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8 - Pharmacology of emergency airway drugs

Published online by Cambridge University Press:  22 August 2009

Jonathan Benger
Affiliation:
United Bristol Healthcare Trust
Jerry Nolan
Affiliation:
Royal United Hospital, Bath
Mike Clancy
Affiliation:
Southampton University Hospitals Trust
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Summary

Objectives

The objectives of this chapter are to:

  • be familiar with the choice of induction, analgesic and neuromuscular blocking drugs

  • understand the advantages and disadvantages of drugs used in emergency airway management

  • understand the basic pharmacology of these drugs

  • be aware of the possible complications caused by these drugs.

Introduction

The term ‘triad of anaesthesia’ is used to describe the components of a balanced anaesthetic:

  • hypnosis

  • analgesia

  • muscle relaxation.

The pharmacology of drugs used commonly in emergency airway management will be considered under these three headings.

In unmodified rapid sequence induction (RSI) an analgesic is omitted and the patient is given a pre-calculated dose of induction drug and neuromuscular blocker only. The rationale behind this is that, should intubation fail, the patient will recover from anaesthesia and paralysis quickly, returning to spontaneous ventilation. Opioids, particularly in high doses, will increase the time to spontaneous ventilation. Some patients may have received analgesia before the induction of anaesthesia (e.g. for pain relief in trauma), and under some circumstances it is appropriate to consider modifying an RSI to include a carefully selected dose of opioid given before the induction drug (e.g. RSI in the presence of raised intracranial pressure: see Trauma and raised intracranial pressure in Chapter 11). Opioids are also useful after intubation, when they may be used in combination with a hypnotic to maintain anaesthesia and reduce sympathetic stimulation.

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Chapter
Information
Publisher: Cambridge University Press
Print publication year: 2008

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References

,British National Formulary, Number 51. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2006.
Peck, T. E., Hill, S. A., Williams, M., Grice, A. S. & Aldington, D. S. (2003) Pharmacology for Anaesthesia and Intensive Care, 2nd edn. London: Greenwich Medical Media.Google Scholar
,Association of Anaesthetists of Great Britain and Ireland (2004) Syringe labelling in critical care area (June 2004 update). London: Association of Anaesthetists of Great Britain and Ireland. See: www.aagbi.org/guidelines.html
,Resuscitation Council (UK) (2008) Emergency treatment of anaphylactic reactions. London: Resuscitation Council (UK). See: www.resus.org.uk/pages/reaction.pdf
,Association of anaesthetists of Great Britain and Ireland (2003) Anaphylactic reactions associated with anaesthesia 3 (revised 2003). London: Association of Anaesthetists of Great Britain and Ireland. See: www.aagbi.org/guidelines.html
Bergen, J. M. & Smith, D. C. (1997) A review of etomidate for rapid sequence intubation in the emergency department. J Emerg Med; 15: 221–30.CrossRefGoogle ScholarPubMed
Jackson, W. L. (2005) Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock? A critical appraisal. Chest; 127: 1031–8.CrossRefGoogle ScholarPubMed
Murray, H. & Marik, P. E. (2005) Etomidate for endotracheal intubation in sepsis: acknowledging the good while accepting the bad. Chest; 127: 707–8.CrossRefGoogle ScholarPubMed
Morris, C. & McAllister, C. (2005) Etomidate for emergency anaesthesia; mad, bad and dangerous to know?Anaesthesia; 60(8): 737.CrossRefGoogle Scholar
Kapklein, M. J. & Slonim, A. D. (2002) Ketamine v propofol: how safe is safe enough?Crit Care Med; 30: 1384–6.CrossRefGoogle Scholar
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