Vecuronium is an alternative nondepolarizing NMBA to rocuronium. Vecuronium is dosed at 0.01 mg/kg IV to prime 3 minutes before an intubating dose of 0.15 mg/kg IV. This time of onset is 75-90 seconds, and the duration of action is approximately 60-75 minutes.^1,28

Nondepolarizing NMBAs are not as popular as SCh because the duration of action remains significantly longer. Sugammadex is a new agent available in Europe that is capable of reversing the paralysis of rocuronium.^29,30 If this product shows continuing promise, rocuronium could soon become the agent of choice in RSI pharmacology.

Postintubation

The postintubation phase of RSI pharmacology is as important as the prior steps. Once the emergency physician has successfully completed laryngoscopy, the patient must have appropriate analgesia and anxiolysis. The same agents used for sedation during RSI can be used for postintubation care; all agents should be titrated to a standardized sedation scale (Table 3).³¹ In the American Journal of Emergency Medicine, Bonomo and colleagues brought to light the fact that emergency physicians are providing inadequate anxiolysis and analgesia after intubation.³² A retrospective study in the Journal of Trauma showed that 25% of patients received analgesia within 30 minutes of intubation; the mean time to receiving analgesia was 57 minutes.³³

The emergency physician must also be wary of postintubation hypo­volemia, which can be caused by decreased venous return secondary to positive-pressure ventilation or pneumothorax, choice of induction agent, and/or decrease in sympathetic drive. Initial management should revolve around crystalloid resuscitation and evaluation for pneumothorax.

Summary

Rapid sequence intubation is a procedure that is mechanically and mentally complicated. The pharmacology behind this process is multifaceted and requires careful planning. The evidence for use of tailored agents for specific clinical scenarios is very compelling and lends credence to expanding our repertoire beyond the traditional cocktail of etomidate and succinylcholine.

References

1. Walls R, Murphy M. Manual of Emergency Airway Management, 3rd ed. Lippincott Williams & Wilkins, 2008.
2. Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? Emerg. Med. J. 2001;18(6):453-7.
3. Cork RC, Weiss JL, Hameroff SR, et al. Fentanyl preloading for rapid-sequence induction of anesthesia. Anesth. Analg. 1984;63(1):60-4.
4. Dahlgren N, Messeter K. Treatment of stress response to laryngoscopy and intubation with fentanyl. Anaesthesia 1981;36(11):1022-6.
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29. Sparr HJ, Vermeyen KM, Beaufort AM, et al. Early reversal of profound rocuronium-induced neuromuscular blockade by sugammadex. Anesthesiology 2007;106(5):935-43.
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Contributor Disclosures

Contributors