1. Lidocaine: 1.0 1.5 mg/kg over 30 60 sec. to blunt intracranial and intraocular pressure spikes.
2. Fentanyl: 2.0 mcg/kg slowly over 3-5 minutes to blunt intracranial and arterial pressure surges.
3. Atropine: 0.02 mg/kg - children <10 years
4. Pancuronium: 0.01 mg/kg (defasciculating dose) or
5. Rocuronium: 0.1 mg/kg (defasciculating dose)
1. OK to remove c-spine collar if in-line stabilization is being provided.
2. Use end-tidal CO2 detector to confirm placement.
· Failed intubation: Review Airway Algorithms.
· Can ventilate with bag and mask (BMV) re-attempt optimal intubation maximum 3 attempts in total.
1. Pancuronium: 0.05 - 0.1 mg/kg q ½ - 1h prn
2. Midazolam: 1 3 mg/hr
3. Morphine: 1 5 mg/hr.
1. Interior Health ER Rapid Sequence Induction Worksheet 2003.
2. Bi-International Trauma Anesthetic and Critical Care Seminars 1999
3. Yeung JK, Zed PJ. Review of etomidate for rapid sequence intubation in the emergency department. CJEM 2002; 4(3): 194-198.
5. Trevisanuto D, Verghese C, Doglioni N, Ferrarese P, Zanardo V. Laryngeal mask airway for inter-hospital transport of neonates. Pediatrics 2005;115:e109e111. URL: http://pediatrics.aappublications.org/cgi/reprint/peds.2004-1468v1
7. Walls RM, Murphy MF. The failed airway in adults. UpToDate 2008 ver.15.3. [CDROM].
1. Primarily to block vagal stimulation in children.
2. Minimum dose 0.1 mg, max dose 1.0 mg.
3. Onset 1-2 min, duration 4 hours
4. Consider especially with ketamine to reduce secretion and bronchospasm.
1. Onset 2 min. Duration 1-2 hr.
2. Reversal Flumazenil 0.1 mg. increments prn. Onset 1-3 min. Peak 3-5 min. *Will need to repeat the dose, as midazolam can last up to 2 hr.
1. Onset 30-60 sec..
2. Preferred in hemodynamic instability and cardiac ischemia.
3. Preferred in head injury and increased ICP.
4. Contraindicated in sepsis because long-term use can cause adrenal suppression.
5. Can produce myoclonus, hiccups, vomiting.
Not yet licensed for use in
1. Onset 20-40 sec. Duration 5-10 min.
2. Only in stable normotensive patient
1. Onset 30-60 sec. Duration 15 min.
2. Increases pulse and BP (PCP derivative).
3. Use in hemodynamic instability.
4. Agent of choice in asthma
5. Not for use in head injury/increased ICP
6. Occasional laryngospasm, apnoea, vomiting and emergence delerium.
7. Airway reflexes well preserved.
8. Increased salivation. Use atropine in children.
1. Onset 30-60 sec. Peak 3-5 min. Duration 30-60 min
2. Reversal Naloxone 0.04 0.1 mg. prn. Duration 20-60 min. Remember to re-dose if multiple doses of Fentanyl given.
1. Onset 45 sec. Duration 10 min.
2. Dose may be repeated if necessary
3. May increase vagal tone. Use atropine in children.
4. Not used with increased ICP, muscle disease, cocaine, open eye, burns
2. Onset 45-60 sec. Duration 40-60 min.
3. Use in head injury as paralytic, or give defasciculating dose prior to succinylcholine.
1. Non-depolarizer, longer duration of action.
2. Lasts 60-90 min.
3. For longer term paralysis if necessary.
1. Use for longer term sedation.
2. Reversal Naloxone 0.04 0.1 mg. prn. Onset <2 min. Peak 5-15 min. Duration 20-60 min. Repeat doses will need to be given.
1. Ideally 3 attempts at intubation should be maximum. Additional attempts will increase supraglottic and glottic trauma leading to swelling and more problems.
2. The most experienced person should make the last attempt.
3. There should be adequate paralysis.
4. Positioning of the patient should be optimal.
5. Pressure should be applied to the thyroid cartilage (not the cricoid, which is compressed to prevent aspiration).
6. Different blades can be tried. The Miller blade will allow lifting of the epiglottis.
7. Different devices can be used in experienced hands, such as the lighted stylet, intubating LMA, gum elastic bougie or fibreoptics.
1. Two people to apply mask. One implements jaw thrust and one applies mask seal.
2. Adequately sized oropharyngeal airway.
3. Nasal vasoconstrictor, lubrication and 2 adequately sized nasopharyngeal airways.
4. Should maintain oxygen saturation of 90% or more
5. Watch for inflation of stomach.
1. Cannot intubate and cannot ventilate
2. Attempt LMA or Combitube while preparing for cricothyrotomy
3. If ventilation is possible with oxygen saturation of 90% or more, consider attempting an alternative method of intubation such as a lighted stylet, gum elastic bougie, glidescope or fibreoptics.
4. Otherwise proceed to cricothyrotomy.
5. If you cannot make yourself do a cricothyrotomy and have no help, and if a supraglottic airway (LMA or Combitube) is in place and functioning well, transport with suboptimal airway protection must be considered. There is increasing experience in pediatric transport using the LMA , and some evidence now exists for safe use in adult transport .
6. Under age 12, the surgical airway of choice is needle cricothyrotomy with transtracheal jet ventilation. This is a temporary measure, not always allowing for adequate CO2 exchange. Again, the LMA alternative can be considered for transport.
7. Review Airway Algorithms.
1. Expect difficulty if:
· History of neck surgery
· Presence of hematoma
· Radiation to neck
· Trauma to neck
2. Procedure (No-drop technique). This requires at least one assistant.
· Define anatomy. The cricoid is just below the thyroid cartilage.
· Prepare the skin and infiltrate with 1% lidocaine if time permits or patient is aware. Some lidocaine directly intratracheal can be helpful with cough in patients with an intact reflex.
· Immobilize the laryngeal cartilage with thumb and 3rd finger of non-dominant hand. Do not let go.
· Make a 2 cm. vertical incision over the cricothyroid membrane.
· Directly identify the membrane with the index finger of the non-dominant hand.
· Make a horizontal 1 cm. incision through the lower (less vascular) portion of the membrane.
· Have your assistant grasp the lower aspect of the thyroid cartilage with the tracheal hook. Again, do not let go.
· Spread the incision vertically with the trousseau dilator.
· Insert a #4 tracheostomy tube vertically directing the curve caudad.
· Confirm placement by expired CO2 testing, sounding with a nasogastric tube if necessary, and check for subcutaneous emphysema.