Common RSI agents
- 1. 1 | P a g e Airway Management – Rapid Sequence Induction – Commonly Used Agents 1. Pre-Medication Agents Lidocaine Class 1b Antiarrhythmic – Na channel blocker Indications: Cardiac arrest – Alternative to amiodarone RSI – has been shown to blunt raise in ICP associated with suctioning & laryngeal stimulation. Anaesthesia – potent local anaesthetic Ventricular arrhythmias – wide complex tachycardia, PVCs Effects: Local anaesthetic effects, PVC suppression, slows AV node conduction Side Effects: Drowsiness, slurred speech, seizures, confusion, hypotension, bradycardia, AVB, nausea, vomiting, respiratory/cardiac arrest Contraindications: 2nd ° & 3rd ° AVB, bradycardia, Stokes-Adams Syndrome. Reduce dose by 50% if patient >70yrs, hepatic dx, CHF or shock Dose: Cardiac Arrest - 1-1.5mg/kg. Max dose 3.0mg/kg. RSI – 1.5mg/kg 2-3 minutes prior to intubation Wide-complex tachy/VT – 1-1.5mg/kg. Max dose 3.0mg/kg. PVCs – 0.5-1.5mg/kg. Max dose 3.0mg/kg. Onset of Action: < 3 minutes Duration of Action: 10-20 minutes Atropine Sulfate Anticholinergic Indications: Symptomatic bradycardia – haemodynamically significant bradycardia with associated hypotension, dysnpoea, chest pain, altered LOC, CHF, shock RSI – all paeds < 1 yr to combat reflex bradycardia, ; consider in paeds 1-10 yrs; adults prior to 2nd dose succinylcholine; adults with HR <60 prior to laryngoscopy; Cholinergic Toxidrome – organophosphate poisoning, nerve gas exposure Asthma – potent bronchodilator Effects: Parasympathetic stimulation, blocks ACh receptors Side Effects: Blurred vision, dilated pupils, dry mouth, tachycardia, drowsiness, confusion, headache Contraindications: Tachycardia, glaucoma Dose: Symptomatic bradycardia – 0.5-1mg IVP every 3-5 mins. Max dose 3mg Cholinergic Toxidrome – 1-5mg IV/IO prn x 5 mins (double dose if IM) Asthma – 0.4-2mg nebulised in 3ml NaCl Paed Dose: RSI – 0.02mg/kg, min 0.1mg Onset of Action: Immediate Duration of Action: 4 hours
- 2. 2 | P a g e Fentanyl Narcotic Analgesic – acts on μ opiate receptors Indications: Analgesia RSI Effects: Analgesia, sedation, less emetic effects than other opioids. Can reduce the sympathetic response to laryngoscopy. Side Effects: Respiratory depression, apnoea, muscle rigidity, bradycardia, respiratory arrest, CNS depression, hypotension, nausea, vomiting Contraindications: Severe haemorrhage, shock, known hypersensitivity, MAOI use, asthma, myasthenia gravis. Reduce dose in paeds, geriatrics and high-risk patients Dose: 2-3mcg/kg slow IV Onset of Action: 3-5 minutes Duration of Action: 30-60 minutes 2. Sedative Agents Etomidate Sedative, hypnotic Indications: RSI – rapid onset, short duration, stable haemodynamic profile. Has cerebroprotective properties, reducing CBF and metabolism in cases of raised ICP. Effects: Rapid induction of anaesthesia Side Effects: Blurred vision, dilated pupils, dry mouth, tachycardia, drowsiness, confusion, headache Contraindications: Hypersensitivity Dose: RSI – 0.2-0.6mg/kg, min 0.1mg. Usual dose 0.3mg/kg Onset of Action: 15-45 seconds Duration of Action: 3-12 minutes Midazolam Benzodiazepine - sedative, hypnotic Indications: RSI Seizures Effects: Sedation, amnesia, Side Effects: Laryngospasm, bronchospasm, dyspnoea, respiratory depression, drowsiness, amnesia, altered LOC, bradycardia, tachycardia, PVCs, retching Contraindications: Hypersensitivity, glaucoma, shock, alcoholic coma Dose: 2-3mcg/kg slow IV Onset of Action: 1-15 minutes (IV-IM) Duration of Action: 1-6 hours (IV-IM)
