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Premedication During Rapid Sequence Intubation: A Necessity or Waste of Valuable Time?

California Chapter of the American Academy of Emergency Medicine
Publication Date
  • Clinical Review
  • Biology
  • Medicine


The California Journal of Emergency Medicine VII:4, Dec. 2006 Page 75 Clinical Review PREMEDICATION DURING RAPID SEQUENCE INTUBATION: A Necessity or Waste of Valuable Time? Joel M. Schofer, MD Department of Emergency Medicine, Naval Medical Center San Diego Correspondence: Joel M. Schofer, MD, 628 Sand Shell Avenue, Carlsbad, California 920��. Tel: 6�9-459-�256. Fax: 760-476-0722. Email: [email protected] INTRODUCTION Every day, thousands of patients who present to emergency departments (EDs) require tracheal intubation for optimal care. Most acute intubations are performed using rapid sequence intubation (RSI), with the administration of an intravenous sedative followed by a paralytic agent, to ob- tain the best chance for successful intubation. Premedication with various agents prior to RSI when certain conditions are present is recommended by experts in acute airway manage- ment, as well as by many authors of major emergency medi- cine textbooks and advanced airway instructional courses. This premedication is touted as a way to limit physiologic responses to intubation that may adversely affect the patient. Despite expert opinions in favor of premedication, a paucity of data in the literature supports these practices. This fact, combined with the chaos, anxiety, and confusion often as- sociated with securing a critical airway, can cause the physi- cian performing RSI to question whether the administration of additional medications is truly essential or simply an un- necessary and burdensome measure. The central nervous, respiratory, endocrine, and cardiovascular systems all respond in various ways to laryngoscopy and tracheal intubation (LTI), and many of these responses can be harmful. See Table � . LTI stimulates the sympathetic nervous system which causes release of catecholamines and an increase in mean arterial pressure, heart rate, myocardial and cerebral oxygen consumption, cerebral blood flow, intraocular pressure (IOP), and intracranial

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