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M U R T A Z A R A S H I D M . D
D E P A R T M E N T O F E M E R G E N C Y M E D I C I N E
R O Y A L C O M M I S S I O N H O S P I T A L , J U B A I L
Rapid Sequence Intubation In
Rapid sequence intubation (RSI) is the virtually
simultaneous administration of a sedative and a
neuromuscular blocking (paralytic) agent to render a
patient rapidly unconscious and flaccid in order to
facilitate emergent endotracheal intubation and to
minimize the risk of aspiration.
CASE (1) AMITRYPTILLINE TIPPER
27 year old overdose benzodiazepines + TCAs 1 hour PTA.
Decreasing LOC, HR 140, wide complex regular, BP 90/50, RR 24,O2 sat
99% on O2.
CASE (2) STAB WOUNDS
22 yr old multiple abdominal stab wounds 6” knife.
Evisceration, agitation and uncooperative.
HR 140, BP 90/50, RR 22,
O2 sat 99% on O2.
ORAL INTUBATION WITHOUT DRUGS
THE CRASH AIRWAY
ARREST SITUATIONS ONLY
PATIENT IS COMPLETELY UNCONSCIOUS,
PULSELESS, UNRESPONSIVE AND APNIC
PRINCIPLES OF RSI
RSI is the standard of care in emergency airway
management for intubations not anticipated to be difficult.
Multiple large prospective observational studies confirm
that the implementation of RSI has led to improved success
and decreased complication rates for emergency
• Emergency intubation is indicated
• The patient has a “full” stomach
• Intubation is predicted to be successful
• If intubation fails, ventilation is predicted to be successful
DO NOT INTUBATE
DYSARTHRIC ANTI IPSILATERAL HORNERS SYNDROME
DUE TO LATERAL CORTICOMEDULLARY STROKE WITH
BLA BLA BLASTEROSIS
ADVANTAGES OF RSI
Facilitates and expedites endotracheal intubation
increased success rate
decreased time to intubation
Minimizes trauma during laryngoscopy
Minimizes hypoxia and hypercapnia
Minimizes risk of aspiration
Minimizes hemodynamic effects of intubation
SEVEN “P” OF RSI
Paralysis with induction
Protection and positioning
Placement with proof
Post intubation management
PREPARATION (10 mins before intubation)
• ETT, stylet, blades, suction, BVM
• Cardiac monitor, pulse oximeter, ETCO2
• One ( preferably two ) iv lines
• Difficult airway kit including cricothyrodotomy kit
• Patient positioning
PREOXYGENATION (5 mins before intubation)
Facemask with oxygen reservoir (non rebreather)
Manual ventilation prior to intubation should be
reserved for patients who are hypoxic (saturation
<91 percent). Slow rate 8 b/m to avoid over inflation
of lungs and stomach.
It allows 3-5 mins of apnea.
PRETREATMENT (3 mins before intubation)
Laryongoscopy can activate coughing and gagging.
Adults: High B.P, Bronchospasm, Increase ICP and
In highly emergent cases it is not worth to wait for
pretreatment and can be judiciously omitted.
Drugs vary according to the condition.
PRETREATMENT MNEMONIC “ABC”
BRAIN AND BABIES
Atropine: Used in infants and sometimes after
second dosage of succinylcholine in adults with
Lidocaine (1.5 mg/kg i.v): Reduces airway
resistance and decreases ICP. Contraindicated in
Mobitz II or Third degree heart block.
Fentanyl ( 3 mcg/kg i.v): Decreases ICP, B.P, Heart
rate. Given in ACS, Aortic dissection.
Fentanyl can cause respiratory collapse and
hypotension. If given only low dosage of 1 mcg/kg.
Fentanyl should be the last pretreatment drug to be
PARALYSIS WITH INDUCTION
Head injury or Stroke: Goal is to maintain
adequate cerebral perfusion and maintain arterial
Etomidate (0.3mg/kg): Excellent sedation and
dosent cause hypotension. No change in B.P. Causes
Ketamine (1-2mg/kg): Use in Septic shock,
Bronchospasm and hypotensive patients with head
injury. Avoid in cerebral hemorrhage.
