RSI rapid sequence intubation question - page 3

I have asked this question on another site and have had no real response. What do you use for rapid sequence intubation dosing references. I have seen a dosing card on the internet and I am looking... Read More

  1. by   rgroyer1RNBSN
    Ok heres our usual RSI stuff from the chopper:

    1.) we usually go with 120 sucs adjust if the pt is smaller then average or larger.

    2.) Etomidate- .03mg/kg

    3.) lido- head injury or if using propofol.

    4.) I prefer versed over etomidate we usually start at 3mgs and give more or less per size.

    5.)our vec dose is .01mgs/kg

    6.) and Morphine start at 4 and titrate to 10 max.
  2. by   rgroyer1RNBSN
    Quote from passgasser
    ERNurse1139
    Please forgive me, some of the tone of my original post was directed elsewhere. It was not meant for those with genuine questions. (I am Passgasser, not MedicRN111.) In answer to your questions:

    Sometimes, we (anesthesia) choose to give a small dose of a non-depolarizing neuromuscular blocker (NDMB) as our first drug in a sequence of drugs to induce general anesthesia. In my case, that is usually about five mg of rocuronium. The dose is small enough that it will not cause the patient to become completely paralyzed, but is large enough to prevent fasciculation. (This works because NDMB's work at a different end of the neuromuscular chain than does succinylcholine.) In order to be effective, the NDMB must be given a long enough time to attach to the appropriate receptors before administration of sux. Whenever I do this, as I am giving the drug I warn the patient they may start to feel a bit weak, and their vision may blur. However, you are exactly correct that in emergent cases, such administration can often be a luxury, one for which you do not have time. The fact of the matter is that not all patients given sux without a defasciculating dose of another medication have myalgia, and for most who do, the myalgia is mild. If you have a patient in the ER in need of emergent intubation, you must assume that they have a full stomach, and you must do a rapid sequence induction. You will often need to know to the second when it is safe and possible to proceed with intubation, and in such cases, fasciculation can help. When the fasciculation ends, tube the patient.

    The only drug that causes true fasciculation in use in the US (that I know of) is succinylcholine. It causes these fasciculations by causing the neurons of motor muscle to fire (depolarization), but for several minutes will not allow them to reset themselves to be able to fire again (repolarization). Hence, you have a brief period of skeletal muscle contraction (fasciculation), followed by several minutes of paralysis, until the drug is cleared from the neuronal junctions, allowing repolarization. (By the way, MedicRN111, would you care to enlighten the audience as to why this works on skeletal muscle, but does not cause what in effect would be a cardiac seizure? After all, isn't the heart just another muscle?)

    So, in emergent situations, giving anything as a defasciculating medication serves only to prolong the time it takes before intubation, and take away the one monitor you have that tells you immediately when it is OK to proceed with intubation. No matter the dose, succinylcholine is always going to work at the same place in skeletal muscle neurons, therefore, giving 10% of the calculated dose up front won't prevent fasciculation. By giving a sub-clinical dose, you will still cause depolarization of some of the neurons, and the rest will depolarize when you give the intubating dose. Now, I can think of at least one instance where giving the dose suggested by MedicRN111 could really bite you on the backside. We know that sux can cause profound bradycardia in pediatric patients. In fact, it will often do so when giving additional doses of the drug. So, without an anticholinergic, if you give 10% of your intubation dose, then give other drugs, then give the intubating dose of sux, you may find yourself in a far worse situation that where you started.

    As to giving anticholinergics, yes, they can dry secretions. However, if that were the only reason they were given, in a situation requiring RSI, they would not have adequate time to do so prior to laryngoscopy. All the secretions in the mouth at the time you start administering drugs will still be there 30 to 45 seconds later when you try to intubate the patient. The primary reason atropine is given with succinylcholine in pediatric patients is to prevent profound bradycardia. To dry secretions, there are better choices than atropine anyway. Robinul is another anticholinergic drug that works very well to dry secretions, and does so with less tachycardia than atropine. In order to do so, it must be given several minutes before induction and intubation. My personal preference is that it not be given, because I have had patients whose mouths were so dry that insertion of the laryngoscope was tougher than usual.

