Questions about RSI meds

GilaRRT · Nov 6, 2007

This is something that you must learn and put into memory. In addition, have a reference on hand to help you pull out doses quickly. Most of the medications are given based on either actual or ideal body weight.

I hope you can appreciate the pitfalls of only memorizing the doses based on the generic 75 kilogram patient.

Many of these medications can be mixed and hung as a drip. Most of the time the meds are given quickly; however, this can vary from medication to medication.

Please explain, "what to look for...?"

Some common things you must know well as an RN who will be involved wit RSI:

-Be an expert in BLS airway management. Proper positioning, proper BVM technique, suctioning, use of airway adjuncts, cric pressure, and ELM. BLS procedures will be the primary back up should an intubation attempt not succeed.

-Have an additional backup plan and know how to perform the proedure well. This will vary from facility to facility. This usually includes using a supraglottic device. (ETC, King, LMA, etc)

-Know how to use and properly set up the equipment. Knowing how to prepare and having everything ready will be crucial to success. Remember SODA: Suction, Oxygen supplies, Drugs, Airway equipment.

-Know how to assess for a difficult airway and anticipate problems. Some people use the LEMON assessment; however, you may not be the one actually performing a mallampatie assessment, but know the overt findings that indicate a difficult airway.

-Know your facility policy and procedure regarding RSI. For example, do you need to premedicate with an opiate, non depolarizing NMB, or lidocaine, or do you simply give etomidate and succ..?

-Know how to rapidly assess for proper placement and how to secure the tube. A good understanding of objective means of verification is crucial. (ie capnography, capnometry, and the esophageal bulb)

-Know when things are not going well. Sometimes physician pride can get in the way and you need to be the one that recognizes a failed airway situation.

Look into taking an airway course if possible.

The following link is to an excellent article on airway management. I think it should be required reading.

http://planet.cnm.edu/healthoccupations/HO_Program_Homes/EMT/Ten%20commandments%20of%20Airway%20Management.pdf

ready4crna? · Nov 6, 2007

Etomidate=0.3mg/kg, so in a 70kg adult=21mg

Fentanyl=50-100mcg IVP

Ketamine=2mg/kg=140mg-slow ivp

Midazolam=1-2mg iv

Propofol=2mg/kg=140mg IVP-fast as patient will tolerate

Thiopental=3mg/kg= 210mg IVP

Sux 1mg/kg= 70mg

Vec .1mg/kg=7mg

Rocuronium=1.2mg/kg=84mg

DISCLAIMER-

The above doses are on the low end of dosing and far from comprehensive. I really discourage you from not learning the weight based dosing for these potentially lethal meds. Even in the ER, you should still take the time to be right before giving any of them, shortcuts with these drugs kill people. Go and get a good basic pharm. book. There are LOTS of pitfalls to all these drugs. For example, sux will usually raise your K level, and if your patient has a preexisting neuro condition (cva, paraplegia, etc.) this K elevation can be dramatic and lethal arrythmias will develop even in small doses of sux.

As for drips post RSI from this list-

Fentanyl,Propofol,Midazolam

Practice safe, Practice smart, MAKE SURE YOU CAN MANAGE THE AIRWAY BEFORE GIVING ANY OF THESE DRUGS!!! and welcome back!

Lizziefive · Nov 6, 2007

Thanks for the responses.

I am ACLS, PALS and of course BLS certified. I just wanted a quick number I could put into my head so when the Dr orders 300mg of sux for an average person I would be able to catch the mistake quickly- sometimes it is good to memorize a ballpark figure- to know if the dose sounds about right based on the persons size. We usually always start low and go from there but we have a lot of new Drs now and I find there just isnt time to double calculate every med dose.

Often I find that the MD or resident push the drugs but they simply ask for the meds to be prepared- so I like to have syringes filled with the norm dose for them.

Thanks again for the responses.

Medic/Nurse, BSN, RN · Nov 6, 2007

It is good to be prepared.

I will (along with GilaRN and readyforCRNA) caution you in remembering the "usual" dosages - you MUST do this on a WEIGHT based formula for every patient. Dose per Kg. Every patient every time.

You will always play the way you practice. Although it is important to know the "answer", I'm always going to be able to detail HOW I arrived at the answer. No exceptions.

Every medication on the RSI list has precautions/cautions/contraindications. NEVER ever give one of these medications unless the AIRWAY issue is being addressed. That being someone at the bedside that is EXPERT in obtaining an airway - by primary and secondary means.

Now, as a nurse you note that you just want to have a way to get the drugs drawn up and ready. Okay. If you are the RN at the bedside of a RSI - you need several things.

1. Pt receiving high concentration oxygen/assisted BVM ventilations

2. Suction ready and turned on.

3. Airway equipment - ETT and 2 back-up devices. Also have an OG or NG ready to place as well. Good BLS airway management is KEY.

4. Confirmation equipment. Stethoscope, ET Co2, Colormetric ETCo2, EDD, etc.

5. Device to secure the ETT or adjunctive airway - note cm at lip with sharpie.

Note that I "left out meds". IF you are "on meds" THAT has to be your ONLY job. These medications are potentially lethal. Once you draw them you do not leave them - EVER. Also all PARALYTICS should have RED FLAG LABELS on them in addition to the syringe label. I never draw these in advance. Even on the aircraft, I'll draw them and we will give them as they are ready.

I remember reading about a clean kill several years ago in a hospital involving a 10ml syringe of unlabeled paralytics that was left at the patients bedside (it was in the same syringe as a flush - it was used to dilute the vec and then drawn back :eek: ). A different RN mistook this as a flush, used it and left the room. The RN that prepared the meds had stepped out for a second as "they" were not quite ready to intubate - tragic outcome. It can happen that fast.

