Intubation Preparation

[punkstar]

For possible and certain intubations, I was just curious as to how much of each medication do you draw up? What medications do you use? I know we have a kit containing all the neuromuscular blockers that needs to be used in an intubation. What does your kit contain? I'm also still trying to understand the medications and how they work...one is a muscle paralyzer...lidocaine is for something else...please fill me in on this ASAP. I don't get much experience as to seeing what medications come into play. Thanks.

[mona4522]

i work in icu... and i assisted with my first intubation today.. we initially gave some fentanyl, then propofol to sedate the patient, the we used suxamathonium as the paralyzing agent.... the patient was only a very small lady so that pretty much did the trick.... that is what we use most often in our unit..

[MassED, BSN, RN]

Ares get premedicated with Lido and benadryl, then they get versed, then morphine, fentanyl, or demerol drops down the line, then they get either sucs or vec, and then there tubed, then there put on a propofol drip or a versed gtt.

that is a lot....

[TraumaNurseRN]

each DOC is different......everywhere!!!

[GilaRRT]

that is a lot....

Not really, IMHO. If the patients hemodynamic status can tolerate large doses of meds, I say go for it. If not, see if the doc will let you premedicate with at least 3 mcg/kg of fentanyl. Anything that will blunt hemodynamic and nervous system changes associated with intubation can help produce a good outcome IMHO.

[Medic/Nurse, BSN, RN]

first and foremost.

be prepared. be very prepared.

know the procedure and medications for your facility.

make reference cards and use 'em.

drugs are only part of the process. never give drugs that you are not familiar with - never start a "drug administration sequence" until everyone is ready.

my "ideal" rsi scenario.

patient opens mouth - i classify the airway (based on how well i can visualize anatomical references - also, check for odd dentition). class of airway can predict the difficult nature of the intubation - not 100%, but gives you a good idea. apply supplemental oxygen via high flow mask to the patient (or assist respirations per bvm).

patient needs to be on ekg monitor, sao2, nibp (cycling 5 min pressures).

suction turned on with rigid wide tip suction available.

ready needed intubation supplies.

1. 2 ett tubes (size i think i need and one size smaller), with stylets placed and 10cc syringes attached - confirm and deflate cuff - add water soluble lubricant if necessary (generally not).

2. rescue airway device. king airway sized for patient. (also, could use lma or combitube).

3. cric kit available. (keeps evil spirits away and allows the intubation fairies to be kind to me - :) goddess of the the airway!!!)

4. add

* laryngoscope handle and blade (check bulb as working and secure) have another with alternate blade - may need another "viewpoint". i use a miller (straight) #3 with good results. personal preference.

* bvm with supplemental oxygen attached

* 2 colormetric end tidal detection devices (should need one, but i seem to drop stuff, if it gets wet it is useless and/or you may have a second attempt - why go hunting).

* commercial tube securing device (can use tape, but this is a better option - use it if you got it!)

* esophageal bulb detector (another way to confirm placement)

* end tidal detector (mechanical with capnography is the gold standard for placement confirmation and ventilation efficacy)

* stethoscope ready

* ng/og tube for placement. 60ml syringe. ng/og securing method.

now, for the drug part.

what is my patients weight? note this!!! most all meds are ideally given in doses that will be needed for the patients size. note all allergies, relevant medical history (some meds are contraindicated in certain instances - know them!!!).

2 iv lines are ideal, but i can go with 1 that is very patent. iv fluids must freely flow and site clear for it to be patent.

i draw and label (with a sharpie, sticker or something) all the meds in order.

pre-medicate with lidocaine (may or may not blunt rise in icp - probably does nothing, but ... ) give 1.5 mg per kg --- max dose 100mg.

wait 2 minutes.

give opiate. ett tube placement may hurt. pain increases icp - i give 3mcg/kg of fentanyl. may give sedation via versed at 2.5 mg if bp is real good and pt needs it.

have suction and bvm ready now!!!

give etomidate (give slowly over 1 minute) at 0.3 mg/kg - may need to assist patient respirations, this can depend on patient reserves. i never try to intubate after - increases risk of aspiration if gag remains. why risk it??

give succs (short acting paralytic) 2.0 mg/kg - max dose 150mg.

assist respirations per bvm - be ready with all intubation "stuff".

position patient in "sniffing" position (pt must not have c-spine precautions). wedge suction under head of patient within reach.

in less than 15 seconds in the attempt!!! the patient is not breathing!!! take laryngoscope in left hand, into patients mouth sweeping the tongue r to l, pull up visualize cords, place ett firmly between them, remain holding in place ett with my l hand, withdraw stylet, inflate cuff, attach bulb detector - release "good!" - reinflates!, apply colormetric device, give bvm breaths, good color change, confirm breath sounds via auscultation, no gastric sounds, secure ett via tape (note cm at the teeth/gum line), can place og tube via direct laryngoscopy (if desired, takes 3 seconds) and then confirm og and secure ett via commercial device - this devices also gives a path for og.

patient ventilation is assisted via bvm or patient placed on ventilator with wave form capnography and sao2 being constantly monitored.

now - additional sedation/analgesia/paralytic.

never, never, never be any part of giving long acting paralytics post intubation without providing liberal (as the bp allows, but even then add fluids, pressors, etc to maintain bp if necessary) medication for sedation and pain.

repeat !!!!!

never ever give paralytics post intubation without sedation/analgesia.

i give versed 2.5 q 2-5 min as needed.

fentanyl 2mcg/kg q 10 min as needed

diprivan does not work well for me imho in a high stimulation transport environment, so....i will do it, but add additional medication as necessary.

then i give longer acting paralytic.

norcuron 1mg/10kg patient weight - min 3mg, max 15mg q 30-1hr as needed.

hopefully, i will get the patient to somewhere else (facility or icu). i stay observant for changes in patient condition that requires additional medications (increased bp, hr, tearing, pupil response). always reconfirm ett verification via auscultation after every any patient transfer.

additionally, one can add atropine in the "pre medication" sequence to blunt vagal response (bradycardia) from the direct laryngoscopy. this is generally necessary in kiddos and the supper rare patient with know issues of hyper-vagal response. it is not routinely ever given in adults due to increases in myocardial oxygen demand from resulting increase in heart rate.

hope this helps.

the key is i know my system and know it well. forward, backward, left, right, day, night and upside down in the rain. it is in my comfort zone and i always work toward my comfort zone. it is the place where i provide the best care i can offer for my patients.

practice safe!!!

good luck!!!

.

[Medic/Nurse, BSN, RN]

Oh yeah, I was operating on fumes last night when I wrote the above post and forgot this vital bit.

CAUTION:

Even though one may know how something is done, UNLESS you are AUTHORIZED to perform ANY advanced procedure - DO NOT DO IT. PERIOD.

All knowledge is power - even if it just adds to your overall understanding of the practice of intubation.

Practice SAFE!

[tridil2000, MSN, RN]

Do you all keep the RSI kit in your fridge? Is the etomidate kept in there? The manufacturer says it needs to be kept at 59' F.

Thanks in advance for info!

[GilaRRT]

Actually, Etomidate has a range for storage that is generally considered "room temperature." This is considered 15-30 degrees Celsius or 59-86 degrees F. However, some of the paralytics may require storage at cooler temperatures. Some institutions store these at room temp for a specified amount of time then change out with new meds or store the meds in a fridge. However, etomidate is not one of those meds as far as I know.