Indications¹

• Risk of Aspiration
• Traumatic injury (d/t decreased gastric emptying)
• GERD
• DM
• s/p esophogeal surgeries
• Ascites
• Small Bowel Obstruction

Premedication¹

• Anxiety / Aggitation
  • Midazolam 1-2mg IV
  • Onsets 60-90s
  • Lower in elderly, higher in obese
  • Watch out for concurrent opioid use
• Prevention of Sympathetic Surge
  • Fentanyl 1-3 mcg/kg IV over 30-60s 3min before RSI
  • Onsets in < 30s
  • Especially important to prevent ICP spike
• Bradycardia / Bradycardia Prevention
  • Atropine 0.01-0.02 mg/kg IV
  • Onset: 2-16min
  • Esp useful in its who are on rate control
• Hypotension
  • Phenylephrine 50-200mcg IV
  • See Push-Dose Pressors for Epi
  • Onset: < 30s
  • Duration: 5min
• Secretion Management
  • Glycopyrrolate 0.2mg IV ²
  • Takes time to onset

Induction

Induction Agents¹

• Propofol
  • 1.5 mg/kg IV (usually 100-200mg) (Wt)
  • 1/2 dose in elderly pts
  • Decreases ICP and sympathetic tone
  • Bronchodilator
  • Drug of choice for pregnancy (Cat. B)
  • Caution in shock d/t hypotension
• Etomidate
  • 0.2-0.6 mg/kg IV (usually 20-50mg; 0.3 mg/kg)
  • Minimal CV effects
  • Decreases ICP
  • Causes myoclonus
  • Causes adrenal suppression, clinical relevance is not known
• Ketamine
  • 1-2 mg/kg (commonly 100mg) AdjBW
  • Sympathomimetic
  • Bronchodilator
  • Can worsen hypotension in pts who are catecholamine depleted
    • NTE 1.5 mg/kg in pts w/ prolonged hypotension
  • Pts w/ severe HF may suffer more from ketamine’s negative inotropic effects than benefit from sympathomimetic activity in vasculature, leading to hypotension
  • Pretreatment with BZDs may prevent emergence phenomenon
• Ketofol
• Midazolam
  • 0.2-0.3 mg/kg IM
  • Onset: 5min
  • Onset w/ opioids: 90s
  • Dose decrease in hemodynamic instability
  • Useful if no IV / IO access

Paralytics¹

• Succinylcholine
  • 1-2 mg/kg IV Wt (common 100mg)
  • 3-4mg/kg IM Wt (common 300mg)
  • Hyperkalemia
    • 0.5-1 mEq/L rise
    • 5-10 mEq/L rise in pts with ALS, stroke, MS, and spinal cord injury
  • Onset: < 60s IV / 3-4min IM
  • Duration: ~ 5min
  • Bradycardia common in peds
    • Most noticeable with propofol
  • Myasthenia graves may need higher doses
  • Pseudocholinesterase deficiency may last for 6-8hrs
  • Can cause malignant hyperthermia
    • Give Dantrolene 2.5 mg/kg
• Rocuronium
  • 0.6-1.2 mg/kg
  • Lasts longer than all bolus induction meds, and effects may be prolonged in those with liver failure
• Sugammadex
  • 16 mg/kg
  • Reverses rocuornium, vecuronium, and pancuronium
  • Works in ~3min
• Neostigmine
  • 0.03-0.07 mg/kg
  • Give with glycopyrrolate to prevent bradycardia
  • Can help to reverse non-depolarizing blockade

References