Awake Intubation

[RSI Calculator]

DRY THEM OUT & PRETREAT GAG

If you can give it early 10-15 min before topicalizing, it will be most effective.

TOPICALIZE

Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. Do not spray more than 2-3 cc down the windpipe.

NEED SUCTION?

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SEDATE (Choose one!)

The Rest

RSI Drugs
 
Agent Dose Induc. Dura-tion Benefits Caveats
Etomidate 0.3 mg/kg IV <1 min 10-20 min ICP Myoclonic jerking or seizures and vomiting in awake patients
Intraocular pressure No analgesia
Neutral BP Cortisol
Propofol 0.5-1.5 mg/kg IV 20-40s 8-15 min Anti-emetic Apnea
Anticon-vulsant BP
ICP No analgesia
Ketamine 1-2 mg/kg IV 1 min 10-20 min Broncho-dilator Secretions
"Dissociative" amnesia BP, ICP
Analgesia Emergence phenomenon
Fentanyl 2-3 mcg/kg IV < 60s 30-90 min Low risk of causing BP
- Reverse w/ Narcan
-
ICP
Myoclonus in high dose.
ICP & cerebral perfusion
Vomiting
 
Midazolam 0.2 mg/kg IV rapid push. 60-90s 15-30 min   Not recommended for RSI owing to slow onset of induction even with recommended doses.
Thiopental         Potent vasodilator & myocardial depressant
Can exacerbate
BP

Paralyze:

  • Depolarizing Neuromuscular Paralytic Agent
    • Succinylcholine 1-2mg/kg IV (DOC)
      • Onset: 30 sec
      • Duration: 12 min
    • Contraindications:
      1. Hyperkalemia
      2. Crush injuries
      3. Significant burn > 48 hr old
      4. Spinal cord injury > 48 hr old
      5. Denervating & neuromuscular disease (Muscular dystrophy, ALS, etc)
      6. Open globe eye injuries
      7. Renal failure ONLY if pt. is Hyperkalemic
         
  • Nondepolarizing Neuromuscular Paralytic Agents
    • Rocuronium 1 mg/kg IV
      • Onset: 45 sec
      • Duration: 40 min
      • Defasciculating: 0.06mg/kg; maintenance: 0.6mg/kg
      • SE: Tachycardia. Longer duration of action makes it a second choice to succinylcholine. Use if succinylcholine contraindicated
    • Vecuronium 0.15mg/kg IV
      • Onset: 90 sec
      • Duration: 75 min
      • Defasciculating: 0.01mg/kg; maintenance: 0.1mg/kg
      • SE: Prolonged recovery time in obese or elderly, or if there is hepatorenal dysfunction
Pass tube (intubate) & Placement verification:
  • BURP (Backward-Upward-Rightward-Pressure)
Post intubation Management
  • Auscultate in axillae & over stomach; Capnography; Air aspiration from tube; CXR.