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Difficulty: MediumPharmacologic Interventions

A 32-year-old man is brought to the emergency department with a severe head injury and a Glasgow Coma Scale score of 6 following a motorcycle collision. He is spontaneously breathing but unable to protect his airway. His blood pressure is 110/70 mm Hg and heart rate is 115/min. The trauma team decides to proceed with rapid sequence intubation (RSI).

Arrange the following pharmacologic interventions in the correct chronological sequence of administration for this patient's airway management, from earliest to latest.

  1. 1Intravenous fentanyl
  2. 2Intravenous etomidate
  3. 3Intravenous rocuronium
  4. 4Intravenous propofol infusion

Answer

The correct chronological sequence for rapid sequence intubation (RSI) is: Pre-treatment with intravenous fentanyl, followed by induction with intravenous etomidate, immediately followed by paralysis with intravenous rocuronium, and finally post-intubation sedation with an intravenous propofol infusion.
Rapid sequence intubation (RSI) strictly follows the '7 Ps' approach: Preparation, Preoxygenation, Pretreatment, Paralysis with induction, Positioning, Placement with proof, and Post-intubation management. Fentanyl fulfills the pretreatment role and is given 3 minutes before intubation. Etomidate and rocuronium fulfill the 'paralysis with induction' role, where the induction agent (etomidate) must be pushed immediately prior to the paralytic (rocuronium) to ensure the patient is unconscious before they are paralyzed. Finally, after the tube is secured, the initial induction agent begins to wear off, necessitating the start of a continuous sedative infusion (propofol) for post-intubation management.

Step-by-Step Solution

1
Identify the clinical scenario and required procedure.
The patient requires definitive airway management via rapid sequence intubation (RSI) due to a depressed level of consciousness and inability to protect his airway.
Establishing a sequence is critical to safely secure the airway while minimizing psychological trauma, hemodynamic instability, and intracranial pressure spikes.
2
Determine the first pharmacologic step (Pre-treatment phase).
Intravenous fentanyl is given first.
Fentanyl is given approximately 3 minutes before induction to blunt the sympathetic response to direct laryngoscopy, which is crucial in patients with traumatic brain injury to prevent life-threatening spikes in intracranial pressure.
3
Determine the second step (Induction phase).
Intravenous etomidate is given second.
At time zero, an induction agent must be pushed to render the patient rapidly unconscious before any paralytic takes effect. Etomidate is chosen for its neutral hemodynamic profile.
4
Determine the third step (Paralysis phase).
Intravenous rocuronium is given third.
Immediately following the induction agent push, a neuromuscular blocking agent is rapidly administered to paralyze the vocal cords and skeletal muscles, allowing for smooth tube passage.
5
Determine the final step (Post-intubation phase).
Intravenous propofol infusion is initiated last.
Once the endotracheal tube is placed and placement is verified, a continuous sedative infusion is started to maintain unconsciousness, as the initial induction dose will rapidly wear off.

Key Concept

Pharmacologic sequencing in Rapid Sequence Intubation (RSI)
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Topics

Pharmacologic Interventions

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