Analgesic use in non-traumatic RSI

[FireMedic65]

Etomidate 0.3 mg/kg IV up to 40mg. Wait 60 seconds, and if insufficient, give the rest of the 40 mg you didn't use with the first dose. Combining agents will get you good results. 0.3 mg/kg of etomidate along with 10 mg of versed or 200 mcg of fentanyl will do quite well. If you don't carry etomidate, 10 mg versed and 200 of fentanyl. If you don't carry fentanyl, versed 10mg and 5mg of morphine. Haldol is another one to consider as an adjunct, particularly if the patient is hypotensive and you don't have a lot to work with for drugs. The above combinations are likely to result in an inability to protect the airway. That's good for tubing, but not good if you can't get the tube.

But I've been able to tube a lot of folks with just 40 mg of Etomidate.

The above does not include adjuncts such as atropine, lidocaine, or LTA lidocaine. And it's assuming you don't have ketamine, propofol, or methohexital. And the doses mentioned are for adults.

'zilla

Thanks zilla, I really appreciate you taking the time to explain that to me. We carry all the medications mentioned in your first paragraph, with the exception of Haldol. We do carry etomidate, but we are unable to use it unless we are running a dual medic truck, which is rare.

The combination of medications you talked about are roughly what I was assuming. With a a little bit of a difference in dosages, it was right on the money of what we have been doing in the past.

Thanks

[akroeze]

Etomidate 0.3 mg/kg IV up to 40mg. Wait 60 seconds, and if insufficient, give the rest of the 40 mg you didn't use with the first dose. Combining agents will get you good results. 0.3 mg/kg of etomidate along with 10 mg of versed or 200 mcg of fentanyl will do quite well. If you don't carry etomidate, 10 mg versed and 200 of fentanyl. If you don't carry fentanyl, versed 10mg and 5mg of morphine. Haldol is another one to consider as an adjunct, particularly if the patient is hypotensive and you don't have a lot to work with for drugs. The above combinations are likely to result in an inability to protect the airway. That's good for tubing, but not good if you can't get the tube.

But I've been able to tube a lot of folks with just 40 mg of Etomidate.

The above does not include adjuncts such as atropine, lidocaine, or LTA lidocaine. And it's assuming you don't have ketamine, propofol, or methohexital. And the doses mentioned are for adults.

'zilla

Thanks for that post Doc! Out of everything you listed my only choice would be Versed/Fentanyl but its good to finally see some clear numbers on recommended dosing.

[chbare]

One thing I see with Midazolam is frequent under-dosing. A good RSI dose should be around 0.1 mg/kg IV. You are looking at about 10 mg for many adults. I find providers are uncomfortable with these higher doses, and the hemodynamic complications with higher doses can be problematic.

Take care,

chbare.

[croaker260]

One thing I see with Midazolam is frequent under-dosing. A good RSI dose should be around 0.1 mg/kg IV. You are looking at about 10 mg for many adults. I find providers are uncomfortable with these higher doses, and the hemodynamic complications with higher doses can be problematic.

Take care,

chbare.

Back in 2002-ish we did an internal review of our MAI/RSI. We found that those tubes which were maintained post intubation with just benzos tend to have more complicatons and required more repeat administrations of the benzo than those (relatively few) tubes that were maintained with Benzos and Opiods. This was pre-vecuronium for us, and included both post-codes and post RSI's. This involved a review of about (IIRC) 120 tubes over a 6 month period.

So while this is an unpublished and not peer reviewed , and a retrospective non randomized review...all of which puts it just a few steps above "This aint no sh*t" in credibility of evidence, the moral of the story is opiods are a useful adjunct in post intubation management regardless of trauma or not.

That said they are a tool, and not perfect for every situation.

[chbare]

I am not arguing against opiates. I prefer to give 2-3 mcg/kg of Fentanyl IV in addition to benzos post intubation. I was just stating the fact that some providers may shy away from properly dosing or perhaps considering a proper does of an alternative agent.

On topic however, I think it is appropriate to simply go with Etomidate and sux if time is of the essence. However, liberal sedation and analgesia status post intubation should be a priority. If you have a little time to pre-medicate, 2-3 mcg/kg of fentanyl IV can make your patient more comfortable and may blunt some of the pain and sympathetic response to pain. Laryngoscopy is in fact a very painful procedure.

Take care,

chbare.

[Dustdevil]

Laryngoscopy is in fact a very painful procedure.

Carpal tunnel or lateral epicondylitis?