CH is a 75 year old female that presents to the emergency department after a fall. Paramedics say she hit her head and has a GCS of 7. The physician decides to pursue intubation because of her GCS, spO2, and possibility for decline. He notes her slightly low blood pressure and asks for your assistance in selecting a sedative for rapid sequence intubation (RSI).

PMH:

Transient Ischemic Attack (1 year ago)

Hyperlipidemia

Hypertension

Hypothyroidism

Type 2 Diabetes Mellitus

Allergies: No known drug allergies

Medications:

Lipitor 80 mg PO QD

Prinivil 40 mg PO QD

Norvasc 5 mg PO QD

Jardiance 10 mg PO QD

Glucophage 500 mg PO BID

Synthroid 112 mcg PO QD

Tylenol 325 mg PO Q6H prn pain

Vitals and Labs:

HR: 70 BPM

RR: 28 BPM

SpO2: 85%

Temp: 98.5 F

BP: 102/72 mmHg

Na: 141 mEq/L

K: 3.8 mEq/L

SCr: 0.7 mg/dL

BG: 134 mg/dL

Which of the following is correct about sedatives used in RSI?

A. Diprivan may cause a decrease in blood pressure.

B.  Ketalar is more likely to cause hypotension as opposed to hypertension.

C.  Versed is more likely to cause hypertension as opposed to hypotension.

D.  Amidate may cause an increase in blood pressure.

Endotracheal intubation may be used in emergent situations to secure a patient’s airway. When the patient is alert and oriented, rapid sequence intubation (RSI) is used to sedate and paralyze a patient immediately prior to endotracheal intubation. When selecting a sedative for RSI, one must take into consideration its onset, duration, hemodynamic effects, contraindications, and adverse effects. Patients requiring RSI present in varying states of health; heart rates and blood pressures may be elevated or decreased upon presentation. As a pharmacist, it is important to understand the hemodynamic effects of agents used in RSI to help determine the best option for each patient and prevent further decline in health.

Answer A is correct. Propofol (Dipirivan) causes global CNS depression which may lead to hypotension and bradycardia. Counsel patients on pain with injection and continuously monitor their blood pressure and heart rate.

Answer B is incorrect. Ketamine (Ketalar) is a noncompetitive NMDA receptor antagonist that exhibits varying effects on blood pressure depending on the patient’s catecholamine levels. For most patients, ketamine will cause increased blood pressure or will have a neutral hemodynamic effect. In rarer circumstances in catecholamine depleted patients, ketamine may cause hypotension. 

Answer C is incorrect. Midazolam (Versed) is a benzodiazepine that enhances the inhibitory effects of GABA. Compared to other RSI sedatives, it has a slower onset, longer duration, and higher number of adverse effects. Midazolam often causes CNS depression and hypotension.

Answer D is incorrect. Etomidate (Amidate) is often the preferred agent in RSI and works by potentiating GABA’s inhibitory effects. It has a relatively neutral effect on hemodynamics, but may sometimes cause a decrease in blood pressure through its decreased synthesis of cortisol.

Medications: Propofol (Dipirivan), Ketamine (Ketalar), Midazolam (Versed), Etomidate (Amidate), Atorvastatin (Lipitor), Lisinopril (Prinivil), Amlodipine (Norvasc), Empagliflozin (Jardiance), Metformin (Glucophage), Levothyroxine (Synthroid), Acetaminophen (Tylenol)

NAPLEX Competencies Covered:

Are 2 - Identify Drug Characteristics

2.2 - Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar name; physical descriptions; or how supplied
Area 3 - Develop or Manage Treatment Plans

3.6 - Drug contraindications, allergies, or precautions

3.7 - Adverse drug effects, toxicology, or overdose