Rapid Sequence Intubation
Procedure Review
By Ken Shields
The Drugs
Lidocaine
Lidocaine has been used as an adjunct to anesthesia since the early 1960s. Initially, lidocaine was used to blunt the cough elicited from endotracheal stimulation; however, in the 1970s, it began to be used to improve hemodynamic stability. More recently, lidocaine has been studied as an agent used to prevent the rise in ICP associated with laryngeal stimulation. It is administered as an IV bolus at a dose of 1.5-2 mg/kg (1 mg/kg per our protocols). Lidocaine should ideally be administered 2-3 minutes before intubation because studies have demonstrated maximum efficacy at this duration.
Versed
Benzodiazepines are sedative-hypnotic agents that act as indirect gamma-aminobutyric acid (GABA) agonists. They are effective anxiolytic and amnestic agents and, as such, are popular for induction. Midazolam, which has a rapid onset and relatively short duration of action, is the best choice of these agents. When dosed as a primary induction agent at 0.1-0.2 mg/kg IV (0.1 mg/kg per our protocols), midazolam produces sedation within 1-2 minutes. Its half-life is 2-4 hours, but its effect is typically shorter.
Succinylcholine
Succinylcholine is considered an ideal paralytic agent because of the rapid onset of action (within 45 seconds) and the drug's short duration (4-5 minutes). Succinylcholine binds to acetylcholine receptors at the neuromuscular junction and stimulates depolarization of the muscle cell. Unlike acetylcholine, succinylcholine produces continuous stimulation of the muscle cell, which is unable to return to its resting state and paralysis occurs.
Vecuronium
Vecuronium is an amino-steroid nondepolarizing agent. It has an intermediate duration of action of 30-60 minutes with an initial dose of 0.1 mg/kg. It produces clinical effects in 30 seconds and intubation paralysis in 1-4 minutes.
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