RSI rapid sequence intubation question

  1. 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 for anyone that may have used it or has a good idea. I saw it when I googled RSI www.rapitube.com We are looking for something to put on our crash carts and on our airway box. Please help
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  2. 44 Comments

  3. by   TazziRN
    AAAAAAAGHHHH!!! I just came home and it was my last day of work for the next 2.5 weeks, or I could have looked up what we have on our crash carts! I don't know the dosages off hand, but it's weight based in kids, of course. In adults we usually use a set amount unless the pt is really tiny or really large, then we adjust.
  4. by   neneRN
    We generally use 20 of Etomidate and 100 of Succ for most inubations....for the suspected head injuries we also add 50 of Lido and 1 of Norcuron. As Tazzi said, we use set amts unless pt is very large/small because Etomidate and Succ are really supposed to be weight based.
  5. by   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
  6. by   jewelcutt
    For a RSI Etomidate .3mg/kg with either Succs 1.5mg/kg or Zemuron 1.2mg/kg. Don't think propofol would be appropriate on a trauma patient, but the dose is 2mg/kg.
  7. by   Rio
    I would discuss the topic with the medical director, pharmacy and clinical staff and come up with your own cheat sheet based on your availability. You'll need pretreatmetn, induction/sedation, paralytics and then post intubation management. This is important because there are many issues with medications involved in the RSI procedure. Lidocaine: no studys have been done to indicate the efficacy of Lidocaine during RSI. Not to start a discussion, but as an example, lidocaine is a negative inotrope and I may avoid using it in multi-trauma pt with a head injury even though "it's always given." De-fasicultaing dose of a NonDepolarizing NMBA, some practitioners are moving away, others are still using. Versed vs Etomidate, etomidate while we use it most of the time, I do not use it in the septic pt due to the issues with cortisol suppression. Succinylcholine: Recently was almost given to a pt with ESRD not knowing K+ level. The issue is the pt did not even need a NMBA, etomidate was enough but they were going to push the SUX because its in the sequence.
    So the key point is to not just know the dosages but also the whys and why nots.
  8. by   trixytop4
    In the facility I work at I Love the RSI Protocol. It is weight based and we already have it figured out. The following are the Medications and dosages that we use in order:
    Lidocaine 1mg/kg Max dose 300mg this is for difisicualtion
    Vercuronium 0.01mg/kg
    Etomidate 0.3mg/kg standard dose 20mg
    Succinylcholine 1mg/kg Max dose 150mg or 2mg/kg Max dose 150mg (only to be used for wt of 70kg or higher)

    This dosage makes for a smooth intubation. You can use versed for sedation after intubation or Fentanyl as a bolus then do a fentanyl drip of 1000mcg in 100ccD5w. We have had a great success rate. Let me know if you would like a copy faxed to you of our chart. I would be glad to share with you. My email address is trixytop4@yahoo.com.
  9. by   MedicRN111
    I have sat back and read these posts long enough. Time to start posting myself. I always get a laugh when people who dont order the meds nor have any clue on how they work, start to offer their advice. Here is correct and recommended doses for RSI, from someone who does it every day. In Order:

    Lidocaine is given for Poss. Head Inj. not difisiculation
    1 mg/kg
    Atropine (Peds Only) Anyone know why??
    0.01-0.02 mg/kg
    Fentanyl
    3 mg/kg
    Etomadate for sedation
    0.3 mg/kg
    Succinylcholine for paralytic
    Give 10% of your calculated dose before anything (difisiculating dose)
    1-1.5 mg/kg max dose of 150mg
    2 mg/kg for Peds Max dose 200mg Can anyone tell me why????
    Vercuronium Long-term paralytic
    0.1 mg/kg
    Versed Long term sedative
    2-5 mg PRN or Versed drip

  10. by   AmiK25
    Quote from MedicRN111
    I have sat back and read these posts long enough. Time to start posting myself. I always get a laugh when people who dont order the meds nor have any clue on how they work, start to offer their advice. Here is correct and recommended doses for RSI, from someone who does it every day. In Order:

    Lidocaine is given for Poss. Head Inj. not difisiculation
    1 mg/kg
    Atropine (Peds Only) Anyone know why??
    0.01-0.02 mg/kg
    Fentanyl
    3 mg/kg
    Etomadate for sedation
    0.3 mg/kg
    Succinylcholine for paralytic
    Give 10% of your calculated dose before anything (difisiculating dose)
    1-1.5 mg/kg max dose of 150mg
    2 mg/kg for Peds Max dose 200mg Can anyone tell me why????
    Vercuronium Long-term paralytic
    0.1 mg/kg
    Versed Long term sedative
    2-5 mg PRN or Versed drip

    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.
  11. by   Larry77
    Quote from MedicRN111
    I have sat back and read these posts long enough. Time to start posting myself. I always get a laugh when people who dont order the meds nor have any clue on how they work, start to offer their advice.
    With an attitude like that please just go back to reading the posts and leave your patronizing to yourself thanks.

