COVID-19 TRAINING FOR HEALTHCARE WORKERS 

Treating the Severely Dyspneic Patient - 

Part 3 
A. Patil, MD 
 
LEARNING OBJECTIVES 
1. To learn medications used for intubation 
2. To learn medications used for post-intubation sedation 
 
LECTURE OVERVIEW 
I. Intubation medications: Sedation 
II. Intubation medications: Paralytics 
III. Post-intubation medications for sedation 
 
I. INTUBATION MEDICATIONS: SEDATION - IV PUSH 
A. Goals: Provide anxiolysis, analgesia and amnesia to relieve discomfort felt from 
dyspnea, and intubation 
1. Etomidate: 0.3mg/kg 
a. Few cardiovascular side effects 
b. Onset of 15-45 seconds, duration of action 3-12 minutes 
2. Midazolam: 0.2mg/kg 
a. Side effects: Hypotension, respiratory depression 
b. Onset of 30-60 seconds, duration of action 15-30 minutes 
3. Propofol: 1.5-3 mg/kg 
a. Side effects: Hypotension, respiratory depression 
b. Onset 15-45 seconds, duration of action 5-10 minutes 
4. Ketamine: 1-2 mg/kg 
 a. Side effects: Increased heart rate and blood pressure, respiration 
maintained 
b. Onset 45-60 seconds, duration 10-20 minutes  
 
II. INTUBATION MEDICATIONS: PARALYTICS – IV PUSH 
A. Goals: To inhibit gag reflex, and prevent patient from moving to optimally be able to 
visualize the vocal cords to aid in success of procedure 
1. Depolarizing agents: May cause hyperkalemia due to depolarization at the 
neuromuscular junction, of up to 0.5 mEq/L 
a. Use with caution in certain patient populations 
i. Hyperkalemia: end stage renal disease, crush/burns greater than 72 
hours out of injury, rhabdomyolysis 
ii. Acetylcholine receptor upregulation: progressive neurologic disease, 
denervating injuries/diseases, prolonged immobilization, inherited 
myopathies 
b. Succinylcholine: 1.5mg/kg 
i. Onset 45-60sec 
ii. Duration of action: 6-10 min 
2. Non-depolarizing agents: no change in serum potassium 
a. Relative contraindication: predicted difficult airway due to length of paralysis 
b. Rocuronium 1-1.2 mg/kg 
i. Onset: 45-60sec 
ii. Duration: 45 min 
 
III. POST-INTUBATION SEDATION - IV INFUSION 
A. Goals 
1. Tolerate treatment – with anxiolysis, analgesia and amnesia 
2. Use minimal sedation needed to tolerate treatment since higher doses are shown to 
prolong duration of intubation, increase risk of delirium, and greater side effects of 
medications. 
B. Sedatives 
1. Propofol 
 i. Short acting 
ii. Side effects: Hypotension, bradycardia, propofol infusion syndrome 
iii. No analgesia 
 
2. Benzodiazepines – midazolam, lorazepam 
i. Short acting 
ii. Side effects: Hypotension, ICU delirium 
iii. Midazolam: active metabolites – can have prolonged sedation in 
elderly, or those with kidney or liver disease 
iv. Lorazepam: Lipophilic – can have buildup in tissues and have 
prolonged sedation 
v. No analgesia 
3. Dexmedetomidine 
i. Short acting 
ii. Hyoptension, bradycardia with minimal effect on respirations and 
amnesia 
4. Ketamine 
i. Provides analgesia and amnesia 
ii. Maintains respiratory drive 
iii. Sympathetic stimulation – can see increased heart rate and blood 
pressure 
C. Analgesia 
1. Fentanyl 
i. Short acting opiate 
ii. Side effects: Hypotension, chest wall rigidity, accumulation in 
adipose tissue 
   
  
MEDICATION  LOADING DOSE  INFUSION 
Propofol  Bolus usually not given   5-50mcg/kg/min 
Midazolam  0.01-0.05 mg/kg  0.02-0.1 mg/kg/hr 
Lorazepam  0.02-0.04 mg/kg  0.01-1mg/kg/hr 
Dexmedetomidine  1mcg/kg in 10 min  0.2-0.7 mcg/kg/hr 
Ketamine  0.1-0.5 mg/kg  0.05-0.4 mg/kg/hr 
Fentanyl  1-2 mcg/kg  50-200mcg/hr 
 
REFERENCES/SUGGESTED READING: 
1. Stollings, Jana et al. “Rapid Sequence Intubation: A Review of the Process and Consideration 
When Choosing Medications”, Annals of Pharmacotherapy. Nov 4, 2013,Vol 48, Issue 1, Page 
62-76 
2. Mace, Sharon. “Challenges and Advantages in Intubation”, Emergency Medicine Clinics of North 
America. Nov 1, 2011. Volume 26, Issue 4, pp 1043-1068