Rapid sequence intubation (RSI) is a process for safely intubating conscious patients by first using sedatives and paralytics. It involves: 1) Preparation with monitoring and drugs ready, preoxygenation to increase oxygen stores before intubation, and pretreatment with lidocaine or fentanyl. 2) Rapidly administering sedatives like etomidate or propofol followed immediately by paralytics like succinylcholine to paralyze before intubation. 3) Properly positioning the patient, intubating, and confirming placement with end-tidal CO2 monitoring before securing the tube and providing post-intubation management.

1. Rapid Sequence Intubation
Steven Podnos MD

2. RSI
• Definition: Using drugs that make emergent
intubation of conscious patients safer and
more controlled
• Process: Use of a sedative /hypnotic agent to
induce relaxation/sleepiness/amnesia
followed by a neuromuscular blocker to stop
any resistance to the intubation process

3. The Seven Ps of RSI
• Preparation
• Preoxygenation
• Pre treatment
• Paralysis
• Protection and Positioning
• Placement with Proof
• Post intubation management

4. Preparation
• Cardiac Monitor, O2 sat, IV access, BP monitor
• Suction, all meds ready and drawn up, crash
cart, bag valve mask
• Difficult airway assessment and alternate
airways available

5. Pre-oxygenation
• Done to avoid using Bag Valve mask
ventilation
• High flow O2 (usually at least 3-5 minutes)
given to “wash out” nitrogen and increases
body oxygen stores. Can extend time allowed
without ventilation for several minutes

6. Pretreatment
• In some cases, Lidocaine 1mg/kg IV or
Fentanyl is given to reduce the physiologic
increase in ICP in patients with head injuries

7. Paralysis and Induction
• RSI is designed to achieve paralytic and
sedated state within one minute. No titration-
use whole doses of drugs

8. Ideal Drugs
• Should have duration of very few minutes in
case intubation is not successful.
• Sedatives used: Etomidate, Midazolam
(Versed), Propofol
• Paralytics used: Succinylcholine (Anectine)

9. Sedative Drugs
• Etomidate-hemodynamically neutral,
• 0.3mg/kg bolus
• Midazolam-0.2mg/kg bolus, does often cause
hypotension
• Propofol-2mg/kg bolus, may cause
hypotension and CPP. Bronchodilator

10. Protection with Positioning
• Avoid Bag Mask Ventilation
• Cricoid pressure very controversial

11. Placement with proof
• MUST have EtCO2 proof , either colorimetric
or quantitative (monitor)
• In cardiac arrest may not see CO2 production.
Positive CO2 for six breaths is definitive
evidence of proper airway placement.
• Clinical and CXR evaluation is not definitive for
placement

12. Postintubation Management
• Fix the ETT location
• CXR for depth of tube
• Fluid bolus for transient hypotension