This document discusses the use of neuromuscular blocking agents (NMBAs) for rapid sequence intubation (RSI) in emergency departments. It provides details on the Maharaj Nakorn Chiang Mai Hospital emergency department's experience with RSI, including: 1) They initially used etomidate + succinylcholine or etomidate + rocuronium for RSI, and now have over 150 experiences with RSI. 2) Common problems encountered include hypotension after the procedure, multiple intubation attempts due to inexperience or poor positioning

1. Why do we need NMBAs
for RSI
ผศ.นพ.สุรพงษ์ หล่อสมฤดี
TIVA Center
Division of Cardiothoracic and Vascular Anesthesia
Division of Transplantation Anesthesia
Chiang Mai University Hospital

2. Hemodynamic Effects
Painful stimulus
Lorsomradee, et al: J Cardiothorac Vasc Anesth. 2007
Oct;21(5):636-43.

4. TIVA VIMA
20
Heart rate (% from baseline)
10
0
+ +
-10
+ + +
+ +
-20 * *
-30
-40
-50 Baseline Before After Before After Before After
Intubation Intubation Incision Incision Extubation Extubation
Heart Rate

5. TIVA VIMA
20 *
MAP (% from baseline)
10
0
-10 +
+ + +
-20 + +
+
-30 + +
-40
-50
Baseline Before After Before After Before After
Intubation Intubation Incision Incision Extubation Extubation
Blood Pressure

7. Multi-compartmental pharmacokinetic models

8. Overview NMBAs
Succinylcholine
• Introduced in 1952
• Only depolarizing NMBA
• NMBA with the fastest onset and ultra-
short duration
• Used for routine intubation in the USA (not
for children)
• But in Europe mainly Rapid Sequence
Induction
• Elimination by pseudocholinesterase

9. Succinylcholine’s strengths
Rapid onset
Profound depth of NMB
Short duration of action

10. Succinylcholine’s
weaknesses
Cardiovascular effects
sinus bradycardia
nodal rhythm
ventricular dysrhythm
Increase IOcP
Increase IGP
Increase ICP

11. Succinylcholine’s weaknesses
• Myalgia
• Masseter spasm
• Fasciculations
• Anaphylaxis
• Abnormal plasma cholinesterase
• Hyperkalemia

12. Contraindications
• MH
• Burn
• UMNL
• Severe muscle trauma
• Severe intraabdomen infection
• Disuse atrophy

13. ROCURONIUM BROMIDE RAPID
SEQUENCE INTUBATION
n = 230 (six clinical trials)
Premedication: midazolam or temazepam
Induction: thiopental (3-6 mg/kg) fentanyl (2-5
mcg/kg)
or + or
propofol (1.5 - 2.5 mg/kg) alfentanil (1
mg)
Rocuronium bromide dose: 0.6 mg/kg
Succinylcholine chloride dose: 1-1.5 mg/kg

14. RAPID SEQUENCE
INTUBATION
Rapid sequence intubation: excellent-to-good conditions achieved within
60 - 90 seconds of administration in most patients
Dose Percentage of patients with
excellent-to-good conditions
Rocuronium bromide (n=120) 0.6 mg/kg 99% (95% confidence
interval 95%-99.9%)
Succinylcholine chloride (n=110) 1.0-1.5 mg/kg 98% (95%
confidence interval 95%-
99.8%)

15. ONSET OF ROCURONIUM
BROMIDE
Onset: rapid to
intermediate
(dose dependent)

16. TRACHEAL INTUBATION
Pre-Medication Meperidine 1 mg/kg
Atropine 0.01mg/kg
Induction Propofol to 2.5mg/kg
Alfentanil to 0.25 mg/kg
Rocuronium bromide 0.6 mg/kg OR
Succinylcholine chloride 1 mg/kg
Intubation 60 sec. later

17. ROCURONIUM BROMIDE:
TRACHEAL INTUBATION
• Median time to 80% block with
0.6 mg/kg is 60 seconds (0.4-
6.0 minutes)
• Median onset time with 0.6
mg/kg is 1.8 minutes (0.6-13
minutes)

18. HISTAMINE RELEASING
POTENTIAL
Significant Insignificant
Tubocurarine +++ Rocuronium bromide
±
Metocurine ++ Vecuronium bromide
±
Atracurium besylate + Pancuronium bromide
±
Mivacurium chloride + Pipecuronium bromid
Succinylcholine chloride + Doxacurium chloride
±

19. Effects of Rocuronium on Heart Rate
100 600 mcg/kg
900 mcg/kg
Heart Rate (beats/min) 90 1200 mcg/kg
80
70
60
50
40
0.0 1.0 2.0 3.0 4.0 5.0 6.0
Time (minutes)
Levy et al. Anesth Analg 1994;78,318-321.

20. Effects of Rocuronium on Mean Arterial Pressure
600 mcg/kg
Mean Arterial Pressure (mmHg)
100 900 mcg/kg
1200 mcg/kg
90
80
70
60
50
0.0 1.0 2.0 3.0 4.0 5.0 6.0
Time (minutes)
Levy et al. Anesth Analg 1994;78,318-321.

21. Effects of Rocuronium on Histamine Release
3.0
Plasma Histamine (ng/ml)
2.5 600 mcg/kg
900 mcg/kg
2.0
1200 mcg/kg
1.5
1.0
0.5
0.0
0.0 1.0 2.0 3.0 4.0 5.0
Time (minutes)
Levy et al. Anesth Analg 1994;78,318-321.

22. ROCURONIUM BROMIDE:
CARDIOVASCULAR PROFILE
• Favorable cardiovascular profile
• Histamine release unlikely
• Mild vagolytic activity

23. Rationale for Selection of NMBs:
• Cardiovascular stability
• Nondepolarizing vs depolarizing
• Organ-independent elimination
• Clinically significant active or toxic
metabolites
• Predictability of duration
• Cumulative effects
• Reversibility
• Time to onset
• Stability of solution

24. Rapid Sequence
Intubation experience in
Emergency Department
Maharaj Nakorn Chiang Mai
นพ.บวร วิทยชำนำญกุล
Emergency Medicine
Chiang Mai University Hospital

25. History
• Awake intubation
• Diazepam ???
• Midazolam

26. • Establish Training EM in 2548
• Workshop RSI in January 2551
• RSI in ER October 2551
• Etomidate + Succinylcholine
• Etomidate + Rocuronium
• Propofol

27. 28
30
25 20
20
15 12
10
3 4
5 1
0
1 attempt 2 attempt 3 attempt
RSI 32 non RSI 36

28. 6
6
5
4 4
4
3
3
2 2 2 2 2
2
1
1
0 0
0
Hypotension Desaturation Vomit prolonged Oral trauma Esophageal
intubation intubation
RSI non RSI

29. Now
• More than 150 experience of RSI
• Staff attending 24 hr
• ER staff in morning shift and some noon –
night shift

30. Quality Control
• Resident 2 : training, coaching, direct
observe
• Difficult airway cart
• No serious adverse event

31. Troubleshoot
• Hypotension after procedure
• > 1 attempt
– Non experience
– Position

32. Prepare : sniff position

33. Prepare : sniff position

34. Troubleshoot
• Hypotension after procedure
• > 1 attempt
– Non experience
– Position
– Not wait til onset of drugs
• Myoclonus 1 time
• Drug preparation time

36. The End
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