    By the way different sources give different guidelines that's why I quoted mine
  12. by   passgasser
    Quote from MedicRN111
    I always get a laugh when people who dont order the meds nor have any clue on how they work, start to offer their advice. Here is correct and recommended doses for RSI, from someone who does it every day.
    Even funnier when someone makes a statement like this, then promptly makes a number of mistakes in their recipie.

    From an anesthesia perspective, there are a lot of ways to skin the cat. I have used each of the drugs listed in various RSI scenarios, depending on the variables that different patients will have, and none of the drugs are "wrong" per se. Since doses are available everywhere, just a few comments about the drugs.

    Lidocaine: Given for two reasons. First, if using propofol, it may attenuate the burning vein sensation that can accompany this drug's administration. Second, given IV, it can help to anesthetize the airway, making the patient less likely to buck against the tube once the paralytic wears off. 300 mg of lidocaine is a HUGE dose, and can cause the patient to seize. It won't help with fasciculations anyway. Back off on that dose.

    Fentanyl: 3 mg/kg? Wow. Never given that much to a patient in my life. It is a narcotic, and can be given to a patient either in pain or about to undergo a painful procedure. When called to the ER for RSI, I don't take fentanyl along. I don't need it.

    Versed: Given IV, it has rapid onset, causing sedation and amnesia. USUALLY, it has little or no effect on respiratory effort. Often, when called to the ICU to intubate a patient, it is the only drug I give prior to intubation. I dose it to effect, then proceed with direct laryngoscopy. However, if doing an RSI fearing potential aspiration, I'll usually give one of the hypnotics and sux.

    Etomidate: Not my favorite drug for induction of general anesthesia, but it does have a place. Propofol is faster acting, but if the patient has a significant cardiac history, I'll use etomidate. If they have a potential brain injury, I'll use sodium thiopental. And as I already said, often I don't give this class of drug at all for emergent intubations outside of the OR.

    Succinylcholine: A rapid and short acting depolarizing paralytic. Give atropine with it when giving the drug to peds patients, as sux can cause profound bradycardia in kids. Also, it is a depolarizer, and will cause a rise in K+ levels, so don't give it to someone who already has a high potassium level. Fasciculations are the muscle twitches you see when the drug causes depolarization, resulting in tensing of the skeletal muscle. This can leave the patient with mild to moderate myalgia for a day or so after administration. Once you understand the drug, you understand that giving 10% of the calculated dose to prevent fasciculations (called a defasciculating dose) is a waste of time. Your initial dose will simply cause milder fasciculations that you may not be able to observe, but can still leave the patient with the myalgia you are trying to prevent.

    There is an upside to fasciculation. Fasciculation can be a direct monitor to tell you exactly when a patient is ready for intubation. Give the sux, then watch the patient's eyelids. In a moment, the eyelid will flutter. When the fluttering stops, intubate the patient. Since you cannot bag ventilate a patient who needs an RSI, and we have all seen patients who, even after prolonged prebreathing of 100% O2, desaturate quickly, sometimes it is in the patient's best interest to trade a short time of mild muscle pain for a direct, easily observed monitor of when you can tube the patient. (By the way, this is not recommended for potential head injury patients, as the fasciculations caused can cause a transient increase in ICP. However, there has been some discussion in the literature lately suggesting that this transient increase may not be clinically significant.)

    Non-depolarizing neuromuscular blockers: (i.e. vecuronium, etc) These are much longer acting paralytics, and take longer to take effect than sux. The only one considered acceptable for RSI is rocuronium, and if you are going to use it, you better be damn sure you will be able to intubate the patient. In small doses, i.e. 5 - 10% of a calculated intubation dose, these are the only drugs that will prevent the fasciculations caused by succinylcholine. Once the sux has worn off, these drugs may be given to provide longer paralysis to prevent patient movement.

    RSI is done whenever you are intubating a patient with a known or potential full stomach (i.e. they have eaten in the last 8 hours) or someone with known GERD. To my way of thinking, this means all ER intubations are RSI. If you are doing an RSI, you also must also have someone doing cricoid pressure. Pressure is applied at the cricoid membrane, NOT THE thyroid cartilage. The textbook says you must apply about 44 Newtons of pressure. That's about 10 pounds. Do not release the pressure until tube position is confirmed by CO2 and ascultation of breath sounds. It is done to help prevent vomiting and aspiration.
  13. by   MedicRN111
    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.
    How do you think it prevents a rise in ICP, by blunting the sympathetic NS.
    Laryngoscopy = Increased chances of Elevated ICP

    Geez.... see this is what I mean!!!