    To MedicRN111, if my last post contained so many errors, would you please be kind enough to show me where? All of us in anesthesia are waiting for you to show us the error of our ways. And if a "trained monkey" could intubate any patient in the OR, perhaps you would care to accompany this trained monkey and show me your skill and proficiency at bronchoscopic intubation of the patient whose epiglottis, much less airway, cannot be visualized with a laryngoscope? Or perhaps you would care to show me your skill at intubation where the patient has a trauma that is filling the oropharynx with blood. You can't suction it out fast enough to tube the patient, what do you do now?

    Well if it was me with the trauma pt. on the chopper I would probabley end up doing a cric, but you do have to remember Im in very emergent situations and dont have time to screw around. so Medic if you can come up with a better answer then that please let us know.
  3. by   BrickCityMedicX
    Quote from AmiK25
    I would think that someone who does it everyday would know that you should not give someone 3 mg/kg of Fentanyl. I have never heard of giving 10% of your Sux dose to defasciculate....only heard of giving 10% of the intubating dose of a non-depolarizing agent. Does the Succs actually work? Also, lidocaine is given for other reasons besides prevention of increased ICP with Succs (which really requires about 1.5 mg/kg). It also blunts the sympathetic nervous system response to laryngoscopy.
    I was under the impression that,

    A) you give NOT 10% of the total dose in order to defasiculate, RATHER a weight based dose of .01 mg/kg

    and, more importantly,

    B) the defasiculating agent is not Succinlycholine, it's Vecuronium...

    and lidocaine is for preventing/blunting the rise in ICP during an intubation where an increase in ICP is suspected, or confirmed.

    And Atropine is to prevent/blunt increased Vagal tone in children when intubating them, as their nervous systems are more sensitive to vagal stimulation.
  4. by   SDS_RN
    Quote from passgasser
    ERNurse1139
    Please forgive me, some of the tone of my original post was directed elsewhere. It was not meant for those with genuine questions. (I am Passgasser, not MedicRN111.) In answer to your questions:

    Sometimes, we (anesthesia) choose to give a small dose of a non-depolarizing neuromuscular blocker (NDMB) as our first drug in a sequence of drugs to induce general anesthesia. In my case, that is usually about five mg of rocuronium. The dose is small enough that it will not cause the patient to become completely paralyzed, but is large enough to prevent fasciculation. (This works because NDMB's work at a different end of the neuromuscular chain than does succinylcholine.) In order to be effective, the NDMB must be given a long enough time to attach to the appropriate receptors before administration of sux. Whenever I do this, as I am giving the drug I warn the patient they may start to feel a bit weak, and their vision may blur. However, you are exactly correct that in emergent cases, such administration can often be a luxury, one for which you do not have time. The fact of the matter is that not all patients given sux without a defasciculating dose of another medication have myalgia, and for most who do, the myalgia is mild. If you have a patient in the ER in need of emergent intubation, you must assume that they have a full stomach, and you must do a rapid sequence induction. You will often need to know to the second when it is safe and possible to proceed with intubation, and in such cases, fasciculation can help. When the fasciculation ends, tube the patient.

    The only drug that causes true fasciculation in use in the US (that I know of) is succinylcholine. It causes these fasciculations by causing the neurons of motor muscle to fire (depolarization), but for several minutes will not allow them to reset themselves to be able to fire again (repolarization). Hence, you have a brief period of skeletal muscle contraction (fasciculation), followed by several minutes of paralysis, until the drug is cleared from the neuronal junctions, allowing repolarization. (By the way, MedicRN111, would you care to enlighten the audience as to why this works on skeletal muscle, but does not cause what in effect would be a cardiac seizure? After all, isn't the heart just another muscle?)

    So, in emergent situations, giving anything as a defasciculating medication serves only to prolong the time it takes before intubation, and take away the one monitor you have that tells you immediately when it is OK to proceed with intubation. No matter the dose, succinylcholine is always going to work at the same place in skeletal muscle neurons, therefore, giving 10% of the calculated dose up front won't prevent fasciculation. By giving a sub-clinical dose, you will still cause depolarization of some of the neurons, and the rest will depolarize when you give the intubating dose. Now, I can think of at least one instance where giving the dose suggested by MedicRN111 could really bite you on the backside. We know that sux can cause profound bradycardia in pediatric patients. In fact, it will often do so when giving additional doses of the drug. So, without an anticholinergic, if you give 10% of your intubation dose, then give other drugs, then give the intubating dose of sux, you may find yourself in a far worse situation that where you started.

