Fentanyl, Ketamine & Rocuronium: The Regimen for Trauma
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An induction with fentanyl, ketamine and rocuronium is the current standard regimen for pre-hospital trauma RSI. In this step Kat Hunter (KSS HEMS Doctor) outlines the drug dosing regimens and interviews Professor Richard Lyon (KSS Director of Research & Innovation) to learn how the regimen was developed and the evidence for its benefit.
The “3:2:2” Regimen
In trauma patients who are cardiovascularly stable and not grossly hypovolaemic, induction of anaesthesia is typically achieved with 3mcg/kg fentanyl, 2mg/kg ketamine and 2mg/kg rocuronium. This is commonly referred to as a “3:2:2” RSI and is an evolution of the more widespread “3:2:1” regime. The larger dose of rocuronium has been adopted in some services to obtain optimal intubating conditions, recognising that body weight can be difficult to estimate. A maximum induction dose of rocuronium 200mg is given, based on a maximum ideal body weight of 100kg.
Reduced Dose Regimens
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In patients suspected to have hypovolaemia and in the elderly, the dose of fentanyl and ketamine should be significantly reduced, typically to 1 mcg/kg fentanyl, 1 mg/kg ketamine and 2mg/kg rocuronium (a “1:1:2” RSI).
In critically unstable patients, consideration can be given to omitting fentanyl resulting in an induction with 1mg/kg ketamine and 2mg/kg rocuronium (a “1:2” RSI).
In extremis, for severely hypovolaemic patients who are peri-arrest and unconscious, consideration can be given to a rocuronium only induction with 2mg/kg rocuronium.
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