I applaud your desire to be prepared. I have worked with some RN's that just rock when it comes to RSI. I want you to be that RN. When I hit your facility and we have to intubate to be able to "fly away now" - I want an awesome RN there to help us. Now, how do you get to awesome.

1. Take a dedicated airway course. You will learn a lot. These are offered at many Trauma symposiums and EMS conferences. PM me if you are interested in one at your facility and I'll get you hooked up with some guys that do a wicked good one. Who knows - maybe you will be the pioneer in getting a great course at your facility. This would be a fresh ConEd offering and is usually $ reasonable and well attended. Just guessing - but it is usually not too pricey. And most all airway courses I've ever taken are fun and I still always learn something.

2. Meet with your Pharmacy educator/director and work out a list of usual per kg doses of these meds. Every facility is different (and even the doc's can vary). Make a "cheat sheet" and carry it with you. All patients have a weight. On the sick folks, develop a worksheet of the doses of the usual meds and keep it handy. This may be something that helps everyone. I'm not a PDA kinda girl - I have to know it or be able to reference it fast, no looking for it in mountains of material for me.

3. Never lose sight of the big picture. Sometimes when you add multiple MD's to a critical situation, folks can start spinning. Keep an eagle eye on that patient. Stay calm when others are not - you will be amazed at how much this will matter!

I will give you some of my usual doses and rates.

Premedication for Intubation:

* Fentanyl: 3 - 8 mcg/kg in prep for intubation ONLY. Yep, that may seem like a lot - but, I'm comfortable with this dose and I'm betting my patients will be more comfortable too. Patients need SBP of 90 at a minimum.

* Some premedicate with Lidocaine 1 -1.5 mg/kg as a way to blunt ICP. Not to sure if there is any definitive answer that it works - but, in these patients I'll generally do it - unless I'm convinced it will hurt them.

* Atropine in kiddos to dry secretions (esp with ketamine) and to block vagal tone and prevent bradycardia. Dose of 0.02mg/kg with a minimum dose in any pedi pt of 0.1 mg

* Etomidate: 0.3mg/kg Push this slowly over 2 minutes. Can cause vomiting. Has been referred to as e-vomi-date.:)

* Succs (unless contraindicated) of 1.5 to 2 mg/kg

* Vec/Norcuron: 0.1mg/kg after intubation is confirmed then every 30 minutes post intubation OR if used as an induction agent - additional doses q 30 minutes.

Post Intubation Management

It is vital that ALL patients receive adequate sedation and analgesia, in addition to paralysis (if necessary) in the post intubation period.

* Versed 0.1 mg/kg bolus dosing for post intubation sedation if SBP>90 q10-30min

* Ketamine 0.1mg/kg/min as an infusion in the intubated patient - does not effect BP as much, but I think personally only like Ketamine in kids.

* Fentanyl 1-2mcg/kg bolus dosing for post intubation analgesia if SBP>90 q 10 min

* Paralytic of choice. Vec/Norcuron or Roc. I prefer Vec/Norcuron over Roc although it has to be given more frequently. The reconstitution/dosing of Vec/Norcuron is easier at 1mg in 1ml.

I do not like propofol in air transport via rotor wing. Will take it out with the patient from a facility, but IMHO the patient will need additional medications. I think it works fine in the low stimulation ICU's, but I have not had great results in HEMS. We do not carry in, but I will take it from the referring facility if necessary.

I'd be glad to assist you with anything you need. Just PM me and I'll get you a RSI worksheet that you can tweak to your facilities needs.

We need great nurses like you!

Practice SAFE!

Altra, BSN, RN · Nov 6, 2007

NREMT-P/RN rocks :caduceus:

Lizziefive · Nov 6, 2007

Hey thanks for the great responses. I am making an RSI cheat sheet with all the mg per kg doses and the average dose for a 70kg pt to use a a reference.

I find it difficult to be a new nurse in the ER- I am lucky that where I work there are many great nurses with 15+ yrs of experience so I am never the only RN during RSI or traumas. Plus allnurses and RNs like you guys are a huge help to me! Sometime there just isnt enough time during the shift to vent/ have things explained which is why I love to come here and chit chat.

I would love to see the RSI worksheet you mentioned.- if its not a bother.

Thanks so much!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Liz

GilaRRT · Nov 7, 2007

I make simple and easy to remember calculations:

Etomidate is dosed at 0.3 mg/kg. This equates to 3 mg for every 10 kg.

10 kg = 3mg, 20 kg = 6mg, 30 kg = 9 mg, 40 kg = 12 mg , 50 kg = 15 mg

60 kg = 18 mg, 70 kg = 21 mg, etc.

Succ is dosed at 2 mg/kg. (dose will vary)

10 kg = 20 mg, 20 kg = 40mg, 30 kg = 60 mg, 40 kg = 80 mg, 50 mg =100mg, etc.

Defasciculating dose of Vecronium is 0.01 mg/kg. This equates to 0.1 mg for every 10 kg.

10kg = 0.1mg, 20 kg = 0.2 mg, etc.

Paralyzing dose of Vec is 0.1 mg/kg. This equates to 1 mg for every 10 kg.

10kg = 1mg, 20 kg = 2 mg, etc.

Analgesic dose of fentanyl is 1 mcg/kg. (dose will vary) 10 kg = 10 mcg, etc.

Off topic side note: We may start to see Roc used much more frequently in the next several years. It has a good hemodynamic profile, no shift of potassium, the onset of action is a little faster than vecronium, and it looks like a reversal agent that is very specific to Roc will be available.

Sugammadex may be the RSI silver bullet of neuromuscular blocade reversal. I do not think trials are completed, so I will wait to make judgment. Intresting development however.