11 The experience of being intubated is unpleasant and painful and seriously disturbs physiologic homeostasis. The alleviation of pain in neonates should be the goal of all caregivers, because repeated painful experiences have the potential for deleterious consequences. 4 Several trials have demonstrated that the use of premedication for intubation of the newborn significantly improves intubating conditions, decreases the time and number of attempts needed to complete the intubation procedure, and minimizes the potential for intubation-related airway trauma. Excellent intubating conditions are characterized by good jaw relaxation, open and immobile vocal cords, and suppression of pharyngeal and laryngeal reflexes assessed by the absence of coughing or diaphragmatic movements in response to intubation. 1, –, 3 Many failed attempts can be attributed to suboptimal intubating conditions. Several studies that evaluated the success rate of neonatal endotracheal intubations have reported that successful intubations frequently require more than 1 attempt and are rarely accomplished within the currently recommended time frame. Midazolam 1-5mg bolus then 0.04-0.Endotracheal intubation is a common procedure in NICUs and should be performed expeditiously in as controlled an environment as possible to reduce complications.Lorazepam 1-4mg bolus then 0.01-0.1mg/kg/hr (titrate q1hr).Cola-complication: need CO2 detection for at least 6 ventilations.End-tidal CO2 detection is primary means of ETT placement confirmation.in cervical spine immobilization, use bimanual laryngoscopy and consider adjuncts such as bougie or video laryngoscopy if minimal blood in oropharynx.Unable to move to cricothyroidotomy (angioedema, goiter, anterior neck mass).Unable to BVM due to facial hair, micrognathia.Expanding neck hematoma, to keep integrity of strap muscles.Consider not paralyzing in these situations.OK to use in crush injury, acute stroke as long as within 3 days of occurrence.ECG changes consistent with hyperkalemia.Stroke 1.5mg/kg - better to overdose than to underdose.May decrease MAP, especially if patient hypovolemic.Consider in patient in status epilepticus (anti-seizure effect).Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure).Consider use in head injured patients with increased ICP AND low or normal BP Evidence for clinically significant rise in ICP equivocal at best.Also consider with hypotension (i.e.: septic shock) Agent of choice for asthmatics as it has bronchodilator effects.Adrenal suppression is likely irrelevant with one-time dose.Does NOT blunt sympathetic reaction to intubation (no analgesic effect).Lowers seizure threshold in patients with known seizure disorder. Especially good for hypotensive/trauma patients.Reactive Airway disease: Lidocaine 1.5mg/kg (suppresses cough reflex).Increased ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it)).Ischemic heart disease/dissection: Fentanyl 3-5mcg/kg.Apneic oxygenation with NC at 6L/min while setting up and increase to 15L/min once patient is sedated.100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2.SOAPME: (Suction, oxygen, airway, pharmacology, monitoring, equipment).Option 2: 1 mcg/kg fentanyl PLUS 1 mg/kg ketamine PLUS 1 mg/kg rocuronium.Option 1: 0.15 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine.Option 2: 2 mcg/kg fentanyl PLUS 2 mg/kg ketamine PLUS 1 mg/kg rocuronium.Option 1: 0.3 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine.Hemodynamically stable, normotensive, well perfusing.However, etomidate and succinylcholine produces less hypotension.Etomidate does not have analgesic properties.Fentanyl with ketamine and rocuronium may blunt hypertensive response to tracheal manipulation as compared to traditional etomidate and succinylcholine RSI.Consider decreasing induction agent dosage for hemodynamic compromise.agent of choice for prolonged paralysis.Duration - 65 minutes (95% complete recovery).0.02mg/kg, no minimum dose (prior minimum 0.1mg no longer recommended).There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations Rapid sequence intubation (RSI) is an airway management technique that produces immediate anesthesia via an induction agent as well as rapid paralysis via a neuromuscular blocking agent.
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