welcome to emergency chaos where we provide tips and tricks to make you a better er nurse today we are going over the medications used in rapid sequence intubation including succeum atomibate ketamine propofol and verset and if you want to learn which is used when and why stick around so now let's get right into the medications right the one key principle is that you should always administer the sedative prior to the paralytic imagine just being awake but unable to move or take a breath so you sedate the patient at first then you administer the paralytic afterwards right and you will usually just push them back to back but you push the set of the sedative in first the sedative in first right i should say that sometimes rare uh times because of the times of onset there may be times when you push the paralytic first and then quickly after push the sedative but for the most part 99.9 percent of times just remember the sedative before the paralytic so the most common the most common sedatives that we use or induction agents are going to be atomidate ketamine propofol and versed one of the most common paralytic agents that we use are sucks and rock and yet pretty much no one says the whole name out you just say sucks or rocks so keep that in mind so let's start off with etaminate it's by far the most used sedative simply because it's hemodynamically stable meaning it won't affect blood pressure as much or it doesn't affect the vital signs as much as the other agents available so it tends to get used the most because a lot of the times when someone is getting intubated it's because they're sick and they're unstable it doesn't so etominate doesn't affect pain so keep in mind that you may be also administering like fentanyl for pain in patients with increased intraocanial pressure so that you prevent worsening icp from the stress and discomfort of being intubated so the typical dose of vitominate is 0.3 milligrams per kilogram with an onset of about 30 seconds and a duration of up to 10 minutes as far as adverse effects i've definitely seen this and it's just myoclonus which is just jerking like movements that kind of mimic a seizure but when i saw it it wasn't with rsi it was with uh when we were cardioverting someone so with with rsi you give a paralytic right afterwards so the patient can't move either way so even if the patient was going to get myoclonus you just gave the paralytic so you probably won't see it right but it is a complication that's uh not a complication but a side effect that's possible uh with using automate so because it automated is hemodynamically stable when is it going to be used it's going to be used in patients who are unstable for example with a soft blood pressure or patients with head injuries as it does not lower the blood pressure or increase the blood pressure because they can be they can both be damaging to normal patients since if you lower the blood pressure in a normal patient you can cause ischemia and if you increase the blood pressure you can cause worsening of icp right so itaminate is also useful in unstable seizure patients in patients with heart disease as again it does not increase or decr does not decrease or increase the blood pressure and it's also useful in shock it's even useful in respiratory patients because it's just a good backup it doesn't have any bronchodilatory effects like other agents we're going to discuss but again it's just an overall safe medication because it doesn't affect vital signs as these other agents now let's talk about ketamine it's a use it's very useful in respiratory issues and it does have bronchodilatory properties and it's useful as well in shock because it increases the heart rate and the blood pressure another good thing about ketamine is that it does have analgesic properties however because it can increase the blood pressure and the heart rate it's not used for cardiac or neural patients since that can be damaging as we've discussed right with an increase in heart rate or d uh and our heart rate or blood pressure i mean the typical dose is 1.5 milligram per kilogram with an onset of approximately 60 seconds in a duration of up to 20 minutes as discussed it's useful in respiratory issues and in shock however it's not useful in patients with cardiac or neurological conditions another use because patients maintain their respiratory drive with ketamine is that it can be used for awake intubations and we're gonna discuss what an awake intubation is later on so just keep watching the video for that one so again ketamine is really useful for respiratory issues because it has bronchodilatory properties and the patients maintain their own respiratory drive while they are sedated with ketamine and then let's go on to the next medication we have propofol and versed so thinking back we pretty much don't use proper versed for intubations um probe we use a lot for conscious sedations um and both probe and merced are often used are used as sedation for patients who are intubated right so after they get intubated these two medications will be used as sedation however they are rarely used but they can still be chosen so that's why i wanted to talk about them here propofol dosing would be 1.5 milligrams per kilogram with an onset of approximately 40 seconds and a duration of up to 10 minutes the main side effect that is they can have cardiovascular depression in other words as we've talked in other videos it can cause hypotension it's a potent anti-convulsant which is why it may be chosen for stable seizure patients but if the patient is unstable it's not going to be picked again because it lowers the blood pressure then there's versed which is isn't also an anti-convulsant oh batteries running low versed which is also an anti-convulsant and that's why it may be chosen but it also does have those hypotensive effects right um the typical dose for versailles is 0.2 milligrams per kilogram and an onset of 60 seconds in a duration of up to 30 minutes propofol or versed again will definitely be used for post uh intubation sedation for the patient all right now let's get into some paralytics sucks is essentially old faithful pretty much loved because compared to other paralytics it's quick on and quick off which as we've discussed before the longer a patient is paralyzed the likelier complications are to occur especially if something goes wrong and the intubation attempt is unsuccessful however it's not used when there is a risk of hyperkalemia and as it can cause hyperkalemia itself itself in susceptible patients so it's not going to be used in renal patients in patients who are found down with an unknown downtime as those patients are prone to getting rhabdomyolysis also not used in burn patients or crush injury patients again related to being wary of hyperkalemia another important and key reason not to use sucks is patients with the history or familial history of malignant hyperthermia as it can cause it so be wary of malignant hyperthermia because it can be deadly it's also not used in patients who we pretty much know nothing about because what if they have renal problems which it being the er that can that tends to happen a lot right we get patients we know nothing about so it's still all faithful because it's quick on and quick off again because the longer a patient is paralyzed the likelihood is for complications the dosing is 1.5 milligrams per kilogram the onset of the onset is approximately 45 seconds with a duration of 10 minutes and then just to summarize not use in patients who may be at risk for hyperkalemia now let's get into rock it's pretty much used when sucks is contraindicated because it doesn't have any crazy side effects you might be thinking so why isn't rock just used instead all of the time well because it takes longer to work with the nonset of around 60 seconds and it lasts forever up to one hour and again as we've discussed longer the patient is paralyzed the likelier complications can just turn bad for example rock is given and the intubation attempt is unsuccessful and the patient starts designing and now the blood pressure is crappy sometimes just trying to back the patient but it's not working and the patient ends up getting the crycotherotomy or worse the patient arrests well of course that's like the worst possible complication but it's i'm just trying to illustrate a point the longer someone is paralyzed the worse the outcomes can turn out but it's still definitely used at times and again the dosing is gonna be one milligram per kilogram onset of 60 seconds and then duration of around 60 minutes and again it's going to be used when sucks is contra indicated but because it does last long you just got to make sure that you have all your backup equipment and supplies ready just in case the intubation is unsuccessful but because you watch this video and you're a good ear nurse you're going to have all the necessary equipment ready beforehand just in case anything goes wrong now let's talk about the intro procedure so your job during the i think that being a good er nurse depends a lot on your experiences and taking the time to look up and familiarize yourself with topics that you don't fully understand i've listed my favorite er nursing related books in the description and i believe you can greatly benefit from them as well always always keep learning you'll be a better nurse you'll be safer and ultimately you'll be able to save more lives if you enjoyed and learned something from the content today i would really appreciate a like and a follow and if anything comes to mind that you would like me to cover please comment below and also if you want to support further i have stickers and shirts up on redbubble for er nurses check them out if you wanted further support and then as always as always teamwork in the er makes the dream work and here at emergency chaos we are proactive we are not reactive thank you for 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