ADVANCES IN AIRWAY PHARMACOLOGY: Emerging Trends and Evolving Controversy
Section snippets
RAPID SEQUENCE INTUBATION
RSI has become the emergency physician's cornerstone for emergent airway management.96 Its use in the ED has been shown to be a safe and effective approach to managing the airway of critically ill patients.21, 97, 98 The procedure consists of several distinct phases that prepare and manage both the patient's airway and the physiologic responses to laryngoscopy and intubation (Fig. 1). Although RSI technique follows a predetermined sequence, there are often many pharmacologic options within each
PRETREATMENT
Patients requiring emergency airway control are most often critically ill or injured. Emergent management of the airway requires the use of drugs to produce rapidly sufficient anesthesia for laryngoscopy and endotracheal intubation, both of which are considered noxious stimuli. The physician securing the airway must consider the physiologic consequences of this manipulation and proceed accordingly. Laryngoscopy and tracheal intubation are known to increase sympathetic activity,37, 42, 58, 104
INDUCTION
The induction phase of RSI is used to produce anesthesia and unconsciousness. There are many types of drugs capable of achieving these goals, and all are generally classified as intravenous anesthetics. Intravenous induction of anesthesia was first introduced in 1934; John Lundy used thiopental as the first injectable induction agent. Today, numerous pharmacologic classes of drugs are used for induction purposes. To be useful in emergency airway management, each agent should facilitate
PARALYSIS
In the paralysis phase of RSI, neuromuscular blocking agents are employed to facilitate rapid and efficacious endotracheal intubation. A neuromuscular blocker, also known as a muscle relaxant, is a drug that interrupts transmission of nerve impulses at the neuromuscular junction. Because all ED patients empirically are classified as having a “full stomach,” they are considered at risk for aspiration of gastric contents; thus, in RSI the time between induction of anesthesia and actual placement
AWAKE/TOPICAL INTUBATION
An awake intubation is performed on the spontaneously breathing, conscious, or semiconscious patient. This procedure is indicated when endotracheal intubation under the usual RSI conditions of unconsciousness and apnea may prove difficult or dangerous for the patient. Because the aim of this procedure is to preserve the patient's ability to maintain his or her own airway during laryngoscopy, induction and paralytic agents are not employed. Because tracheal manipulation and intubation are
SUMMARY
The practice of emergency medicine is a constant onslaught of decision making and challenges and the issues of airway management are no exception. Obtaining proper airway control requires thoughtful organization and planning, and necessitates a thorough working knowledge of the drugs or medications employed. Because there are so many agents available, expertise in airway pharmacology has become essential. The emergency physician who is well versed in the uses, and the physiologic effects,
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Cited by (23)
Rapid sequence intubation
2008, Pediatric Emergency MedicineAirway management in critical illness
2007, ChestCitation Excerpt :The exact incidence of morbidity and mortality related to airway management facilitated by the use of IV induction agents in the ICU is unknown; however, it is likely to be underreported. Several comprehensive reviews42on pharmacologic agents used for airway management in the ICU have been published; we will therefore provide a brief overview of commonly used agents and discuss controversies surrounding their use. Propofol is a popular hypnotic agent for several reasons.
Rapid Sequence Intubation
2007, Pediatric Emergency MedicineAirway management of the critically ill patient: Rapid-sequence intubation
2005, ChestCitation Excerpt :Fentanyl is commonly used because of its rapid onset of action and short duration of action. Fentanyl blunts the hypertensive response to intubation (40% incidence of hypertensive response compared with 80% in control subjects),41 although it has only marginal effects on attenuating tachycardia.41,42 Derivatives of fentanyl, sufentanil and alfentanil, are more effective than fentanyl at blunting both the tachycardic and hypertensive responses to intubation.42–45
Rapid sequence induction medications: An update
2003, Journal of Emergency Nursing
Address reprint requests to Paula Susanna Wadbrook, MD, Department of Emergency Medicine, Scott & White Medical Center, 2401 South 31st Street, Temple, TX 76508