Pretreatment agents for rapid sequence intubation in adults
- David Caro, MD
David Caro, MD
- Program Director
- Assistant Professor of Emergency Medicine
- University of Florida College of Medicine, Jacksonville
- Section Editor
- Ron M Walls, MD, FRCPC, FAAEM
Ron M Walls, MD, FRCPC, FAAEM
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Adult Resuscitation
- Neskey Family Professor of Emergency Medicine
- Harvard Medical School
- Brigham and Women's Hospital
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
The first task of any clinician managing an acutely unstable patient is to secure the airway. Emergency clinicians often use rapid sequence intubation (RSI) to accomplish this task.
RSI is the most common method used in emergency airway management for intubations not anticipated to be difficult. RSI involves the use of a sedative and a neuromuscular blocking agent to render a patient rapidly unconscious and flaccid for emergent endotracheal intubation and to minimize the risk of aspiration.
Manipulation of the airway during laryngoscopy and endotracheal intubation causes physiologic responses that may be harmful to patients with specific medical conditions. Pretreatment agents may be incorporated into RSI protocols to blunt such physiologic responses and protect patients from their potentially harmful effects.
The use of pretreatment medications for RSI will be reviewed here. The performance of RSI, including the use of induction and neuromuscular blocking agents, and other aspects of emergency airway management are discussed elsewhere. (See "Rapid sequence intubation for adults outside the operating room" and "Rapid sequence intubation (RSI) in children" and "Induction agents for rapid sequence intubation outside the operating room in adults" and "Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults outside the operating room".)
PHYSIOLOGIC RESPONSES TO LARYNGOSCOPY AND INTUBATION
The pharynx, larynx, and carina of the trachea are highly innervated with sympathetic and parasympathetic nerves. The innervation of the upper and lower airways is discussed elsewhere. (See "Neuronal control of the airways".)
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- PHYSIOLOGIC RESPONSES TO LARYNGOSCOPY AND INTUBATION
- PRETREATMENT MEDICATIONS AND THEIR INDICATIONS
- Principles for the use of pretreatment agents
- Ultrashort-acting opioid
- Alpha-adrenergic agents
- CHOICE OF PRETREATMENT AGENTS
- General approach
- Asthma (elevated airway resistance)
- Elevated intracranial pressure
- Cardiovascular emergencies
- SUMMARY AND RECOMMENDATIONS