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    RSI & Status Asthmaticus: Drug Dose Onset/duration Cons Pros

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    Afina Abdul Aziz
    Rapid sequence induction (RSI) is a technique used to quickly secure a patient's airway by administering induction agents and paralytics, followed by intubation. It was developed for surgery but is now commonly used in critical care situations like status asthmaticus. Status asthmaticus refers to a severe exacerbation of asthma that is refractory to maximal medical therapy and generally requires intubation and mechanical ventilation to reduce time without oxygen and prevent exhaustion.

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    RSI & Status Asthmaticus: Drug Dose Onset/duration Cons Pros

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    Afina Abdul Aziz
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    Rapid sequence induction (RSI) is a technique used to quickly secure a patient's airway by administering induction agents and paralytics, followed by intubation. It was developed for surgery but is now commonly used in critical care situations like status asthmaticus. Status asthmaticus refers to a severe exacerbation of asthma that is refractory to maximal medical therapy and generally requires intubation and mechanical ventilation to reduce time without oxygen and prevent exhaustion.

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    Rapid sequence induction (RSI) is a technique used to quickly secure a patient's airway by administering induction agents and paralytics, followed by intubation. It was developed for surgery but is now commonly used in critical care situations like status asthmaticus. Status asthmaticus refers to a severe exacerbation of asthma that is refractory to maximal medical therapy and generally requires intubation and mechanical ventilation to reduce time without oxygen and prevent exhaustion.

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    25 views2 pages

    RSI & Status Asthmaticus: Drug Dose Onset/duration Cons Pros

    Uploaded by

    Afina Abdul Aziz
    Rapid sequence induction (RSI) is a technique used to quickly secure a patient's airway by administering induction agents and paralytics, followed by intubation. It was developed for surgery but is now commonly used in critical care situations like status asthmaticus. Status asthmaticus refers to a severe exacerbation of asthma that is refractory to maximal medical therapy and generally requires intubation and mechanical ventilation to reduce time without oxygen and prevent exhaustion.

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    RSI & Status Asthmaticus

    RSI

    Rapid sequence induction of anaesthesia is a specific technique originally used by anaesthetists, described formally in
    1970 by Stept and Safar who used it in a series of 80 patients between 1967 and 19691, showing it to reduce the risk of
    gastric aspiration. By definition it involves pre-oxygenation followed by the rapid delivery of a short acting induction agent
    and a neuromuscular blocking agent accompanied by cricoid pressure (as described by Sellick in 1961)2 and the
    insertion of a cuffed endotracheal tube. It differs from standard anaesthetic techniques mainly in its speed of delivery of
    predetermined doses of anaesthetic and depolarising muscle relaxing drugs. However its was developed to induce a
    state of anaesthesia for surgery and not primarily for airway control. With the advent of critical care this procedure was
    increasingly used for the rapid control and protection of the airway and for ventilation. This technique is often referred to
    as ‘rapid sequence intubation’ (RSI). Once the decision has been made to do an RSI, it is important to ensure that all
    necessary personnel, equipment and drugs are ready.

    Personnel: Intubator (Anaesthetist, or appropriately trained emergency physician), doctor to inject drugs, cricoid
    pressure by trained person; competant nurse to assist.

    Equipment: Good IV cannula; suction checked and to hand; tilting trolley; bougie to hand; laryngoscopes x2 (large
    blade); ready access to difficult intubation equipment; endotracheal tubes of various sizes (cuffs checked); syringe; BVM
    with reservoir bag; CO2 detection apparatus; full ECG, BP, SpO2 & CO2 monitoring; Stethoscope; tube tie/tape;
    connector; ventilator; CXR

    Drugs: O2; Rapidly acting paralysing agent; rapid IV induction agent (all doses less in elderly, debilitated or already
    reduced GCS); some add fentanyl/alfentanyl (not in asthmatics); maintenance of anaesthesia (usually propofol infusion
    4-12mg/kg/hr); ongoing paralysis

    Drug Dose Onset/duration Cons Pros

    Suxamethonium 100mg <1m/3-15m hyperkalaemia, muscle very rapid onset and short
    (1-1.5mg/kg) aches, raised gastric/ duration
    ocular pressure,
    bradycardia

    Atracurium 0.5mg/kg 2-2.5m/25-45m Bronchospasm and longer acting for


    (induction), hypotension, longer maintenance
    50mg acting
    q15-25mins

    Vecuronium 100mcg/kg 2.5-3m/25-40m (rare bronchospasm) less hypotension


    (induction),
    10-15mcg/kg
    q15mins

    Rocuronium 600mcg/kg 1-2m/30m bronchospasm, Rapid onset


    arrythmias

    Thiopental 1-4mg/kg <30s/5-10m hypotension, very rapid onset, anti-fit


    respiratory depression, (status epilepticus),
    larygngeal/ reduces CNS activity
    bronchospasm, tissue (head injury)
    necrosis if
    extravasated

