1. Pharmacologic Adjuncts to Airway Management and Ventilation
EMS 352
DR AQEELA BANO

2. Pharmacologic Adjuncts to Airway Management and Ventilation
Decrease the discomfort of intubation
Decrease the incidence of complications
Make aggressive airway management possible for patients who are unable to cooperate

3. Sedation in Emergency Intubation
Reduces anxiety, induces amnesia, decreases gag reflex
Undersedation:
Inadequate cooperation
Complications of gagging
Incomplete amnesia

4. Sedation in Emergency Intubation
Oversedation:
Uncontrolled general anesthesia
Loss of protective airway reflexes
Respiratory depression
Complete airway collapse
Hypotension

5. Sedation in Emergency Intubation
Desired level of sedation dictates dose
Two major classes:
Analgesics: decrease perception of pain
Sedative-hypnotics: induce sleep, decrease anxiety

6. Butyrophenones Potent, effective sedatives Do not produce apnea
Haloperidol and droperidol relieve anxiety.
Do not produce apnea
Little effect on cardiovascular system
Not recommended to induce anesthesia

7. Benzodiazepines Sedative-hypnotic drugs Diazepam and midazolam
Provide muscle relaxation, mild sedation
Used as anxiolytic and antiseizure medications
Provide anterograde amnesia

8. Benzodiazepines Neuromuscular blockers preferred for muscle relaxation
Potential side effects:
Respiratory depression
Slight hypotension
Flumazenil: benzodiazepine antagonist

9. Barbituates Sedative-hypnotic medications Thiopental Methohexital
Short acting
Rapid onset
Methohexital
Ultra-short acting
Twice as potent
Can cause
Respiratory depression
Drop in blood pressure
Potentially irreversible in hypovolemic patients

10. Opioids/Narcotics Potent analgesics with sedative properties
Two most common: fentanyl, alfentanil
Can cause respiratory and central nervous system depression
Naloxone: narcotic antagonist

11. Nonnarcotic/Nonbarbituate
Etomidate
Hypnotic-sedative drug
Often used in induction of general anesthesia
Fast-acting, short duration
Little effect on pulse rate, blood pressure, intracranial pressure (ICP)

12. Nonnarcotic/Nonbarbituate
Etomidate (cont’d)
No histamine release and bronchoconstriction
High incidence of myoclonic muscle movement
Useful induction agent in patients with:
Coronary artery disease
Increased ICP
Borderline hypotension/hypovolemia

13. Neuromuscular Blockade in Emergency Intubation
Cerebral hypoxia can make patients combative and uncooperative.
Requires aggressive oxygenation, ventilation
Neuromuscular blocking agents are safer.

14. Neuromuscular Blocking Agents
Affect every skeletal muscle
Within about 1 minute, patient is paralyzed
Must be able to secure the airway
No effect on LOC.

15. Pharmacology of Neuromuscular Blocking Agents
Skeletal muscles are voluntary.
Impulse to contract reaches a motor nerve
Acetylcholine (Ach) is released.
Diffuses, occupies receptor sites
Triggers changes in electrical properties of the muscle fiber (depolarization)

16. Pharmacology of Neuromuscular Blocking Agents
Paralytic medications
Relax the muscle by impeding the action of Ach
Two categories: depolarizing and nondepolarizing

17. Depolarizing Neuromuscular Blocking Agent
Competitively binds with ACh receptor sites
Not affected as quickly by acetylcholinesterase
Succinylcholine chloride is the only agent.
Fasciculations can be observed during its administration.

18. Depolarizing Neuromuscular Blocking Agent
Very rapid onset of total paralysis
Short duration of action
Use with caution in patients with burns, crush injuries, and blunt trauma
Can cause bradycardia

19. Nondepolarizing Neuromuscular Blocking Agents
Bind to ACh receptor sites but do not cause depolarization of the muscle fiber.
Prevent fasciculations before a depolarizing paralytic

20. Nondepolarizing Neuromuscular Blocking Agents
Most commonly used
Vecuronium bromide (Norcuron)
Pancuronium bromide (Pavulon)
Rocuronium bromide (Zemuron)
Do not give before the airway is secured.

21. Rapid-Sequence Intubation (RSI)
Safe, smooth, rapid sedation and paralysis followed immediately by intubation
Generally used for patients who are unable to cooperate

22. Preparation of the Patient and Equipment
Explain procedure, reassure the patient
Apply a cardiac monitor and pulse oximeter.
Check, prepare, assemble equipment
Have suction available

23. Preoxygenation Adequately preoxygenate all patients.
If the patient is breathing spontaneously and has adequate tidal volume:
Apply high-flow oxygen via nonrebreathing mask.
If patient is hypoventilating:
Assist ventilations with a bag-mask device and high-flow oxygen.

24. Premedication
Stimulation of the glottis with intubation can cause dysrhythmias and increase ICP.
If your initial paralytic is succinylcholine, administer nondepolarizing paralytic.
Atropine sulfate should be administered to decrease potential for bradycardia.

25. Sedation and Paralysis
As soon as patient is sedated, administer paralytic agent
Onset should be complete within 2 minutes.
Signs of adequate paralysis include:
Apnea
Laxity of the mandible
Loss of the eyelash reflex

26. Intubation Intubate trachea as carefully as possible.
If you cannot intubate within 30 seconds, ventilate for 30–60 seconds before trying again.
If ventilating with a bag-mask device, do so slowly.

27. Intubation Once tube is in the trachea: Inflate cuff. Remove stylet.
Verify position of the ET tube.
Secure the tube.
Continue ventilations.

28. Intubation Intubate trachea as carefully as possible.
If you cannot intubate within 30 seconds, ventilate for 30–60 seconds before trying again.
If ventilating with a bag-mask device, do so slowly.

29. Intubation Once tube is in the trachea: Inflate cuff. Remove stylet.
Verify position of the ET tube.
Secure the tube.
Continue ventilations.

30. Maintenance of Paralysis and Sedation
Additional paralytic administration may be necessary after intubation.
If you administered succinylcholine, administer a nondepolarizing agent to maintain paralysis.
If you administered a long-acting paralytic, additional dosing is usually not necessary.

31. Maintenance of Paralysis and Sedation
Modification for unstable patients
If oxygen saturation drops, ventilate slowly.
If patient is hemodynamically unstable, judge whether sedation is appropriate.

32. Maintenance of Paralysis and Sedation
Additional paralytic administration may be necessary after intubation.
If you administered succinylcholine, administer a nondepolarizing agent to maintain paralysis.
If you administered a long-acting paralytic, additional dosing is usually not necessary.