Intubation and Sedation

Specialties Emergency

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Etomidate and Vec are given for initiation of intubation. What time frame does it become inappropriate that the MD does not order continued sedation?

Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.

wtbcrna and qcumba:

I think also we've gotten a bit off topic here and may be loosing some "regular" ED RN types - the OP was referring to RSI, and I'm assuming with generally accepted RSI dosing; not induction....

I think the OP's question/points were good ones that apply across the board to most ED folks and the uses these same ED folks would be needing to utilise it for; I think when we start talking about uses/doses outside of that box it just clouds the picture.

I would say that the general ED RN MUST be familiar with the agents and doses typically used in their setting, which "should" mirror the agents and doses typically used in "most" ED settings; not discounting the occasional MD who orders something a little different or particular.

It would obviously NOT be in the scope of the ED RN practice (and maybe even prohibited by their state BON) to be using some indution agents or even using the "usual" agents at induction doses; of course one of the rationales for that would be their general unfamiliarity with said agents and doses.

So maybe we can reel it back in here a bit and help with the OP's question/statement about need for continued sedation s/p RSI and the appropriate ways to go about this.

Good information by all however!

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Hypotension is not uncommon with larger doses of midazolam. The literature varies, but you are most likely looking at least 0.1 mg/kg for an induction dose. Midazolam is not really an optimal RSI induction agent IMHO. Anecdotally, I tend to favour etomidate (hypnomidate outside of the United States I believe?) for it's haemodynamic profile and rapid onset/short duration. However, I understand that most of us are not policy makers.

Hi,yes I tend to agree,I don't really think it's the best option either,sometimes we have to use huge doses to get the patient out enough to intubate,that we end up with a patient with no blood pressure, very often they don't have much of a bp to start with! but to get our physician's and older RN's to change thier way of doing things is almost impossible.

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Specializes in Anesthesia.
Hi,yes I tend to agree,I don't really think it's the best option either,sometimes we have to use huge doses to get the patient out enough to intubate,that we end up with a patient with no blood pressure, very often they don't have much of a bp to start with! but to get our physician's and older RN's to change thier way of doing things is almost impossible.

You would actually be better off giving high dose fentanyl or other similar opioid plus Versed rather than doing Versed alone for inductions. Some providers steer away from etomidate because they fear that it may cause adrenal suppression. You can use any induction drug(s) for intubation, but they are most beneficial when used in combination with other drugs ie. propofol, versed, and fentanyl, or etmodiate, versed, and fentanyl. There are a myriad combination of drugs that you can use for intubation, but the key is to try to keep your patient as hemodynamically stable as possible. I personally like to use a lower dose of propofol (about 1mg/kg or less) with 2-5mg of Versed, 100-150mcg or more of Fentanyl, and 100mg of lidocaine for emergent intubations ( I also sometimes like to mix 1mg to 2mg of ketamine per cc of propofol to help with hemodynamically stability and analgesia).

The key to remember is that each induction and each sedation strategy should be personalized for each patient and their individual comorbidities/presenting problems.

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Specializes in Anesthesia.
wtbcrna and qcumba:

I think also we've gotten a bit off topic here and may be loosing some "regular" ED RN types - the OP was referring to RSI, and I'm assuming with generally accepted RSI dosing; not induction....

I think the OP's question/points were good ones that apply across the board to most ED folks and the uses these same ED folks would be needing to utilise it for; I think when we start talking about uses/doses outside of that box it just clouds the picture.

I would say that the general ED RN MUST be familiar with the agents and doses typically used in their setting, which "should" mirror the agents and doses typically used in "most" ED settings; not discounting the occasional MD who orders something a little different or particular.

It would obviously NOT be in the scope of the ED RN practice (and maybe even prohibited by their state BON) to be using some indution agents or even using the "usual" agents at induction doses; of course one of the rationales for that would be their general unfamiliarity with said agents and doses.

So maybe we can reel it back in here a bit and help with the OP's question/statement about need for continued sedation s/p RSI and the appropriate ways to go about this.

Good information by all however!

I think we are all in agreement that a patient needs to have continued sedation after intubation no matter if it is an RSI or not. Unless you are planning on having the patient intubated only for a very short time it will be necessary to start sedating the patient immediately after intubation.

As far as staying with the same original topic I would say there is a lot more to gained by broadening the discussion and letting it go where it may rather than keeping with same topic we all agree on and know should be done in the first place.

There are numerous sedating protocols for patients that are intubated/mechanically ventilated pick one that your providers can agree and go with it.

FYI: Trauma and Emergency C-Section patients have the highest recall rates during intubation/anesthesia which has led to numerous lawsuits and cases of patient PTSD from recall sometimes it can't be helped that patients remember other times it is the healthcare providers fault....

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Can RNs administer norcuron or anectine during rapid sequence intubation in TN?

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Specializes in ED.

We use a combo o

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Specializes in ED.

We use a combo of versed, succ, etomidate, and Ativan depending on pt age, condition, hemodynamic stability, and vitals. The combo chosen depends on the doc. Our facility typically uses propofol for sedation, and I start it up as soon as I have confirmation of placement.

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Can RNs administer norcuron or anectine during rapid sequence intubation in TN?

Yes, I believe so.

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I got this one! Been an ER RN for 13 yrs, was a paramedic before that. I got the h1n1 from a pt in 2009-and was in ARDS in 12hrs. was endo'd and stayed on a vent for 4mo. When i woke up i couldnt wait to tell people what i experienced! Holy.......@#*!. It was terrible..I had always had a calmness about me, could handle almost anything..worked great under pressure,,,thrived off of it. Now .......I get anxiety just by the smell of a hospital. My career is over..Even though my body is only 70% better, it is awfull to not be able to control yourself. Guys...i was terrified while i was under. I had the worst dreams (nightmares). Please be carefull what is said around the pt while they are under. I know we are all guilty of inappropriate comments around a sedated pt but it does affect us pts.. I felt awefull of the things i might have done to my pt now....God i am humbled....but what do i do for you now?

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