    The 3 mg/kg should of been mcg/kg of Fentanyl. Common typo. LOL (the effects of being up all night) LOL
  14. by   MedicRN111
    Quote from passgasser
    Even funnier when someone makes a statement like this, then promptly makes a number of mistakes in their recipie.

    From an anesthesia perspective, there are a lot of ways to skin the cat. I have used each of the drugs listed in various RSI scenarios, depending on the variables that different patients will have, and none of the drugs are "wrong" per se. Since doses are available everywhere, just a few comments about the drugs.

    Lidocaine: Given for two reasons. First, if using propofol, it may attenuate the burning vein sensation that can accompany this drug's administration. Second, given IV, it can help to anesthetize the airway, making the patient less likely to buck against the tube once the paralytic wears off. 300 mg of lidocaine is a HUGE dose, and can cause the patient to seize. It won't help with fasciculations anyway. Back off on that dose.

    Fentanyl: 3 mg/kg? Wow. Never given that much to a patient in my life. It is a narcotic, and can be given to a patient either in pain or about to undergo a painful procedure. When called to the ER for RSI, I don't take fentanyl along. I don't need it.

    Versed: Given IV, it has rapid onset, causing sedation and amnesia. USUALLY, it has little or no effect on respiratory effort. Often, when called to the ICU to intubate a patient, it is the only drug I give prior to intubation. I dose it to effect, then proceed with direct laryngoscopy. However, if doing an RSI fearing potential aspiration, I'll usually give one of the hypnotics and sux.

    Etomidate: Not my favorite drug for induction of general anesthesia, but it does have a place. Propofol is faster acting, but if the patient has a significant cardiac history, I'll use etomidate. If they have a potential brain injury, I'll use sodium thiopental. And as I already said, often I don't give this class of drug at all for emergent intubations outside of the OR.

    Succinylcholine: A rapid and short acting depolarizing paralytic. Give atropine with it when giving the drug to peds patients, as sux can cause profound bradycardia in kids. Also, it is a depolarizer, and will cause a rise in K+ levels, so don't give it to someone who already has a high potassium level. Fasciculations are the muscle twitches you see when the drug causes depolarization, resulting in tensing of the skeletal muscle. This can leave the patient with mild to moderate myalgia for a day or so after administration. Once you understand the drug, you understand that giving 10% of the calculated dose to prevent fasciculations (called a defasciculating dose) is a waste of time. Your initial dose will simply cause milder fasciculations that you may not be able to observe, but can still leave the patient with the myalgia you are trying to prevent.

    There is an upside to fasciculation. Fasciculation can be a direct monitor to tell you exactly when a patient is ready for intubation. Give the sux, then watch the patient's eyelids. In a moment, the eyelid will flutter. When the fluttering stops, intubate the patient. Since you cannot bag ventilate a patient who needs an RSI, and we have all seen patients who, even after prolonged prebreathing of 100% O2, desaturate quickly, sometimes it is in the patient's best interest to trade a short time of mild muscle pain for a direct, easily observed monitor of when you can tube the patient. (By the way, this is not recommended for potential head injury patients, as the fasciculations caused can cause a transient increase in ICP. However, there has been some discussion in the literature lately suggesting that this transient increase may not be clinically significant.)

    Non-depolarizing neuromuscular blockers: (i.e. vecuronium, etc) These are much longer acting paralytics, and take longer to take effect than sux. The only one considered acceptable for RSI is rocuronium, and if you are going to use it, you better be damn sure you will be able to intubate the patient. In small doses, i.e. 5 - 10% of a calculated intubation dose, these are the only drugs that will prevent the fasciculations caused by succinylcholine. Once the sux has worn off, these drugs may be given to provide longer paralysis to prevent patient movement.

    RSI is done whenever you are intubating a patient with a known or potential full stomach (i.e. they have eaten in the last 8 hours) or someone with known GERD. To my way of thinking, this means all ER intubations are RSI. If you are doing an RSI, you also must also have someone doing cricoid pressure. Pressure is applied at the cricoid membrane, NOT THE thyroid cartilage. The textbook says you must apply about 44 Newtons of pressure. That's about 10 pounds. Do not release the pressure until tube position is confirmed by CO2 and ascultation of breath sounds. It is done to help prevent vomiting and aspiration.


    We are talking about RSI here. Not Intubating someone in the OR, a controlled environment, where a trained monkey could Intubate. The only place in a OR for a RN is to be handing the instruments to the MD. I understand the whole CRNA thing, but having any form of RN maintaining a airway is not her place. Other than that I wont even comment on this long drawn out post. I dont even have time to start picking it apart, with its multiple errors.

    I can picture it now:

    Nurse. Yes Doctor? Sponge my forehead! Yes Doctor.

    HAHA

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