paralysis, so the patient can still breath on their own. Then succinylcholine because it has a short half life, and it will cause paralysis, but if you bail on intubating, you don't have to have to bag for that long.

This sounds like overcautious BS

6. Intubate.

7. After confirming that you've successfully intubated the patient, administer the remaining initial dose of the nondepolarizing agent.

8. Maintain. Readminister vecuronium bromide (0.01-0.015 mg/kg) every 20-45 minutes) or pancuronium bromide (0.01 mg/kg) every 20-60 minutes. Midazolam (2-5 mg) every 2-3 minutes. <_<

Does that sound right? What would you do differently?

I don't know of any county nearby that allows rapid sequence induction. I just wanna know it. Posting this for my sake also just to remember the dose, ordering, and reason. In paramedic school, rapid sequence induction, or they said intubation, covered it by saying "RSI, you'll never do that", and moved on. I personally don't believe they know how to do it either.
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Have to come up with 3 characters in addition to the answers in quotes.
 
Aprz said:
The book said that you wanted to cause weakness, not complete paralysis, so the patient can still breath on their own. Then succinylcholine because it has a short half life, and it will cause paralysis, but if you bail on intubating, you don't have to have to bag for that long.
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If you're performing RSI you probably had an indication for it...one which wasn't they were doing a great job breathing on their own.

So paralyze to paralyze or don't RSI.
 
Set up equipment

Place Patient on Monitor and NC at 6lpm even if bagging

Obtain IV/IO access

Push 2mg/kg Ketamine
Push 2mg/kg Succs
Increase NC to 15lpm
Apply cricoid pressure as needed
Intubate (confirm placement, Capnography, Lung Sounds, Etc...)
Discontinue NC
Push Versed 0.1mg/kg to max of 10mg
Push 1mcg/kg of Fent

Continue to monitor patients airway and need for further medication

This is not copy and pasted verbatum from the protocols, just a meat and potatoes.


Where did you go to Medic school? Maybe they said "You'll never do that" Because they do not do it where you work or in surrounding areas? BUt many agencies around the country do.
 
Agree with Vene, I really don't see a need for an initial "low dose" paralytic prior to the actual full paralytic dose. I've actually never seen that done.

The general gist of what you had is correct:
-get everything set up and ready
-pre-oxygenate
-Induction agent
-paralytic agent
-intubate

Goal of RSI is to intubate without BVM ventilation. You're assuming there's a full stomach and you don't sit there for several minutes bagging the patient while trying to titrate sedatives. Weight based dosages are given in a short span of time to render patient unconscious and paralyzed.

Depending on the patient and scenario (increased ICP, COPD, hypotension), will play a role in which meds you use and if you use any additional agents such as lidocaine, fentanyl, etc...

In the hospital setting here I usually use etomidate, versed or even propofol for induction (depending on scenario and other factors). Then it's usually succs or vec for paralysis.
 
If you're going to administer a paralytic, don't half *** it, give it. If you've come to the point where RSI is the proper decision, get it done. Giving less to "weaken them" (which I've never heard of anyway) is wasting time, and is potentially dangerous due to the fact that everyone reacts differently to different doses of drugs. I'd given a patient 100mg of Roc before and all it did was slow their breathing from 50+ to 16.

I'm also not a fan of succs anyhow.


When I RSI'd, it was 3mcg/kg of Fent, 0.3mg/kg of etomidate, and 1mg/kg of Roc. It got the job done when I needed it to.



Go on Amazon and get the "Manual of Emergency Airway Management"
 
Linuss said:
Giving less to "weaken them" (which I've never heard of anyway) is wasting time, and is potentially dangerous due to the fact that everyone reacts differently to different doses of drugs.
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In their defense giving a "defasiculating dose" of the non-depolarizing paralytic prior to a the full dose of a depolarizing paralytic is standard in textbooks.

Perhaps they worded it awkwardly, it isn't to weaken them but rather to keep fasiculations from occurring.
 
Agreed. The defasciculating dose of the depolarizing paralytic is taught in every RSI class… Nobody ever does it. :)

For me it's it etomidate, succinylcholine … The tube… then Vecuronium and versed.

