Common RSI agents

Airway Management – Rapid Sequence Induction – Commonly Used Agents

1. Pre-Medication Agents

Lidocaine Class 1b Antiarrhythmic – Na channel blocker

Indications: Cardiac arrest – Alternative to amiodaroneRSI – has been shown to blunt raise in ICP associated with suctioning & laryngeal stimulation.Anaesthesia – potent local anaestheticVentricular 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 SulfateAnticholinergic

Indications: Symptomatic bradycardia – haemodynamically significant bradycardia with associated hypotension, dysnpoea, chest pain, altered LOC, CHF, shockRSI – 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 exposureAsthma – 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 3mgCholinergic 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

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Fentanyl Narcotic Analgesic – acts on μ opiate receptors

Indications: AnalgesiaRSI

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


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


Midazolam Benzodiazepine - sedative, hypnotic

Indications: RSISeizures

Effects: Sedation, amnesia,

Side Effects: Laryngospasm, bronchospasm, dyspnoea, respiratory depression, drowsiness, amnesia, altered LOC, bradycardia, tachycardia, PVCs, retching

Contraindications: Hypersensitivity, glaucoma, shock, alcoholic coma

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Dose: 2-3mcg/kg slow IV

Onset of Action: 1-15 minutes (IV-IM)

Duration of Action: 1-6 hours (IV-IM)

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


Duration of Action: 4 hours

Propofol Sedative, hypnotic

Indications: RSI – induction and maintenance of anaesthesiaSedation: 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



3. Paralytic Agents

Succinylcholine Depolarizing neuromuscular blocking agent

Indications: RSI – paralytic agent

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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



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



RocuroniumNon-depolarizing neuromuscular blocking 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


PancuroniumNon-depolarizing neuromuscular blocking agent

Indications: RSI – paralytic agent (derivative of curare)

Effects: Competes with ACh at nAChR sites, resulting in paralysis

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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



Atracurium Non-depolarizing neuromuscular blocking agent


Effects: Binds competitively at ACh sites, antagonising action of Ach, resulting in paralysis

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


Bibliography

1. Bledsoe B. & Clayden D. (2012) Prehospital Emergency Pharmacology – 7 th Edition . Boston, MA: Pearson2. Pollak A. (ed.) (2011) Critical Care Transport. Burlington, MA: Jones & Bartlett3. Derr P. & Criddle L. (2011) Emergency & Critical Care Pocket Guide. Burlington, MA: Jones & Bartlett

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Health & Medicine

Common RSI agents