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Rapid Sequence Intubation: Pretreatment - #PHARMFAX

Updated: Aug 28, 2023

The six "P"s of rapid sequence intubation are preparation, preoxygenation, pretreatment, paralysis and induction, placement of tube, and postintubation management.

 



The six "P"s of rapid sequence intubation are preparation, preoxygenation, pretreatment, paralysis and induction, placement of tube, and postintubation management.


Before we decide on paralyzing someone, always think pretreatment. The acronym "LOAD" was utilized in the past for severe TBIs to mitigate elevations in ICPs. LOAD stands for lidocaine, opioids, atropine, and defasciculation dosing. The purpose of pretreatment is to blunt the sympathetic response to an endotracheal tube being passed.


Lidocaine and opioids were considered neuroprotective, but literature more supports the latter. Succinylcholine can cause bradycardia, especially in pediatrics, hence the use of prophylactic atropine. Defasiculation dosing utilized a small dose of rocuronium with succinylcholine to prevent defasiculations. Evidence outside of opioids do not support routine use.


I've changed the meaning of the acronym LOAD to make it more applicable to my practice. It makes me consider lidocaine, access, opioids, delay or down. By thinking of LOAD in this manner, it helps me prepare for complications.


Consider these questions as you go through LOAD; is this a case for nebulized or topical lidocaine for an awake intubation? Does the patient need opioids for pain control or neuroprotection? What access does the patient have to get medications into the patient?. Down or delay? Determine whether you need vasoactive support via push dose or continuous infusion vasopressors, and agents for delayed sequence intubation.


Thats what works for me, do what makes to you. Did you save the #PHARMFAX for later? Hit the like and follow button for more, share the #PHARMFAX with a friend, and I hope you learned something new.


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References

  1. Engstrom et al. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med. 2023 Aug;70:19-29. doi: 10.1016/j.ajem.2023.05.004.

  2. Kramer et al. Rapid Sequence Intubation in Traumatic Brain-injured Adults. Cureus. 2018 Apr; 10(4): e2530.

  3. Hampton J. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm. 2011 Jul 15;68(14):1320-30. doi: 10.2146/ajhp100437.


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