Know your RSI!

[notice textalign=”center”]AIRWAY[/notice]

As some of the more junior residents realize this time of year… fumbling your way through an intubation looks bad all around. Help yourself by really becoming comfortable with induction and paralytic agents. A difficult airway is, after all, owned by the ED. I wouldn’t want anyone else, even Anesthesia, intubating when there is a difficult airway. But you can’t be good at difficult airways until you have the basics mastered.

Lets review:

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Etomidate 0.3 – 0.6 mg/kg

Ketamine 1 – 2 mg/kg

Propofol 2 – 2.5 mg/kg

Versed 0.2 mg/kg



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Succinylcholine 1.5 mg/kg

Rocuronium 0.8 – 1.2 mg/kg

Vecuronium 0.01 mg/kg




    • stan on June 10, 2014 at 8:47 pm
    • Reply

    Mene, what would you recommend for post-intubation drug cocktail?

    1. Great question! There is actually a lot of evolving thoughts on this, with the most recent suggestion to go with opiate drip *only* which gives you a fairly awake patient. This can be tricky because if you intubated a combative or mentally ill patient you may need sedation as well as pain control.

      Post-intubation packages usually include something for pain (fentanyl drip) and something for sedation (versed, propofol, etc).

      I usually get extremely upset when I see an intubated patient getting re-paralyzed (Vec). This seems barbaric and if you understand your medications and drips you should be able to avoid this.

      I think this is actually a great subject for another post, coming soon!

    • Anonymous on June 18, 2014 at 11:23 am
    • Reply

    Totally agree with Mene about keeping your cool and remembering your drugs when preparing for intubation.

    Particularly important to remember that paralyzing your trauma patients is very often not in the patient’s best interest. Sedation and pain control are aptly named for the appropriate reasons. And each time you paralyze someone on a ventilator, you lose the ability to rapidly evaluate their airway when they get transferred to the CT-scanner, to re-evaluate their neuro status, and to really check to see if your interventions made a difference. Critical to remember in your future practice…

    As to his other point, for all the discussion about EM physicians being “jacks of all trades, masters of none”, we OWN difficult airways. We are the only ones who can perform all aspects of airway control, starting from initial assessment to surgical options. Anesthesia does not own surgical airways, and surgeons certainly do not own direct laryngoscopy and its adjuncts.

    We own a couple of other things, too, that get missed, but that can wait for another day….

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