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

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 obtain 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 management, as well as by many authors of major emergency medicine 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 associated with securing a critical airway, can cause the physician performing RSI to question whether the administration of additional medications is truly essential or simply an unnecessary 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 pressure (ICP). Laryngospasm, bronchospasm, cough, and dysrhythmias can also result. In children, LTI will often lead to a paradoxical bradycardia due to stimulation of the vagus nerve. These physiologic responses are worsened by prolonged and aggressive LTI attempts, as well as by stimulation of the carina with the endotracheal tube. In theory, these responses could adversely affect patients with such conditions as myocardial ischemia, aortic dissection or aneurysm, head trauma, ocular trauma, traumatic bleeding, asthma, and chronic obstructive pulmonary disease (COPD). See Table 2. Table . Physiologic responses increased by laryngoscopy and intubation _______________________________________________ • Blood pressure • Pulse • Cerebral oxygen demand • Myocardial oxygen demand • Cerebral blood flow • Intracranial pressure • Intraocular pressure • Laryngospasm • Bronchospasm • Cough • Dysrhythmia _______________________________________________