Go to the ALiEMU module on the Pharmacology of Emergency Airway Management (Part 1).
| Role | Team Member | Background |
| Authors | Chris Edwards, PharmD, BCPS @emergencypharm | Emergency Medicine Pharmacist, University of Arizona Medical Center |
| Rob Pugliese, PharmD, BCPS @theEDpharmacist | Emergency Medicine Pharmacist, Thomas Jefferson University | |
| PharmD Reviewer | Meghan Groth, PharmD, BCPS @EMpharmgirl | Emergency Medicine Pharmacist, University of Vermont Medical Center |
| Physician Reviewer | Lewis Nelson, MD, FAACT, FACMT, FACEP @LNelsonMD | Professor of Emergency Medicine, New York University |
| Creator and Lead Editor | Bryan Hayes, PharmD, DABAT, FAACT @PharmERToxGuy | Emergency Medicine Pharmacist, Clinical Associate Professor; University of Maryland |
| Chief of Design and Development | Chris Gaafary, MD @cgaafary | EM Chief Resident, University of Tennessee Chattanooga |
Course 3 Outline
- Review of the medications that should be planned for and prepared alongside critical supplies required for intubation
- The role of preoxygenation and apneic oxygenation
- Choosing medications to facilitate awake intubation
- Sedation methods for delayed sequence intubation
- The pediatric airway
Summary
1. The 7’Ps of RSI
- Medications should be planned for and prepared alongside the other critical supplies required for intubation including:
- Pretreatment, oxygenation, induction and paralytic selection, post-intubation analgesia/sedation
- Communicate all plans clearly with the team
2. Preoxygenation and apneic oxygenation
- Standard pre-oxygenation: Non-rebreather mask with oxygen turned up past 15L max indicator
- Apneic oxygenation: Oxygen via nasal cannula set at 15L or higher during apneic period and throughout intubation attempt.
- Both strategies should be utilized for a majority of intubation situations
3. Awake Intubation
- Topical anesthetics to facilitate intubation of awake patient
- 4% lidocaine solution atomized into airway using nasal or naso-tracheal delivery system
- 2% viscous lidocaine gargled by patient
- 2% lidocaine jelly used as lubricant on endotracheal tube
- Max total lidocaine dose is 300mg (based on data for intradermal use)
- There are numerous modalities for providing conscious sedation for awake intubation with consideration for prevention of oversedation and the unique pharmacology of the sedative agent selected
4. Delayed sequence intubation (procedural sedation for preoxygenation)
- Ketamine studied at dose of 1mg/kg slow IV push followed by 0.5mg/kg additional doses until adequate dissociation was achieved (average dose used 1.4mg/kg)
- Once sedated, oxygenation can occur via non rebreather or positive pressure ventilation for three minutes
- After preoxygenation, assess level of sedation from initial sedative dose prior to administering paralytic for intubation
5. The Pediatric Airway
- Know where your pediatric equipment and resources are located and practice using them before you encounter a child requiring emergent airway management
- Preparation and practice with actual pediatric equipment and supplies, especially in primarily adult institutions, is the key to optimizing care in this population
- The Broselow® Pediatric Emergency Tape has pre-calculated doses for most meds used in RSI/PALS and also equipment sizes (endotracheal tube size).
Read more about The CAPSULES series.
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