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Pretreatment agents for rapid sequence intubation in adults

Author
David Caro, MD
Section Editor
Ron M Walls, MD, FRCPC, FAAEM
Deputy Editor
Jonathan Grayzel, MD, FAAEM

INTRODUCTION

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 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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Literature review current through: Nov 2016. | This topic last updated: Thu Sep 24 00:00:00 GMT+00:00 2015.
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References
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  1. Choyce A, Avidan MS, Harvey A, et al. The cardiovascular response to insertion of the intubating laryngeal mask airway. Anaesthesia 2002; 57:330.
  2. Kihara S, Brimacombe J, Yaguchi Y, et al. Hemodynamic responses among three tracheal intubation devices in normotensive and hypertensive patients. Anesth Analg 2003; 96:890.
  3. Tong JL, Ashworth DR, Smith JE. Cardiovascular responses following laryngoscope assisted, fibreoptic orotracheal intubation. Anaesthesia 2005; 60:754.
  4. Xue FS, Liao X, Liu KP, et al. The circulatory responses to tracheal intubation in children: a comparison of the oral and nasal routes. Anaesthesia 2007; 62:220.
  5. Xue FS, Zhang GH, Sun HY, et al. Blood pressure and heart rate changes during intubation: a comparison of direct laryngoscopy and a fibreoptic method. Anaesthesia 2006; 61:444.
  6. Kerr ME, Rudy EB, Weber BB, et al. Effect of short-duration hyperventilation during endotracheal suctioning on intracranial pressure in severe head-injured adults. Nurs Res 1997; 46:195.
  7. Rudy EB, Turner BS, Baun M, et al. Endotracheal suctioning in adults with head injury. Heart Lung 1991; 20:667.
  8. Caro DA, Bush S. Pretreatment agents. In: Manual of Emergency Airway Management, 3rd, Walls RM, Murphy MF. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008.
  9. Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J 2001; 18:373.
  10. McCauley CS, Boller LR. Bradycardic responses to endotracheal suctioning. Crit Care Med 1988; 16:1165.
  11. Sørensen M, Engbaek J, Viby-Mogensen J, et al. Bradycardia and cardiac asystole following a single injection of suxamethonium. Acta Anaesthesiol Scand 1984; 28:232.
  12. Viby-Mogensen J, Wisborg K, Sørensen O. Cardiac effects of atropine and gallamine in patients receiving suxamethonium. Br J Anaesth 1980; 52:1137.
  13. Cozanitis DA, Dundee JW, Khan MM. Comparative study of atropine and glycopyrrolate on suxamethonium-induced changes in cardiac rate and rhythm. Br J Anaesth 1980; 52:291.
  14. Magee DA, Sweet PT, Holland AJ. Effect of atropine on bradydysrhythmias induced by succinylcholine following pretreatment with D-tubocurarine. Can Anaesth Soc J 1982; 29:573.
  15. Brandt MR, Viby-Mogensen J. Halothane anaesthesia and suxamethonium III. Atropine 30 s before a second dose of suxamethonium during inhalation anaesthesia: effects and side-effects. Acta Anaesthesiol Scand Suppl 1978; 67:76.
  16. Greenan J, Dewar M, Jones CJ. Intravenous glycopyrrolate and atropine at induction of anaesthesia: a comparison. J R Soc Med 1983; 76:369.
  17. Latorre F, Ellmauer S, Dick W. [Atropine in the premedication of patients at risk. Its effect on hemodynamics and salivation during intubation anesthesia using succinylcholine]. Anaesthesist 1992; 41:76.
  18. Shipton EA, Roelofse JA, Luus HG. Effect of intramuscular atropine and glycopyrrolate on the cardiovascular response to tracheal intubation. S Afr Med J 1984; 66:528.
  19. Aouad MT, Sayyid SS, Zalaket MI, Baraka AS. Intravenous lidocaine as adjuvant to sevoflurane anesthesia for endotracheal intubation in children. Anesth Analg 2003; 96:1325.
  20. Davidson JA, Gillespie JA. Tracheal intubation after induction of anaesthesia with propofol, alfentanil and i.v. lignocaine. Br J Anaesth 1993; 70:163.
  21. Jakobsen CJ, Ahlburg P, Holdgård HO, et al. Comparison of intravenous and topical lidocaine as a suppressant of coughing after bronchoscopy during general anesthesia. Acta Anaesthesiol Scand 1991; 35:238.
  22. Lin CS, Sun WZ, Chan WH, et al. Intravenous lidocaine and ephedrine, but not propofol, suppress fentanyl-induced cough. Can J Anaesth 2004; 51:654.