- 3. 3 | P a g e Ketamine NMDA antagonist - anaesthetic, analgesic Indications: RSI – dissociative induction agent Analgesia – sub-anaesthetic doses can provide rapid pain relief Effects: Dissociation, analgesia, anaesthesia, amnesia, bronchodilatory properties, HTN and tachycardia can be useful in pts. who’s haemodynamic status is unknown Side Effects: Hallucinations, increased muscle tone, nausea, vomiting, increase in bronchial secretions, hypertension, respiratory depression, tachycardia, delirium, confusion, raised ICP Contraindications: Hypertension, hypersensitivity Dose: 1-2mg/kg IV every 10-20 minutes Onset of Action: 45-60 seconds Duration of Action: 4 hours Propofol Sedative, hypnotic Indications: RSI – induction and maintenance of anaesthesia Sedation: Maintenance of sedation Effects: Ultra short acting sedation, amnesia, anaesthesia, decreases cerebral oxygen demand and ICP – however, this can reduce CPP Side Effects: Local site pain, respiratory depression, hypotension, bradycardia, transient apnoea, nausea, vomiting, headache Contraindications: Hypersensitivity, raised ICP, egg/soy sensitivity Dose: RSI: 2mg/kg IV induction; followed by 25-75 mcg/kg/min infusion. Sedation: 0.5-1mg/kg IV Onset of Action: 10-45 seconds Duration of Action: 5-10 minutes 3. Paralytic Agents Succinylcholine Depolarizing neuromuscular blocking agent Indications: RSI – paralytic agent Effects: Binds to ACh receptor sites, resistant to AChE, muscle paralysis followed by flaccidity Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure, increased ICP, malignant hyperthermia, raised K+, fasciculations Contraindications: Hypersensitivity, penetrating eye injuries, glaucoma Dose: 1-2mg/kg IV Onset of Action: 30-60 seconds Duration of Action: 5-10 minutes
- 4. 4 | P a g e Vecuronium Non-depolarizing neuromuscular blocking agent Indications: RSI – paralytic agent (derivative of pancuronium) Effects: Competes with ACh at nAChR sites, more potent than pancuronium Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure, increased ICP, malignant hyperthermia Contraindications: Hypersensitivity, penetrating eye injuries, glaucoma Dose: 0.1mg/kg IV Onset of Action: 90-120 seconds Duration of Action: 60-75 minutes Rocuronium Non-depolarizing neuromuscular blocking agent Indications: RSI – paralytic agent Effects: Binds competitively at ACh sites, antagonising action of Ach, resulting in paralysis Side Effects: Bronchospasm, hypertension, tachycardia Contraindications: Hypersensitivity, impaired hepatic/respiratory function, severe obesity Dose: 0.6-1.2mg/kg IV; maintenance dose 0.1-0.2mg/kg continuous infusion Onset of Action: <120 seconds Duration of Action: 30-60 minutes Pancuronium Non-depolarizing neuromuscular blocking agent Indications: RSI – paralytic agent (derivative of curare) Effects: Competes with ACh at nAChR sites, resulting in paralysis Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure, increased ICP Contraindications: Hypersensitivity, 1st trimester pregnancy, caution with neonates, myasthenia gravis Dose: 0.1mg/kg IV; maintenance 0.015-0.1mg/kg infusion Onset of Action: 30-45 seconds Duration of Action: 30-60 minutes Atracurium Non-depolarizing neuromuscular blocking agent Indications: RSI – paralytic agent Effects: Binds competitively at ACh sites, antagonising action of Ach, resulting in paralysis
- 5. 5 | P a g e Side Effects: Wheezing, respiratory depression, apnoea, aspiration, arrhythmias, bradycardia, sinus arrest, hypertension, hypotension, hyperkalaemia, increased intraocular pressure, increased ICP Contraindications: Hypersensitivity, impaired hepatic/respiratory function, severe obesity, caution with asthmatics Dose: 0.4-0.5mg/kg IV Onset of Action: 2-3 minutes Duration of Action: 30-40 minutes Bibliography 1. Bledsoe B. & Clayden D. (2012) Prehospital Emergency Pharmacology – 7th Edition. Boston, MA: Pearson 2. Pollak A. (ed.) (2011) Critical Care Transport. Burlington, MA: Jones & Bartlett 3. Derr P. & Criddle L. (2011) Emergency & Critical Care Pocket Guide. Burlington, MA: Jones & Bartlett