This document discusses drugs used in airway management during intubation. It covers: 1) Premedication drugs like opioids, lidocaine, and muscle relaxants given before intubation to reduce stress responses. Fentanyl is mentioned as a commonly used opioid. 2) Induction agents for intubation including midazolam, propofol, etomidate, and ketamine. Pros and cons of each are provided. 3) Muscular blockade drugs like succinylcholine and rocuronium for intubation, including dosages and side effects. 4) Post intubation sedation options like midazolam and fentanyl infusions to prevent injury and stress responses

1. DRUGS IN AIRWAY
MANAGEMENT
AIRWAY COURSE

2. • Premedication/Preinduction
• Induction/Sedation
• Muscular blockade
• Post Intubation

3. A) PREMEDICATION/PREINDUCTION
• Rationale for use:
– Stimulation of the airway with a laryngoscope and endotracheal tube:
extremely noxious stimulus
• Intense sympathetic discharge ⇒ hypertension and tachycardia (pressor
response).
• In critically ill: induce myocardial and cerebrovascular injury.
• Provoke bronchospasm and coughing
– Aggravate underlying conditions: asthma, intraocular hypertension,
and intracranial hypertension
• Attenuation of the stresses with placement of an airway ⇒
unmask relative hypovolemia and/or vasodilation
(postintubation hypotension).
• Drugs: opioids, lidocaine, β-adrenergic antagonists, and non-
depolarizing neuromuscular blockers.

4. Lignocaine Opioid Atropine Defasciculating

5. Fentanyl
• Opiod
• Commonly use as analgesia in trauma. 50-80
times more potent then morphine.
• Dosage : 2 mcg/kg (50-100mcg) slow push.
• Onset : Immediate (pt might cough)
• Duration : about 1 H
• Caution : Hypotension, bradycardia with large
dose

6. B) INDUCTION/SEDATION

7. Midazolam 0.1 mg/kg 3-5 min 30 min Most common Hypotension

8. CHOICE OF DRUGS:
DORMICUM
• Uses:
– Induction agent
– Post intubation sedation
• Dosage: 0.1 mg/kg
• The good:
- most available everywhere
- familiar
• The bad:
-slow onset > 3-5 minutes
-hypotension

9. CHOICE OF DRUGS:
PROPOFOL
• Uses:
– Induction agent
– Post intubation sedation
• Dosage: 2 mg/kg
• The good:
– Rapid onset of less than 3 minutes
– Rapid offset kinetics
– Readily titratable
– Pleasant emergence and little hangover
• The bad:
– Cardiac comorbidities: significant hypotension

10. Choice of drugs:
etomidate
• Uses: provide good intubation conditions with very
few hemodynamic derangements
• Dosage: 0.3 mg/kg
• The good:
– Onset and offset pharmacokinetic similar to propofol
– No significant effects on myocardial contractility
• The bad: effect on adrenal production of steroids.
– Inhibits adrenal steroidogenesis through the inhibition of
mitochondrial hydroxylase (bolus or infusion)
– Adrernal suppression may last up to 72h.
– Use in sepsis and septic shock discouraged

11. Choice of Drugs:
Ketamine
• Uses:
– Adjunct induction agent in combination with etomidate and
rocuronium for hemodynamically unstable patients with
contraindications to the use of succinylcholine
• Dosage: 2 mg/kg
• The good:
– Has analgesic, sedative, and amnestic effects.
– Decreases airway resistance
– May be better than sodium pentothal as induction agent
• The bad:
– Slower onset and offset compared to propofol or etomidate
– Stimulates the cardiovascular system (raises heart rate and BP by
direct stimulation of the CNS).

12. C) NEUROMUSCULAR BLOCKADE
AGENT

13. Choice of Drugs:
Succinylcholine
• Dosage:
– IV: 1 - 2 mg/kg
– Subcutaneous: 3 – 4 mg/kg
– margin of safety in dosing up to 6mg/kg
– >6mg/kg – cause phase 2 block
• The good:
– Excellent intubation conditions in < 1 min: drug of choice
• Adverse effect:
1. Fasciculation
2. Hyperkalemia
• Susceptible : burn, denervation, crush injury, intraabdominal infection,
myopathies, renal failure
1. Bradycardia
2. Prolonged neuromuscular blockade
3. Malignant hyperthermia
4. Trismus/masseter muscle spasm

14. • Intubating dose: 1mg/kg
• The good:
– Alternative to succinylcholine for use during RSI
• The bad:
- Worst in difficult intubation, can’t
intubate, can’t ventilate.
Choice of Drugs:
Rocuronium

15. D) POST INTUBATION

16. • Aim to keep pt sedated to facilitate ventilation
& prevent laryngeal injury or increase
sympathetic activity.
• Midamorphine infusion
• Midainfusion
• Fentanyl infusion

17. THE END