    As to giving anticholinergics, yes, they can dry secretions. However, if that were the only reason they were given, in a situation requiring RSI, they would not have adequate time to do so prior to laryngoscopy. All the secretions in the mouth at the time you start administering drugs will still be there 30 to 45 seconds later when you try to intubate the patient. The primary reason atropine is given with succinylcholine in pediatric patients is to prevent profound bradycardia. To dry secretions, there are better choices than atropine anyway. Robinul is another anticholinergic drug that works very well to dry secretions, and does so with less tachycardia than atropine. In order to do so, it must be given several minutes before induction and intubation. My personal preference is that it not be given, because I have had patients whose mouths were so dry that insertion of the laryngoscope was tougher than usual.

    To MedicRN111, if my last post contained so many errors, would you please be kind enough to show me where? All of us in anesthesia are waiting for you to show us the error of our ways. And if a "trained monkey" could intubate any patient in the OR, perhaps you would care to accompany this trained monkey and show me your skill and proficiency at bronchoscopic intubation of the patient whose epiglottis, much less airway, cannot be visualized with a laryngoscope? Or perhaps you would care to show me your skill at intubation where the patient has a trauma that is filling the oropharynx with blood. You can't suction it out fast enough to tube the patient, what do you do now?

    I see that this post is quite old but I gained some very valuable information from this. I just started working in the ED a few months ago and also rotate to SDS so this gave me a bit more insight and knowledge than I had before. passgasser did a phenominal job of explaining everthing in both posts.:bowingpur
  5. by   poppy07
    What is defasciculate? Also, is there any difference in "rapid sequence intubation" vs. "intubation"? Thanks
  6. by   TraumaNurseRN
    Since When Does Surgery Do Rsi As In The Field Or The Ed Does??? Ed Is An Uncontrolled Environment As Apposed To The Or.
  7. by   TraumaNurseRN
    It's funny how the OR thinks ED is like "driving through the hood" sometimes.....Try what we do in the environment we have is all I have to say....then come talk to us after the shift.....This attitude that they are superior just floors me. We ALL have our role, and each department has their own policies....Even RSI....which, if totally different monster enroute to the ED, in the ED....and then in the OR where everything is there at the bedside and sterile....I makes me laugh.....literally out loud!
  8. by   TraumaNurseRN
    Quote from skipaway
    It's a shame you so underestimate your fellow RNs. You, being an RN, have slammed only yourself. Are you just an RN who sponges a Doctor's brow? I'd guess not. Why don't you try to shadow a CRNA and see what we do everyday. It may change your perspective.
    OR=controlled environment
    ED= uncontrolled environment..........HUGE DIFFERENCE!!!!
    SERIOUSLY.....THERE'S A HUGE DIFFERENCE. THIS IS EMERGENCY NURSING SITE....PLEASE UNDRSTAND THAT.
  9. by   poppy07
    that doesn't answer my question. what is this nonsense defensive mechanism about OR vs. ED?
  10. by   northshore08
    Poppy, go back into the thread for a good explanation of defasciculation.

    Plain intubation is just that...no meds, just put the tube in. Pt needs to be pretty much unconscious, no gag reflex, or at least not combative enough to fight being intubated. RSI is intubation using a set of meds designed to sedate and paralyze as you are intubating.

    Hope this helps.
  11. by   northshore08
    BTW, as to your last question, just let it go. That's a whole other thread.
  12. by   MassED
    Quote from Larry77
    My reference says Etomidate 0.3mg/kg and Succinylcholine 1-2mg/kg (or can use Rocuronium 0.6-1.2/kg)

    from Emergency and Critical Care Pocket guide by Informed
    I have that pocket guide too, love it!
  13. by   rodrn
    http://secure2.acep.org/BookStore/p-...ing-guide.aspx I use this from ACEP and I love it. All the other info in informed is good but I only put this card in my pocket, as well as their other card for emergency drips.
    Last edit by rodrn on Apr 21, '09 : Reason: more to add

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