Midazolam, barbiturates and propofol can be used in
head injury but risk of hypotension must be
PARALYSIS WITH INDUCTION
Midazolam (0.2-0.3mg/kg): Can cause hypotension,
use etomidate if patient has hemodynamic
Do not use Ketamine due to stimulant effect.
• Severe Bronchospasm:
Hemodynamically stable: Ketamine, Propofol,
Hemodynamically unstable: Ketamine or Etomidate
PARALYSIS WITH INDUCTION
Cardiovascular : Etomidate preferred in CAD and
Aortic dissection. Use fentanyl as pretreatment.
Shock: Etomidate or Ketamine. If refractory septic
shock, with etomidate give Hydrocortisone
In patient in which we need “awake” look, use
ketamine. Provides analgesia, amnesia and
sedation without respiratory concern.
NEUROMUSCULAR BLOCKING AGENTS
PRODUCE PARALYSIS. NOT PROVIDE
SEDATION OR ANALGESIA. USED IMMEDIATELY
AFTER INDUCTION AGENTS.
DEPOLARIZING: Succinylcholine (Sch), binds to
Ach receptors produces fasciculation's and paralysis.
NON DEPOLARIZING: Rocuronium, Vecuronium,
and Pancuronium. Competitively inhibit the post-
synaptic Ach receptor and produce paralysis.
SUCCINYLCHOLINE (1.5 mg/kg): Mostly preferred
agent due to rapid onset (45-60 sec) and offset (6-10
mins). Better to overdose than under dose.
SIGNIFICANT HYPERKALEMIA DEMONSTRATED BY EKG
MALIGNANT HYPERTHERMIA (FAMILY OR PERSONAL Hx.)
STROKE OR BURN 72 HOUR OLD, DUE TO UPREGULATION OF
SIGNIFICANT NEUROMUSCULAR Dx OR MUSCULAR DYSTROPHY
BRADYCARDIA ESP. IN CHILDREN
BLOCKING AGENTS (NMBAS)
USED WHEN DEPOLARIZING AGENTS ARE
CONTRAINDICATED OR PROLONGED BLOCKADE IS
ROCURONIUM (1 mg/kg): Short onset (45-60 sec), duration upto 45
mins. Effect comparable to Succinylcholine.
VECURONIUM (0.15 mg/kg): onset about 90 sec.
A predicted difficult airway is the most common relative
contraindication to the use of nondepolarizing NMBAs for RSI
REVERSAL OF NONDEPOLARIZING AGENTS
COMPETITIVELY BIND Ach RECEPTORS
NEOSTIGMINE: Acetyl cholinesterase inhibitor which allows ACh to
continue to stimulate the neuromuscular junction and cause muscular
SUGAMMADEX: is a novel agent that encapsulates and binds with
molecules of rocuronium or vecuronium, thereby rapidly reversing
their neuromuscular blocking effects. Still pending for FDA.
In Myasthenia Gravis dose of Depolarizing agent should be increased
while dose of non-depolarizing should be decreased.
PROTECTION (CRICOID PRESSURE) AND
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). Bag-mask ventilation is
unnecessary if the patient has been successfully
Provided oxygen saturation remains above 90 percent, bag-
mask ventilation is unnecessary, even between
A common error is to apply pressure to the thyroid cartilage
PLACEMENT WITH PROOF
After paralysis has been achieved finally the tube is
placed through glottis and cuff is inflated.
The most accurate means of confirming ETT
placement is End-tidal CO2 (EtCO2) determination.
A single-view chest radiograph is only useful to determine
depth of placement (eg, tracheal versus right mainstem).
RSI remains incomplete until the properly placed
endotracheal tube is secured. Several techniques are
commonly used to secure the tube, including taping, tying
Hypotension can occur due to decreased venous return
from increased intrathoracic pressure due to mechanical
ventilation or due to sedatives.
VARIATIONS OF TECHNIQUE — The general
approach described above is a commonly accepted
way of performing rapid sequence intubation (RSI).
There are, however, a number of variations,
depending on clinical circumstance.