Although, I was taught by an anesthesiologist that 2 mg of midaz prior to the administration of etomidate will reduce the possibility of trismus associated with it.
 
Linuss said:
If you're going to administer a paralytic, don't half *** it, give it. If you've come to the point where RSI is the proper decision, get it done. Giving less to "weaken them" (which I've never heard of anyway) is wasting time, and is potentially dangerous due to the fact that everyone reacts differently to different doses of drugs. I'd given a patient 100mg of Roc before and all it did was slow their breathing from 50+ to 16.

I'm also not a fan of succs anyhow.


When I RSI'd, it was 3mcg/kg of Fent, 0.3mg/kg of etomidate, and 1mg/kg of Roc. It got the job done when I needed it to.



Go on Amazon and get the "Manual of Emergency Airway Management"
Click to expand...


We've got ketamine here now to Linuss.

: happydance:
 
The OP doesnt mention sedation until after paralysis... Please Please Please sedate your patients prior to making them paralized!
 
My bad, the book did mention it being the defasciculation dose, but I feel like it mentioned all over the place to not giving the remainder of the medication until after the tube has been secured, and I felt like that was for to back out.

The defasciculation dose is typically 10% of the normal dose; it does not induce paralysis, but does cause weakness.
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Thanks Linuss, I'll go buy that book with Christmas money, haha. Actually gonna work a ton over the holidays cause nobody wanted to work those shifts. Holiday pay too.

I did mention sedation at the bottom of step 2, lol. Not that it matters, but in the book, they called it the premedicate stage and clumped it together. The book said to maintain sedation after intubating. I've never seen midazolam used/given, but that's probably because I work in IFT in Santa Clara County, Alameda County, and Contra Costa County, CA. From what I've read, it seems like midazolam has a pretty short half life/doesn't last long. It's great to sedate quickly, but sounds like you'd have to keep pushing it every couple of minutes to keep them sedated. Am I correct?

Just so y'know, I think I got the take home point: go big or go home. :P

Edit: My class is taught in Santa Clara County, CA. I'm 4 months into it.
 
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I think there's been Cochrane's on both atropine in peds send lidocaine in head injury / CVA and there's little evidence for either practice beyond tradition.

Defasciculation sounds logical, although I've never seen it done outside of through OR. If anyone has good references on what it does to the risk of succinylcholine-induced hyperkalemia or MH, I'd love to see them.

Preoxgenation is key to preventing desaturation if you end up in a difficult airway situation. This can be accomplished with a NRB or BVM, and seems one of the few reasonable times to use FiO2 1.0 on someone normally saturated.

My experience has been that many EMS systems use very low doses of midazolam (mine limits me to 5mg as a single dose, which seems barely adequate even when combined with fentanyl). It seems like physicians are more willing to use a true 0.1mg/kg and enter the 10 mg range.

Anecdotally, it seems like the onset for midazolam is quite slow. I've never been comfortable pushing the versed then the sux, the same way you can with an anesthetic agent like ketamine. A fair percentage of my patients have been hyperventilating and needing PPV when using midazolam.

As usalsfyre and others are fond of pointing out - I'd be reluctant to rely on the sux wearing off prior to critical hypoxia developing. Paralysis can bring its own problems, particularly if the patient is hyperventilating or is status asthmatics.
 
Just to add to the above - most patients that need paralysis for incubation don't need long-term paralysis postintubation. I think we often jump the gun on this in EMS.
 
Systemet, how come? Instead of a paralytic, just maintain sedation instead?
 
Ill agree with not needing a long term paralytic in most cases. However, we are told to have trauma patients paralyzed as well as sedated when flying them.

When I asked why, I was given some anecdotal story of a trauma patient waking up in the helicopter and becoming violent. When I mentioned that it sounded like inadequate sedation, the person changed the subject.

I just keep them sedated with midaz. It works for me.
 
How often would you readminister midazolam? Every 2-3 minutes? The book didn't mention a sedation dose in this procedure, but the dose I was taught in school was 2-5 mg q 2-3 minutes to a max of 0.1 mg/kg. Seems like I'd be giving a lot of midazolam in a short amount of time.
 
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