Administration of sedative followed rapidly by a paralytic. RSI was created as a response to the deleterious effects of aspiration. The technique was to decrease the amount of time that a patient’s airway was unprotected during induction.
Pretreatment Agents
- Fentanyl: 2-10 mcg/kg; Reduces sympathetic responses, useful for patients with head injuries or myocardial ischemia.
- Lidocaine: Can decrease airway reactivity, helpful in asthma, and provide neuroprotection in head injuries.
- Atropine: Used to prevent bradycardia, especially in children.
- Defasciculating dose: A small dose of a non-depolarizing agent, such as rocuronium, is given before succinylcholine to prevent muscle fasciculations.
Sedative
Etomidate: 0.3-0.4 mg/kg; suitable for most situations including haemodynamically unstable, other than sepsis or seizures; anesthetic and sedative. Protection from myocardial and cerebral ischemia. Able to decrease intracranial pressure and maintain a normal arterial pressure. Etomidate-induced adrenal suppression. Cortisol levels have been reported to be suppressed up to 72 hours after a single bolus of etomidate in this population at risk for adrenal insufficiency. Controversial in patient with sepsis.
Ketamine: 1.5-2 mg/kg; dissociative anesthetic, for hemodynamically unstable; treatment for depression, pain management. Preserved breathing and airway reflexes, stimulated heart function with increased blood pressure, and moderate bronchodilation.
Propofol: 1-2.5 mg/kg; Use for Haemodynamically stable patients; anesthetic, procedural sedation. Airway suppression.
Paralytic
Rocuronium 0.6—1.2 mg/kg. Onset of action is dose-dependent from 45—120 seconds, with a duration of action 30—90 minutes. Metabolized in the liver with a half-life of 1.4—2.4 hours. Hepatotoxicity.
Succinylcholine: 1.0—1.5 mg/kg. Onset of 45—60 seconds, and a duration of action of 4—6 minutes of paralysis. Hyperkalemia, malignant hyperthermia, elevated IOP, fasciculations and bradycardia.
Apnea time
Rocuronium has a 40-second longer safe apnea time when compared to succinylcholine. Safe apnea time is defined as the time required for a patient to clinically desaturate, with an SpO2 < 88% after paralysis.
The proposed mechanisms for succinylcholine’s decreased safe apnea time is due to the increased muscle oxygen consumption due to the associated fasciculations with succinylcholine.
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