Rapid sequence intubation (RSI) involves the simultaneous administration of an induction agent and neuromuscular blocking drug to facilitate endotracheal intubation. It allows for increased success rates, decreased intubation times, and reduced risks of aspiration, hypoxia, and trauma. The key steps of RSI are preparation, preoxygenation, pretreatment, paralysis with induction, positioning, placement with proof of tube position, and post-intubation management. Confirmation of tube placement involves clinical assessment and mechanical methods like end-tidal CO2 monitoring and ultrasound. Complications can be minimized by adhering to the standardized RSI protocol.

1. RAPID SEQUENCE
INTUBATION IN
EMD
Dr ASHMAL KT
JR, EMERGENCY MEDICINE
GMC,KANUR

2.  RSI is the simultaneous administration of an induction and a
neuromuscular blocking agent to facilitate tracheal intubation
and is preferred for emergency intubation .
 RSI is usefull in patient with intact gag reflex
 ADVANTAGES :
• Increased success rate and decreased time to intubate.
• Minimize trauma ,hypoxia ,hypercapnia.
• Minimize aspiration
• Better C spine control
CONTRA INDICATION :
• Cardiopulmonary arrest , Operator inexperiance
• Distorted anatomy of face or airway

3. Emergency Airway management algorithm.

4. STEPS OF RSI ( 7 P’S)

5. PREPARATION
 ASSESED FOR INTUBATION DIFFICULTY
 DETERMINING DOSAGE , DRUGS ,TUBE SIZE
,LARYNGOSCOPE TYPE,BLADE .
 CONTINOUS CARDIAC MONITORING AND PULSE OXIMETRY.
 > 1 GOOD QUALITY IV LINES.
 REDUNDANCY IS ALWAYS DESIRABLE IN CASE OF
EQUPIMENT FAILURE
 RESCUE PLAN FOR INTUBATION FAILURE
 PROPER COMMUNICATION BETWEEN OTHER TEAM
MEMBERS.

6. Identification of the Difficult Airway
L—Look Externally.
E—Evaluate 3-3-2.
3 fingers are placed along the floor
of the mouth,beginning at the mentum.
3 of his fingers between the open
incisors
2 fingers are placed in the laryngeal
prominence .,
 M—Mallampati Scale.
 O—Obstruction or Obesity
 N—Neck Mobility.

8. Teeth out to
intubate, teeth in to ventilate.
Impossible BMV was five times
more likely if one of
these factors was present and
25 times more likely with four or
more.
upper airway device, often can
convert acan’t intubate, can’t
oxygenate situation to a can’t
intubate, can oxygenate
situation, which allows time for
rescue of a failed airway.

9. PREOXYGENATION
 Preoxygenation optimizes blood oxygen content and also displaces nitrogen in the
alveoli, creating a potential reservoir of oxygen.
 Administer 100% oxygen for 3 minutes, using a non-rebreather mask supplied with 15
L/min of oxygen.
 Permit 6 to 8 minutes of safe apnea before oxygen desaturation to less than 90%
occurs.
 Additional preoxygenation does not improve arterial oxygen tension.
 If time is insufficient for a full 3-minute preoxygenation phase, eight vital capacity
breaths with high-flow oxygen can achieve oxygen saturations.
 Desaturation time in obese patients can be prolonged by preoxygenating with the
patient in a head-up position and by continuing supplemental oxygen via nasal
cannula at a flow rate of 5–15 L/min.
 In obese patients, it extends the time to desaturation to 95% from 3.5 to 5.3 minutes.
Apneic oxygenation takes advantage of a physiologic principle termed aventilatory
mass flow.

10. PRETREATMENT
 Decreases adverse physiologic responses to laryngoscopy and
intubation.
 Reflex sympathetic response to laryngoscopy(RSRL) causes
increases in heart rate and blood pressure; this may be harmful in
patients with elevated intracranial pressure, myocardial ischemia,
and aortic dissection.
 Fentanyl can decrease the reflex sympathetic response to air way
manipulation. It may aid in patients in whom a rise in blood
pressure and heart rate could be detrimental, such as patients
with elevated intracranial pressure and cardiovascular conditions.
 Lidocaine has a vanishing role in emergency airway management
and may disappear completely in the near future from emd .
 Reactive airway disease: Albuterol, 2.5 mg, by nebulizer. If time
does not permit albuterol nebulizer, give lidocaine 1.5 mg/kg IV.

12. PARALYSIS WITH INDUCTION
INDUCTION AGENTS :
 Etomidate used in more than 90% of all ED intubations .
 No sufficient evidence to support the recommendation that
etomidatebe avoided in patients with septic shock.

