This is a Important Topic in Emergency Medicine

1. Dr Swarup Das
Apprentice of DEM (2nd Batch)

2. RSI is simultaneous administration of an induction &
neuromuscular blocking agent to facilitate tracheal intubation.
Advantage:
RSI particularly useful in the pt with an intact GAG Reflex a “Full Stomach”
& a life threating injury or illness requring immediate airway manegment.
 Increased success rate.
 Decreased time to intubation.
 Minimizes trauma during laryngoscopy
 Minimizes hypoxia and hypercapnia
 Minimizes risk of aspiration
 Better C –Spine Control
 Minimizes hemodynamic effects of intubation

3.  Absolute:
 Cardiopulmonary arrest present/imminent
 Operator inexperience
 Distorted Facial & Airway Anatomy
 Relative:
 Anticipated technical difficulties with laryngoscopy
and/or intubation

4. Plan & Preparation
Pre oxygenation
Pretreatment
Paralysis with induction
Protection and positioning
Placement with proof
Post intubation management
TIME ZERO
t – 10 minutes
t + 90 seconds

5.  RSI Best approach?
 Evaluate Airway – LEMON
 Primary & Backup Method !!
PREPARATION
Equipment for RSI
 Laryngoscope handle
 Laryngoscope blade – Mac 3, Mac 4 (curved blades)
Miller 4 (straight)
 Magill forceps
 Stylet
 ETT securing device
 ETT tubes in various sizes
 Water soluble lubricant
 Xylocaine spray
 10 cc syringe
 Assorted size of oral or nasopharyngeal airways
 Suction equipment including yaunker and suction catheters
 Bag-valve-mask
 ETCo2 monitoring device or esophageal intubation detecting device (EDD)

6. NITROGEN WASH-OUT
OXYGEN WASH-IN
pO2
LUNGS
pO2
BLOOD
pO2
TISSUES
Pre-oxygenate the patient with 100%O2 for 3-5 min. by placing the BVM over the patient’s
face, creating a tight seal and allowing the patient to breathe on their own.
This will wash out nitrogen and establish an oxygen reservoir. This reservoir will allow for
several minutes of apnea without arterial desaturation.
BVM ventilation should only be provided if the patient’s SpO2 falls below 90%.
.

7. LOAD
L idocaine  optional
O piates  optional
A tropine  still mandatory for kids < 8
D efasciculating  optional (if succinylcholine planned)

8. Paralysis with Induction Agent
INDUCTION AGENTS
Etomidate
Thiopental
Ketamine
Propafol
Midazolam
PARALYTIC AGENTS
DEPOLARIZING
Succinylcholine
NON-DEPOLARIZING
Vecuronium
Rocuronium
+

9.  This phase of RSI refers to protecting the airway against
aspiration prior to placement of the endotracheal tube by
avoiding bag-mask ventilation and applying cricoid pressure
(Sellick's maneuver).
Positioning….
 Ensure bed is at appropriate height for person intubating.
 Patient should be positioned as close to the head of the bed as
possible.
 Sniffing position: head extension, neck flexion ( suspected case: Jaw
Thurst)
Protection & Positioning

10. After paralysis has been achieved finally the tube is
placed through glottis and cuff is inflated.
PROOF/ VERIFICATION (verify correct tube placement using both clinical exam and mechanical testing)
PLACEMENT WITH PROOF
Clinical Verification
 Visualize placement of tube
through cords
 Lung auscultation (bilateral
breath sounds)
 Abdomen auscultation (no
gastric sounds with bagging)
 Clinical improvement
 Tube condensation (not reliable)
Mechanical Verification
Pulse oximetry
End tidal CO2 detection
Esophageal detector device

11. RSI remains incomplete until the properly placed endotracheal
tube is secured
.
 SecureSeveral techniques: taping, tying etc
 Sedative
 Ongoing Paralysis Agent Indicated?
 NG/OG
 Vent Settings
 Maintaing Cuff Pressure (20-30 cm of H2O)
 CXR
Hypotension can occur due to decreased venous return from
increased intrathoracic pressure due to mechanical ventilation or
due to sedatives