Indications & Goals - Setting the Stage
- Objective: Ensure patient safety and comfort; facilitate emergency procedures via controlled sedation/paralysis.
- Indications & Primary Goals:
⭐ RSI is the most frequent ED indication for neuromuscular blockade.
Sedative Superstars - Calm & Composed
Choice depends on patient stability, procedure, and desired sedation depth.
| Sedative | Onset (IV) | Duration | Key Pro(s) | Key Con(s) | RSI Dose (IV) |
|---|---|---|---|---|---|
| Midazolam | 1-5 min | 30-60m | Anxiolysis, Amnesia, Anticonvulsant; Reversible | Resp dep, Hypotension (esp. w/ opioids) | 0.1-0.3 mg/kg |
| Propofol | <1 min | 5-10m | Rapid on/off, Antiemetic, Reduces ICP | Hypotension, Apnea, Resp dep, Pain on inj, PRIS | 1.5-2.5 mg/kg |
| Ketamine | 1-2 min | 10-20m | Analgesia, Bronchodilation, Preserves reflexes | Emergence reactions, ↑Secretions, Laryngospasm | 1-2 mg/kg |
| Etomidate | <1 min | 5-15m | Cardiostable, Minimal BP change | Adrenal suppression (even 1 dose), Myoclonus, N/V | 0.2-0.3 mg/kg |
- Titrate to effect; monitor vitals closely during and after administration.
Paralytic Powerhouses - Motionless Mastery
Key agents for RSI muscle relaxation. Depolarizing vs. Non-depolarizing.
| Agent | Class | Onset (IV) | Duration | Dose (IV) | Key Features & ⚠️ Cautions |
|---|---|---|---|---|---|
| Succinylcholine | Depolarizing | 30-60s | 5-10 min | 1-1.5 mg/kg | Rapid; ⚠️ HyperK+ (burns, crush, neuro), fasciculations, ↑IOP/ICP, Malignant Hyperthermia (MH) |
| Rocuronium | Non-depolar. | 60-90s | 30-60 min | 0.6-1.2 mg/kg | Fastest NDMR; Sugammadex reversal available |
| Vecuronium | Non-depolar. | 2-3 min | 45-60 min | 0.1 mg/kg | Longer onset; stable hemodynamics; powder |
| Cisatracurium | Non-depolar. | 2-3 min | 40-60 min | 0.15-0.2 mg/kg | Hoffman elim. (good for organ failure); less histamine release |
📌 SCh: "Sux" for Short action. Roc: "Rocks" for Rapid Onset (among NDMRs).
RSI Rendezvous - Airway Aces
- Pre-treatment (Optional): 📌 LOAD (Lidocaine, Opioid, Atropine, Defasciculator).
- Induction Agents (Sedatives):
- Etomidate: 0.3 mg/kg IV; hemodynamically stable.
- Ketamine: 1-2 mg/kg IV; bronchodilator, ↑BP/HR.
- Propofol: 1.5-2.5 mg/kg IV; rapid on/off, ↓BP.
- Paralytic Agents (Neuromuscular Blockers):
- Succinylcholine: 1-1.5 mg/kg IV; depolarizing, rapid onset (<60s), short duration.
- Rocuronium: 0.6-1.2 mg/kg IV; non-depolarizing, longer duration.
⭐ Avoid Succinylcholine in crush injuries, extensive burns (>24-48h), or denervating neuromuscular diseases due to life-threatening hyperkalemia risk.
Monitoring & Mayhem - Watchful Vigilance
- Vitals: Continuous ECG, HR, BP, SpO₂, EtCO₂ (essential for ventilation).
- Sedation Level: RASS/Ramsay scales (e.g., RASS target -2 to -4).
- Paralysis (NMB): Train-of-Four (TOF) count; aim for 1-2 twitches.
- Use peripheral nerve stimulator (ulnar/facial nerve).
- Adverse Events:
- Hypotension, hypoxemia/apnea.
- Aspiration.
- Awareness during paralysis.
- Hyperkalemia (succinylcholine).
⭐ TOF ratio >0.9 indicates adequate recovery from NMB, crucial before extubation.
High‑Yield Points - ⚡ Biggest Takeaways
- RSI (Rapid Sequence Intubation) is crucial for emergency airway management.
- Etomidate for hemodynamic instability; Ketamine for bronchospasm/hypotension.
- Succinylcholine: fastest onset/offset paralytic, risk of hyperkalemia (burns, crush injuries).
- Rocuronium: common non-depolarizing agent; Sugammadex for rapid reversal.
- Effective pre-oxygenation (100% O2, 3-5 min) prevents desaturation during apnea.
- Waveform capnography (ETCO2): gold standard for confirming ETT placement.
- Difficult airway assessment (e.g., LEMON) is vital before RSI.
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