13. PARALYTIC AGENTS
1. DEPOLARIZING NMBA
Depolarizing neuromuscular blocking agents have high affinity for
cholinergic receptors of the motor end plate and are resistant to
acetylcholinesterase.
Succinylcholine :
oThe most commonly used agent for neuromuscular blockade in ED RSI
 Succinylcholine is rapidly hydrolyzed by plasma pseudocholinesterase
to succinylmonocholine
oSuccinylcholine is two joined acetylcholine molecules and is rapidly
hydrolyzed by plasma cholinesterase .
oRapid onset after IV dosing and a shorter duration of action

14. • IM succinylcholine (4 milligrams/kg) will act more slowly and
last longer; however, this is best reserved for the rare setting
where paralysis is required absent IV access.
• After brief fasciculation, complete relaxation occurs at 60
seconds, with maximal paralysis at 2 to 3 minutes
• Succinylcholine provides excellent intubation conditions and is
the preferred agent for RSI in the ED
• Serum potassium will transiently rise an average of 0.5 mEq/L
with succinylcholine, usually without any clinical impact.
• Do not use succinylcholine in patients with suspected
preexisting significant hyperkalemia (especially renal failure),
myopathies, or myasthenia gravis.
• Succinylcholine remains the agent of choice for RSI in acute
burn, trauma, stroke, and spinal cord injury if intubation occurs
earlier than 5 days after onset of the condition.

16. ROCURONIUM.
• Rocuronium is an intermediate-duration nondepolarizing agent .
•There are no absolute contraindications to rocuronium.
•The onset of action approximates that of succinylcholine, but the
duration of action is prolonged.
VECURONIUM BROMIDE
•Intermediate- to long-acting nondepolarizing agent
•Vecuronium has no cardiac effects , Exretion is biliary .
Sugammadex is a reversal agent that encapsulates the molecules of
the nondepolarizing agent that are circulating in plasma.Reverses
blockade from rocuronium or vecuronium within minutes.
Paralysis After Intubation:A sedating dose of a benzodiazepine, such as
midazolam (0.1 mg/kg IV), combined with an opioid analgesic, such as fentanyl (3–
5 μg/kg IV) or morphine (0.2–0.3 mg/kg IV)

18. Patient Positioning
 This phase of RSI refers to protecting airway against aspiraion prior to placement of
ETT
 Flex the lower neck and extend the atlantooccipitaljoint (sniffing position) to align the
oropharyngeal–laryngeal axis for a direct view of the larynx.
 Ensure bed is at appropiate height for person intubating.Patient head just below
intubators xiphoid
 The bestposition occurs when the ear is horizontally aligned with the sternal notch.
 The Sellick or cricoid maneuver (application of direct pressure on the cricoid ring in
the unconscious or paralyzed patient) can impair bag-mask ventilation, worsen the
laryngoscopic view, and hamper insertion of the tube.
Do not recommend routine use of the Sellick maneuver, and it should beconsidered
optional, applied selectively,
 BMV should not be initiated unless the oxygen saturation falls to 90% , after
administration of an induction agent and NMBA.

20. PLACEMENT WITH PROOF
 patient is relaxed sufficiently to permit laryngoscopy. This is
assessed most easily by moving themandible to test for mobility and
absence of muscle tone .
 Glottic exposure may be aided by backward-upward-rightward
pressure (BURP maneuver) applied to the thyroid cartilage.
 The typical correct tube insertion depth is 22 cm,
 To minimize oxygen desaturation, limit each intubation attempt
(insertion of blade) to no more than 30 seconds.
 Between intubation attempts, use a bag-valve mask to reoxygenate
the patient to 100% oxygen saturation.
 First-pass success is higher with bougie-assisted intubation.

22. CONFIRM ATION OF ET TUBE LOCATION
 Mainstem bronchial or esophageal intubation may cause
hypoxia, hypoxemia, hypercarbia, bradycardia, and cardiac
arrest.
1. CLINICAL VERIFICATION 2. MECHANICHAL
 5 Point Auscultation - Pulse oximetry
 Visualize cord placement -End Tidal Co2 detection
 Clinical improvement -Esophageal detection
device
 Tube fogging - POCUS
-
CXR

23. END TIDAL CO2
 Capnometers and
capnographs measure carbon
dioxide in expired air of the
ETT.
 Colorimetric end-tidal carbon
dioxide detectors have a pH-
sensitive filter paper that
changes color from yellow to
purple with carbon dioxide
exposure.
 Capnography measures
expired carbon dioxide in real
time, displaying either the
peak value with each breath or
continuous graphical
waveforms

24. POCUS
 Position the probe cephalad to the
cricoidmembrane, just above the sternal notch.
 The visualization of two separate structures
(“DOUBLE TRACK SIGN”) likely indicates esophageal
intubation.

25. Post Intubation Management.
 chest radiograph to confirm that mainstem intubation has not
occurred and to assess the lungs.
 place the patient on continuous monitoring.
 long-acting NMBAs (eg, pancuronium, vecuronium) are better to
avoide.
 Benzodiazepine (eg, midazolam,( 0.1–0.2 mg/kg IV) and Opioid
analgesic (eg, fentanyl, 3–5 μg/kg IV, or morphine (0.2–0.3 mg/kg
IV) is given to improve patient comfort and decrease sympathetic
response to the ETT,
 Propofol infusion(5–50 μg/kg/min IV) helpful for managementof
neurologic emergencies because iduration of action is very short
(<5 minutes), allowing frequent neurologicexaminations.

28. COMPLICATIONS OF ENDOTRACHEAL INTUBATION