RSI Meds and Doses

Question 1

RSI Meds and Doses

RSI Preparation

Answer 1

BLESSED B
BVM
Laryngoscope
ET-Tube
Syringe
Stylet
Suction
End-Tidal CO2
Drugs
Backup

Question 2

RSI Meds and Doses

Female ET Tube

Answer 2

Females: 7.5 ET max, inflate 4ml, 18 cm

Question 3

RSI Meds and Doses

Male ET Tube

Answer 3

Males: 8 ET max, inflate 5 ml, 20 cm

Question 4

RSI Meds and Doses

Difficult to bag:

Answer 4

Mask seal, obesity, age > 55, no teeth, stiff lungs

Question 5

RSI Meds and Doses

Difficult to tube:

Answer 5

Look, eval 3-3-2, mallampati, obstruction, neck mobility

Question 6

RSI Meds and Doses

Difficult to cric:

Answer 6

Surgery, hematoma/abscess, radiation, neck tumor/trauma

Question 7

RSI Meds and Doses

Preoxygenation/denitrogenation:

Answer 7

100% FiO2 x 3 min or 8 VC breaths (non rebreather)- put nasal cannula on underneath. Consider CPAP mask or PEEP valve if unable to get O2 sat > 95%

Question 8

RSI Meds and Doses

Pretreatment

Lidocaine:

Answer 8

1.5mg/kg IV (for head trauma, increased ICP, bronchospasm, asthma)

Question 9

RSI Meds and Doses

Pretreatmentfor ICP, cardiac ischemia, aortic dissection

Fentanyl:

Answer 9

3 mcg/kg IV over 1-2 min (for ICP, cardiac ischemia, aortic dissection)

• best option for increased ICP
• caution: respiratory depression, hypotension, chest wall rigidity

Question 10

RSI Meds and Doses

Pretreatment

Atropine (for peds with bradycardia)

Answer 10

0.01-0.02 mg/kg IV

Question 11

RSI Meds and Doses

Pretreatment

Paralytic:

Answer 11

Roc 1mg/kg or Vec 0.1 mg/kg (defasciculation) if using sux - wait 2 min
In ICP if HTN use nicardipine, use hypertonic saline (250 ml over 10-15 min)

Question 12

RSI Meds and Doses

Etomidate

Answer 12

0.3mg/kg IV- 20 mg- onset <1 min, duration 10-20 min- nonbarbiturate hypnotic
Protects from myocardial and cerebral ischemia, causes minimal histamine release
Benefits: less change to hemodynamics, decrease ICP, decrease intraocular pressure
Caveats: Myoclonic jerking, seizures, vomiting, no analgesia, decreased cortisol
Caution: in septic patients (adrenals)

Question 13

RSI Meds and Doses

Propofol

Answer 13

2mg/kg IV over 1 min- 150 mg- onset 20-40s, duration 8-15 min- lipophilic
Myocardial depression and vasodilation
Benefits: antiemetic, anticonvulsant, decrease ICP
Caveats: hypotension, apnea, no analgesia

Question 14

RSI Meds and Doses

Ketamine

Answer 14

2mg/kg IV- 140 mg onset-1 min, duration 10-20min- phencyclidine derivative
Preserves respiratory drive (awake intubation), direct smooth muscle relaxation and bronchodilation (refractory status asthmaticus)
- not prefered in elderly or patients with risk of
Cardiac ischemia
Benefits: bronchodilator, dissociative amnesia, analgesia (good in hypotensive and TBI)
Caveats: HTN, tachy (catecholamine release), laryngospasm, increase secretions, emergence phenomenon

Question 15

RSI Meds and Doses

Ketofol

Answer 15

(100 mg ketamine, 100 mg propofol to make 20 ml)- 0.2 ml/kg- 14ml

Question 16

RSI Meds and Doses

Versed

Answer 16

0.3mg/kg IV- hypotension

Question 17

RSI Meds and Doses

Succinylcholine

Answer 17

1.5mg/kg IV (2 mg/kg in peds) onset 45-60 s, duration- 5-9 min(avoid in ICP)
Depolarizing neuromuscular blocker- high affinity for cholinergic receptors, resistant to
acetylcholinesterase
Contraindications: malignant hyperthermia, strokes with hemiparesis > 72 hrs, ICU stay > 2 weeks, burns/trauma> 72
hours, NMI disease, myopathies/muscular dystrophies, preexisting hyperkalemia, guillain-barre, severe infection > 5d
Complications: fasciculations, transient increased intragastric, intraocular and ICP, masseter spasm alone or with
malignant hyperthermia, bradycardia, prolonged apnea with pseudocholinesterase deficiency or myasthenia gravis,
serum K will rise 0.5 mEq/L
Malignant hyperthermia- rapid fever, muscle rigidity, acidosis, hyperkalemia- treat with dantrolene (2.5mg/kg)

Question 18

RSI Meds and Doses

Rocuronium

Answer 18

1mg/kg IV onset 1-3 min, duration 30-45 min
Nondepolarizing neuromuscular blocker- compete with acetylcholine for cholinergic receptors , can be antagonized by anticholinesterase
Complication: tachycardia, long duration of action
Reversal: sugammadex- 2-4mg/kg- encapsulates drug Neostigmine (cholinesterase inhibitor)- can give with glycopyrrolate

Question 19

RSI Meds and Doses

Vecuronium

Answer 19

0.1mg/kg IV onset 2-4 min, duration 25-40 min

Complication: prolonged recovery time in obese, elderly or hepatorenal dysfunction, hypotension

Question 20

RSI Meds and Doses

Position:

Answer 20

Bed, axes, Sellick, BURP, DL–Face parallel, ears/notch, 30 degree Heads-up, collar plan

Question 21

RSI Meds and Doses

Placement & confirmation:

Answer 21

Visualize thru cords, BL LS, fog in tube, EtCO2, capnography, CXR, US

Question 22

RSI Meds and Doses

Post-tube mgmt:

Answer 22

Distance@teeth, tube secured, recheck BS & VS, vent settings, NGT, CXR, ABG after 10 min, sedate, vent settings.

Question 23

RSI Meds and Doses

Vent settings:

Answer 23

Assist control-volume
Vt (protection)- 6-8 cc/kg PBW
IFR/flow rate (comfort)- 60-80 lpm
RR (ventilation)- initial 18- titrate based off CO2 (if acidotic may have to increase)
FiO2/PEEP (oxygenation)- Start at 100% and PEEP 0-5, wait 5 minutes draw ABG, titrate
goals: PaO2 55-90 mmHg, SpO2 88-95% PaCO2 40 mm Hg, FiO2 40-60%
check plateau pressure: <30, if higher lower Vt
In obstructive patients: increase expiratory time, permissive hypercapnia
IFR- 80-100, PEEP 0, RR 10 to start (I:E 1:4-5)

Question 24

RSI Meds and Doses

Post Intubation Analgo-sedation:

Answer 24

Titrate to calm, spontaneously breathing
Fentanyl 2 mcg/kg bolus then 1 mcg/kg/hr
hydromorphone 0.5-1 mg bolus then q10min till effect and
Midazolam 0.05 mg/kg bolus then 0.025 mg/kg/hr
propofol 0.5mg/kg bolus then 20 mcg/kg/hr
Propofol infusion syndrome-metabolic acidosis, bradycardia, hyperlipidemia,hepatomegaly
Rhabdomyolysis, green urine
ketamine 1 mg/kg bolus then 0.5 mcg kg/hr

Question 25

RSI Meds and Doses

Vent Troubleshooting

Answer 25

Take pt off vent, use bag! check for displacement, obstruction, PTX, equipment failure