Pretreatment medications for rapid sequence intubation in adults outside the operating room
- 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 priority for managing an acutely unstable patient is to ensure that there is a patent and functioning airway. When endotracheal intubation is indicated, emergency clinicians often use rapid sequence intubation (RSI) to accomplish this task.
RSI is the recommended method for emergency airway management for intubations that are not anticipated to be of sufficient difficulty as to make laryngoscopy or intubation likely to fail. RSI involves the use of a sedative and a neuromuscular blocking agent to render a patient rapidly unconscious and flaccid for emergency 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 in adults is reviewed here. The performance of RSI, including the use of induction and neuromuscular blocking agents, and other aspects of emergency airway management in adults and children are discussed separately. (See "Rapid sequence intubation for adults outside the operating room" and "Rapid sequence intubation (RSI) outside the operating room in children: Approach" and "Induction agents for rapid sequence intubation in adults outside the operating room" and "Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults outside of 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
- Beta-2 agonists
- Short-acting opioid
- Alpha-adrenergic agents
- CHOICE OF PRETREATMENT AGENTS
- General approach
- Asthma (elevated airway resistance)
- Elevated intracranial pressure
- Cardiovascular emergencies
- SUMMARY AND RECOMMENDATIONS