RSI and conscious sedation – Flashcards
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Pre-treatment/Induction
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Administration of an appropriate sedating/induction agent Meds given rapidly via IVP Goal = LOC; "Make me forget before you paralyze me" Assess LOC
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Rapid Sequence Intubation
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Sequential administration of a sedative and paralytic in order to facilitate emergency intubation
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indications RSI
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compromised respiratory status resp arrest or cardiac arrest very anxious
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contraindications RSI
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co-morbidities current airway status does not need intubation pt can protect own airway allergy to sedatives/ paralytics
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Basic Preparation for the RN
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Cardiac monitoring Capnography - assess end tidal CO2 oximetry two IV lines emergency equipment (ventilator) and crash cart at bedside pre-oxygenation at 100% for at least 3 min
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Etomidate
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MOA: general anesthetic, sedative I: Most commonly used anesthetic in emergent RSI for induction (bringing about paralysis) PE: Usually given due to low adverse CV effects and its versatility Given via rapid IVP
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Ketamine
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Dissociative induction agent that provides analgesia and amnesia Used for awake sedations or for patients with contraindications to other meds such as difficult airways, elderly, cardiovascular disease Smooth muscle relaxer and bronchodilator, used to reduce bronchospasm
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Propofol
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MOA: general anesthetic I: induction, and maintenance of anesthesia post-intubation for continued sedation AE: Arrhythmia Hyper/ hypotension Apnea Rash PE: Has been associated with both fatal and life-threatening anaphylactic reactions do not give if have EGG allergy Highly fat-soluble (cross BBB) Given by injection
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Paralysis
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Depolarizing and non-depolarizing neuromuscular blocking agents are used to facilitate RSI Medications correlate with and act on cholinergic receptors --> succ, roc, vec Assess muscle fasciculation, apnea Monitor oxygenation and time spent from induction to intubation
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Succinylcholine
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MOA: depolarizing NMBD I: Due to quick onset of action, used to facilitate endotracheal intubation Provides optimal intubating conditions most quickly AE: MALIGNANT HYPERTHERMIA, hyperkalemia CI: use of digoxin skeletal muscle myopathies, such as muscular dystrophy Do not use over long periods of time due to its tendency to cause muscular fasciculations Injectable form only
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order of paralysis: succinylcholine
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1) Fasiculations in chest and abdomen 2) Neck arms and legs 3)Facial, pharynx, and larynx 4)Respiratory muscles
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Rocuronium
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MOA: Non-depolarizing NMBD Adjunct to general anesthesia to facilitate endotracheal intubation and to provide skeletal muscle relaxation during sx or mechanical ventilation AE: Tachycardia, transient hypotension, hypertension Fewer AE and contra than with vecuronium PE: Used if succinylcholine is contraindication. Injectable form only
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Vecuronium
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MOA: Non-depolarizing NMBD I: Used less frequently in RSI and more frequently for continued paralysis AE: Skeletal muscle weakness, Paralysis, Muscle atrophy Typically has no CV effects PE: administered IV
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order of paralysis: rocuronium, vecuronium
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1) Small muscles (fingers, eyes) 2)Limbs, neck, trunk 3)Intercostal muscles, diaphragm
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Post-intubation care
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monitoring the patient by the RN is critical Will need respiratory at the bedside with the ventilator
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Conscious Sedation
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Aka procedural sedation Is a medically controlled state in which consciousness is depressed, but the patient can still maintain an airway and respond to commands, protective reflexes remain intact
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indications CS
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Painful procedures Facilitate wound care (debridement) Anxiety and pain management during procedures Reduction of fractures Endoscopy/colonoscopy Cardioversions
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commonly used medications for CS
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anesthetics: propofol, etomidate opioid analgesics: fentanyl, morphine barbiturates benzos (anxiolytics, amnesics): midazolam, diazepam, lorazepam ketamine
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Naloxone
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reversal agent for NARCOTICS
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Flumazenil
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reversal agent for BENZOS
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RASS Score
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Used to assess and score a patient's sedation level to ensure appropriate sedation throughout procedure Score is from +4 to -5. A score of 0 is Alert and calm
