The next CAPSULES module is in! Part 2 of our 2-part airway series is now published on the Academic Life in EM University (ALiEMU) website. Pharmacology of Airway Management – Part 1 provided some outstanding information on topics such as preoxygenation and apneic oxygenation, awake intubation, delayed sequence intubation, and the pediatric airway. We are excited to announce the next installment of the popular CAPSULES series: Pharmacology of Emergency Airway Management – Part 2.

In part 1, we introduced a multimedia-enhanced learning experience and continue with that theme in part 2. You will find HD videos throughout the module providing further educational content. Some of the quizzes are also accompanied by video cases followed by a question based on the case you just watched. If you cannot use audio on your device, no problem, all videos are closed captioned (just hit the CC button in the YouTube window). We hope these videos further enrich your ALiEMU CAPSULES educational experience and we welcome any suggestions or comments!

Go to the ALiEMU module on the Pharmacology of Emergency Airway Management – Part 2.

Take Home Points

Sedatives in Rapid Sequence Inducation (RSI)

• Sedatives are necessary for the humane use of paralytics
• Never use a paralytic without first sedating the patient
• Etomidate remains the most commonly used sedative agent for RSI
  • Minimal hemodynamic effects make it an attractive option
  • Etomidate does cause adrenal suppression, but there is conflicting data about the clinical significance of this effect
• Ketamine has been associated with similar intubating conditions when compared to etomidate and utilization has increased in recent years
  • May increase BP and HR. Use caution in CAD, hypertension, tachycardia, or catecholamine depletion
  • Bronchodilatory effects may be beneficial in reactive airway disease
  • Ketamine does not need to be avoided in head injury patients
• Propofol is another sedative frequently used for RSI
  • Propofol has anticonvulsant and bronchodilatory effects that may make it an attractive choice for certain patient populations
  • Propofol has been associated with significant reductions in BP, and should be avoided in hemodynamically unstable patients

Paralytics in RSI

• Paralytics are frequently used to optimize intubating conditions and have been shown to increase the rate of first attempt intubation success
• Succinylcholine has long been considered the gold standard for paralytics in RSI
  • Favorable pharmacokinetics including a rapid onset and short duration of action
  • Long list of contraindications
  • May increase oxygen consumption at cellular level
• Rocuronium dosed at 1-1.2 mg/kg produces similar intubating conditions to succinylcholine
  • Rocuronium lasts much longer than succinylcholine and will outlast most sedatives used for induction
  • Remember to add a longer acting sedative once the intubation is complete

Post-intubation Analgesia and Sedation

• Intubation and the events leading up to intubation can be painful
• Quality sedation starts with good analgesia
• Be aware that long acting paralytics will outlast short acting sedatives for RSI and initiate post intubation sedation and analgesia at an appropriate time

Premedications

• A number of premedications have been described in the literature to minimize adverse effects from RSI medications or laryngeal manipulation
• Conflicting evidence and/or safety concerns make most premedication regimens somewhat controversial

Read more about The CAPSULES series.

Author information

Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School

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