Intubation meds

Use sedation and paralysis unless pt is already unconscious or newborn.
Do not use sedation or muscle relaxation when the airway is partially obstructed (facial trauma, epiglottitis), or if there is any concern that bag-valve-mask will be inadequate.

1. preoxygenate 100% O2 for 2-5 minutes, using cricoid pressure
2. atropine 0.01 mg/kg. MINIMUM 0.1 mg, max 0.5 mg (i.e. if <10 kg, give 0.1 mg, if >50 kg, give 0.5 mg). Giving less than 0.1 mg can cause a paradoxical bradycardia
3. cricoid pressure, when patient loses consciousness
4. sedative
5. paralytic

Sedatives

Midazolam (Versed) 0.05 to 0.10 mg/kg
- decreases HR, BP, RR
- amnestic

Ketamine 1-2 mg/kg (up to 4)
- give with atropine to minimize oral secretions
- increases BP, HR, ICP
- causes bronchodilation - use in asthmatics
- contraindicated in eye injuries

Thiopental 2-5 mg/kg
- rapidly induces LOC and apnea
- causes profound hypotension, decr ICP, cerebral blood flow
- use low dose 1-2 mg/kg if hypotensive
- increases oral secretions
- causes bronchospasm, laryngospasm - don't use in asthmatics

Lidocaine 1-2 mg/kg
- optional anesthetic
- use if elevated ICP is a concern
- decreases ICP spike, cough reflex
- minimizes CV effects of intubation
- controls ventricular dysrhythmias

Paralytics

Rocuronium 1 mg/kg (0.6 to 1.2)
- coadmin with sedative
- onset 30 to 60 seconds, duration 30-60 min
- minimal effect on HR/BP
- reverse w/ atropine, neostigmine in 30 min.

Vecuronium 0.1 mg/kg (to 0.2)
- onset a little later 70-120s, duration a little longer 30-90 min
- minimal hemodynamic fx
- reverse w/ atropine, edrophonium in 30 min

Pancuronium 0.1 to 0.2 mg/kg
- onset like vec (70-120 s), lasts 45-90 minutes
- reverse in 45 min w/ atro/neostig

Etomidate  0.3 mg/kg
- short acting 3-5 min
- main advantage: minimal hemodynamic fx
- can cause a short self-limited episdode of myoclonus and depress cortisol levels

Succinylcholine 1-2 mg/kg
- onset same as roc (30-60 s), but lasts only 3-10 min
- irreversible, depolarizing, muscle fasciculations occur after dose, then relaxation
- can cause tachyarrythmias (well tolerated) or serious brady (responsive to atropine)
- increases ICP, intraocular pressure.
- because it is so short-acting, one good indication is status epilepticus, because you can see if the pt is still seizing afterward
- risk factors for sux related hyperK: burns, massive trauma, UMN neuromuscular dz (ie stroke), diffuse muscle wasting, , serious abdominal infx. Also don't use in malig hyperthermia, pseudocholinesterase deficiency