    Propofol 1.5-2.5mg/kg 20-40s/2-4m apnoea, hypotension + rapid onset, good airway


    +, stinging in injection relaxation, smooth
    induction, no hang over,

    Etomidate 0.2-0.3mg/kg 20-40s/2-3m extraneous good cardiovascular


    movements, adrenal stability, more widespread
    suppression ED use

    Ketamine 1-4mg/kg 30-60s/10-15m Emergence (esp maintains airway reflexes /


    (usually with adults), movement, breathing, analgesic
    midazolam) secretions, raised ICP/ properties, safe, difficult
    ocular pressure, locations eg pre-hospital,
    vomiting, increased good in hypotension,
    myocardial O2 demand bronchodilator, IM dose
    RSI & Status Asthmaticus
    Status Asthmaticus;

    Generally accepted to be
    required when pCO2 is high/rising,
    p02 is low/dropping, pH ↓, GCS
    altered or patient is becoming
    exhausted despite maximal
    therapy.
    Patients are likely to have very
    high lung compliance, high auto
    PEEP (air trapping) and hypoxia.
    Must be pre-oxygenated with
    100% O2
    Need rapid successful tube
    placement to reduce time without
    O2
    NIV may help to prevent RSI
    being necessary (increased O2
    delivery, reduced work of
    breathing by improved compliance
    and PEEP can overcome the auto-
    PEEP-generated need for
    increased work)
    Risk of barotrauma with NIPPV,
    high pressures may be required-
    beware tension pneumothoraces.
    Avoid Atracurium (causes histamine release), use vecuronium instead

    Medline Search, 1955 to Nov 07


    [exp Intubation, Intratracheal/ or rapid sequence induction.mp. or rsi.mp. or intubation.mp. or crash
    induction.mp. or airway management.mp] AND [exp Asthma/ or asthma.mp.] AND [exp
    Anesthetics/ or exp Anesthesia, General/]

    88 papers found, 10 papers relevant.

    1. No help with the use of pre-treatment iv lignocaine (BestBET)3


    2. Initial NIV then if intubation required; prolonged expiration phase in ventilator settings, and
    permissive hypercapnia generally results in a good outcome (Review)4
    3. Ketamine and benzodiazepines may be used for induction (and maintenance) of anaesthesia,
    reviews and case series. 5,6,7 (Ketamine has some innate bronchodilatory effects)
    4. Some case series describe success with Isolfurane in otherwise refractory cases8
    5. Halothane has also been described in case reports as being useful for refractory cases5,9
    References
    1. Stept WJ, Safar P. Rapid induction-intubation for prevention of gastric content aspiration. Anesthesia and Analgesia
    1970 Jul-Aug; 49(4): 633-6
    2. Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet
    1961;ii:404-6
    3. Butler J. Jackson R. Best evidence topic report. Lignocaine as a pretreatment to rapid sequence intubation in
    patients with status asthmaticus. Emergency Medicine Journal. 22(10):732, 2005 Oct
    4. Gluckman T J. Corbridge T. Current Opinion in Pulmonary Medicine. 6(1):79-85, 2000 Jan
    5. Kruger AD. Benad G. The treatment of status asthmaticus using ketamine-experimental results and clinical
    experience. [Review] [102 refs] [German] Anaesthesiologie und Reanimation.17(3):109-30, 1992
    6. 'Hommedieu CS. Arens JJ. The use of ketamine for the emergency intubation of patients with status asthmaticus.
    Annals of Emergency Medicine. 16(5):568-71, 1987 May
    7. Rock, M J. Reyes de la Rocha, S. L'Hommedieu, C S. Truemper, E. Use of ketamine in asthmatic children to treat
    respiratory failure refractory to conventional therapy. Critical Care Medicine. 14(5):514-6, 1986 May
    8. Gonzalez Martin IJ. Mora Quintero ML. Abreu Gonzalez J. Ormazabal Ramos C. Glez Miranda F. Hernandez Nieto L.
    Treatment of life threatening asthma with isoflurane. [Spanish] Anales de Medicina Interna.9(1):36-8, 1992 Jan
    9. O'Rourke, P P. Crone, R K. Halothane in status asthmaticus. Critical Care Medicine. 10(5):341-3, 1982 May

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