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Chapter 13: Airway Management

A 60-year-old woman with no past medical history was noted to have slurred speech and left-sided weakness after eating dinner. She was sent to the emergency department (ED). Her initial computed tomography (CT) scan shows no acute disease. Because the patient arrived in the ED within an hour and had no contraindications to thrombolytics, tissue plasminogen activator (TPA) was administered.

During her hospitalization, she was noted to have become hypoxic and febrile. Her vitals are the following: blood pressure (BP) of 110/70 mmHg, heart rate (HR) of 120 beats/min (bpm), respiratory rate (RR) of 25 breaths/min, and O2 ­saturation of 90% on NRB. Her laboratory studies show the following:

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White blood cell count 14,000/μL
Sodium 145 mEq/L
Potassium 5.5 mEq/L
Chloride 109 mEq/L
CO2 25 mEq/L
Blood urea nitrogen 25 mg/dL
Creatinine 1.5 mg/dL
Lactic acid 5 mmol/L
Glucose 105 mg/dL

The chest radiograph shows no acute disease. The patient’s hypoxia continues to progress, and now her work of breathing is more labored. The family and the patient have agreed to intubation. Inspection of her airway reveals Mallampati class I. For rapid sequence intubation, what medications would you use?

A. Fentanyl, etomidate, and rocuronium

B. Lidocaine, propofol, and rocuronium

C. Fentanyl, etomidate, and succinylcholine

D. Patient is not a candidate for NMB

A. Fentanyl, etomidate, and rocuronium

Rapid sequence intubation is performed to decrease the risk of aspiration. There are 3 pharmacologic components: pretreatment, induction, and neuromuscular blockade. Pretreatment is performed to minimize the physiologic responses to the presence of laryngoscopy and endotracheal tube. Medications used for pretreatment include the following: (1) atropine, which is used to blunt the muscarinic effects; (2) lidocaine (1.5 mg/kg IV) 2–3 minutes before intubation may decrease airway resistance and increase intracranial pressure; (3) fentanyl (3 μg/kg) may blunt the sympathetic response during RSI; and (4) α-adrenergic via epinephrine (5–20 μg) or phenylephrine (50–200 μg) may prevent episodes of hypotension during intubation secondary to induction agents.

Induction agents include etomidate, benzodiazepines, ketamine, propofol, and barbiturates. Etomidate (0.3 μg/kg) is an imidazole-derived sedative hypnotic that acts directly on the gamma-aminobutyric acid (GABA) complex. It also is a reversible inhibitor of 11β-hydroxylase causing adrenal suppression that might last 12 to 24 hours. Potential complications include myoclonus and adrenal insufficiency. Benzodiazepines, usually midazolam (0.1–0.3 μg/kg IV) is an amnestic sedative that effects the GABA complex with anticonvulsant properties. In 10% to 25% of patients, it can cause hypotension and has no analgesic properties., Ketamine (1–2 mg/kg IV) is a dissociative, amnestic sedative with analgesic properties. It effects the N-methyl-D-aspartate (NMDA) component ...

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