  23. Nishino T, Hiraga K, Sugimori K. Effects of i.v. lignocaine on airway reflexes elicited by irritation of the tracheal mucosa in humans anaesthetized with enflurane. Br J Anaesth 1990; 64:682.
  24. Pandey CK, Raza M, Ranjan R, et al. Intravenous lidocaine suppresses fentanyl-induced coughing: a double-blind, prospective, randomized placebo-controlled study. Anesth Analg 2004; 99:1696.
  25. Pandey CK, Raza M, Ranjan R, et al. Intravenous lidocaine 0.5 mg.kg-1 effectively suppresses fentanyl-induced cough. Can J Anaesth 2005; 52:172.
  26. Warner LO, Balch DR, Davidson PJ. Is intravenous lidocaine an effective adjuvant for endotracheal intubation in children undergoing induction of anesthesia with halothane-nitrous oxide? J Clin Anesth 1997; 9:270.
  27. Yukioka H, Hayashi M, Terai T, Fujimori M. Intravenous lidocaine as a suppressant of coughing during tracheal intubation in elderly patients. Anesth Analg 1993; 77:309.
  28. Groeben H, Silvanus MT, Beste M, Peters J. Combined intravenous lidocaine and inhaled salbutamol protect against bronchial hyperreactivity more effectively than lidocaine or salbutamol alone. Anesthesiology 1998; 89:862.
  29. Groeben H, Silvanus MT, Beste M, Peters J. Both intravenous and inhaled lidocaine attenuate reflex bronchoconstriction but at different plasma concentrations. Am J Respir Crit Care Med 1999; 159:530.
  30. Maslow AD, Regan MM, Israel E, et al. Inhaled albuterol, but not intravenous lidocaine, protects against intubation-induced bronchoconstriction in asthma. Anesthesiology 2000; 93:1198.
  31. Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J 2001; 18:453.
  32. Butler J, Jackson R. Towards evidence based emergency medicine: best BETs from Manchester Royal Infirmary. Lignocaine premedication before rapid sequence induction in head injuries. Emerg Med J 2002; 19:554.
  33. Brooks D, Anderson CM, Carter MA, et al. Clinical practice guidelines for suctioning the airway of the intubated and nonintubated patient. Can Respir J 2001; 8:163.
  34. Grover VK, Reddy GM, Kak VK, Singh S. Intracranial pressure changes with different doses of lignocaine under general anaesthesia. Neurol India 1999; 47:118.
  35. White PF, Schlobohm RM, Pitts LH, Lindauer JM. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology 1982; 57:242.
  36. Bachofen M. [Suppression of blood pressure increases during intubation: lidocaine or fentanyl?]. Anaesthesist 1988; 37:156.
  37. Samaha T, Ravussin P, Claquin C, Ecoffey C. [Prevention of increase of blood pressure and intracranial pressure during endotracheal intubation in neurosurgery: esmolol versus lidocaine]. Ann Fr Anesth Reanim 1996; 15:36.
  38. Yano M, Nishiyama H, Yokota H, et al. Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology 1986; 64:651.
  39. Dutt A, Joad AK, Sharma M. Induction for classic laryngeal mask airway insertion: Does low-dose fentanyl work? J Anaesthesiol Clin Pharmacol 2012; 28:210.
  40. Chung KS, Sinatra RS, Halevy JD, et al. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth 1992; 39:774.
  41. Cork RC, Weiss JL, Hameroff SR, Bentley J. Fentanyl preloading for rapid-sequence induction of anesthesia. Anesth Analg 1984; 63:60.
  42. Dahlgren N, Messeter K. Treatment of stress response to laryngoscopy and intubation with fentanyl. Anaesthesia 1981; 36:1022.
  43. Kerr ME, Sereika SM, Orndoff P, et al. Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries. Am J Crit Care 1998; 7:205.
  44. Vacanti CA, Silbert BS, Vacanti FX. The effects of thiopental sodium on fentanyl-induced muscle rigidity in a human model. J Clin Anesth 1991; 3:395.
  45. Caspi J, Klausner JM, Safadi T, et al. Delayed respiratory depression following fentanyl anesthesia for cardiac surgery. Crit Care Med 1988; 16:238.
  46. Roy S, Fortier LP. Fentanyl-induced rigidity during emergence from general anesthesia potentiated by venlafexine. Can J Anaesth 2003; 50:32.
  47. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Acad Emerg Med 2005; 12:508.
  48. Sacchetti A, Senula G, Strickland J, Dubin R. Procedural sedation in the community emergency department: initial results of the ProSCED registry. Acad Emerg Med 2007; 14:41.