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Airway Management in Mechanical Ventilation 169

TABLE 6-7 Indications for Rapid Sequence Intubation

Indication Notes

Airway obstruction Inability to maintain patent airway
with other devices (e.g., oropharyngeal
airway, laryngeal mask airway)

Severe brain injury Glasgow coma scale of 8 or less

Severe hypoxemia PaO /F O (P/F) ratio , 250 mm Hg
2
2
I
Abnormal respiratory Spontaneous frequency , 10/ min or .
frequency 30/min
Hemodynamic instability Deteriorating hemodynamic values
(e.g., vital signs, CVP, PAP, PCWP)

Modified from http://www.traumaburn.com. Retrieved April 21, 2004.
© Cengage Learning 2014

cricoid pressure, intubation, and post-RSI stabilization (Figure 6-13). (Bergen et al.,
1997; Robinson et al., 2001; Sokolove et al., 2000; Smith et al., 2000).
In preparing for RSI, the following equipment and supplies should be readily
available: cardiac monitor, intravenous access for pre-RSI medications, pulse oxim-
eter, oxygen, drugs for advanced cardiovascular life support (ACLS), and cricothy-
rotomy tray for unsuccessful RSI attempts.
Sedation and muscle paralysis facilitate RSI. Different drugs are available for RSI,
and they should be chosen based on the patient’s condition, indications, and con-
Pre-RSI medications traindications. Common pre-RSI medications include etomidate (Amidate) for
should be chosen based on
the patient’s condition, indica- sedation and induction (Guldner et al., 2003; Smith et al., 2000) and succinylcho-
tions, and contraindications.
line (Stewart, 2003; Walker, 1993) as a paralytic agent. For adult patients, 20 mg or
0.3 mg/kg of etomidate may be given intravenously over 30 to 60 sec. Succinylcho-
line may not be necessary if etomidate alone provides adequate sedation and results

Common pre-RSI in successful intubation. If succinylcholine is needed, 100 mg or 1 to 1.5 mg/kg
medications for adults include should be adequate. Since the onset of etomidate and succinylcholine is about 60 sec,
20 mg of etomidate (Amidate)
for sedation and 100 mg of intubation should be ready to proceed prior to administration of pre-RSI medica-
succinylcholine. tions. Cricoid pressure using the Sellick’s maneuver (Figure 6-14) may be done to
close off the esophagus and to minimize aspiration. However, extreme care must
be exercised because excessive cricoid pressure may also close off the airway itself
(Walters, 2011).
Cricoid pressure is
applied to close off the After sedation and relaxation of respiratory muscles are achieved, oral intubation
esophagus and to minimize is done using traditional method as described earlier in this chapter. If post-RSI pa-
aspiration.
ralysis and sedation are desired, vecuronium bromide (Norcuron, a steroidal-based
nondepolarizing neuromuscular blocking agent), diazepam (Valium, an antianxiety
agent), and fentanyl (Sublimaze, a synthetic opiate analgesic) may be used. The sug-
gested adult IV dosages for vecuronium, diazepam, and fentanyl are 0.1 mg/kg, 5 to
10 mg, and 200 μg, respectively.

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