Rapid Sequence Intubation (RSI)

1. RAPID SEQUENCE INTUBATION (RSI)
A method used in an emergency to safely and rapidly intubate a patient while protecting the airway by minimizing
the risk of regurgitation and aspiration of gastric contents into the lungs. Aspiration of acidic volumes of stomach
content into the lungs can cause aspiration pneumonitis, bronchospasm or obstruction, and atelectasisleading to
cyanosis, dyspnea, and overall morbidity.
Risk Factors for Aspiration:
 Delayed gastric emptying (severe pain, trauma, recent opioid administration, alcohol, vagotomy, diabetes,
Parkinson’s disease), history of gastric banding
 Abdominal obstruction or ileus
 Incompetent lower esophageal sphincter, hiatus hernia, or gastroesophageal reflux disease
 Neurological or neuromuscular disease
 Pregnancy
Indications for RSI:
 Inability to maintain airway patency or protect the airway against aspiration
 Failure to ventilate or oxygenate
 Anticipation of respiratory failure
 Pregnancy (from the second trimester onwards)
RSI is performed on patients with an unfasted or unknown fasting status (e.g. trauma/critically ill/injured patient,
emergency surgery, resuscitation, and in patients with a reduced conscious level).
Contraindications for RSI:
 Total upper airway obstruction, which requires a surgical airway
 Total loss of facial/oropharyngeal landmarks, which requires a surgical airway
 “Difficult” airway causing endotracheal intubation to be unsuccessful
 “Crash” airway in which patient is already unconscious and apneic, in an arrest situation
Steps of RSI:
1) Preoxygenation/Denitrogenation
Using a tight-fitting nonrebreather mask, supply 10-15 L of 100% O2 for 3 - 5 minutes or until SaO2 > 90%,
with at least 20 degrees of head elevation. This maximizes the amount of oxygen in the patient’s lungs
preventing desaturation during the period of apnea.
2) Protect and Position the C-Spine Optimally
Maintain cervical spine immobilization during the entire intubation process if injury of the cervical spine is
suspected. Removing the front of the cervical collar, so the mandible can be displaced anteriorly to allow
visualization of the vocal cords. Position the head and neck in the sniffing position by flexing the neck and
extending the atlanto-occipitaljoint.
3) Premedication
Medications given 3-5 minutes prior to sedation and paralysis to help reduce the patient’s adverse or reflex
sympathetic responses to RSI (laryngoscopy, hypnotics) such as bradycardia, tachycardia, hypertension, and
increased intracranial/intraocular pressure. Premedications attenuate the catecholamine surge in RSI.
Potential premedications include one of the following;
1. Atropine 1-2 mcg/kg IVP
 Used in children to prevent bradycardia
2. Lidocaine 1.5 mg/kg IVP
 Recommended in patients with suspected increases in ICP
 Avoid in dysrhythmia or hypotension

2. 3. Fentanyl 1-3 mcg/kg IVP
 Avoid in children and patients with shock states
4. Vecuronium 0.01 mg/kg IVP
 Prevents fasciculation if intended to use succinylcholine
5. Rocuronium 0.06 mg/kg IVP
 Prevents fasciculation if intended to use succinylcholine
4) Pressure to the Cricoid
To prevent gastric reflux and aspiration during positive pressure ventilation, applying a pressure of 30N with
a thumb and index finger, compresses the cricoid cartilage against the cervical vertebrae, blocking the upper
end of the esophagus and protecting the airway.
5) Induce
Prior to intubation, medications are used to provide loss of consciousness, blunt sympathetic responses,
provide amnesia, and improve intubating conditions. The ideal induction agent should provide a rapid onset
and rapid recovery from anesthesia with minimal cardiovascular and systemic side effects.
Commonly Used Induction Agents:
1. Propofol 1-3 mg/kg IVP
 Use: Hemodynamically stable patients, reactive airways disease (bronchodilation),
status epilepticus (anticonvulsant), and patients with intracranial pathology
 Drawbacks: Hypotension, Myocardialdepression, Reduced cerebral perfusion, Pain
on injection, Very short acting ~ 3-10 minutes
 Does NOT provide analgesia
2. Ketamine 1-2 mg/kg IVP
 Effects: Sympathetic stimulation (↑HR, ↑BP)
 Use: Hypotension/shock, reactive airways disease (bronchodilation), pain, maintain
cerebral perfusion to prevent brain injury, sepsis
 Drawbacks: Increased secretions (premedicate with atropine), caution in
cardiovascular disease(hypertension, tachycardia), increases intracranial pressure
 Provides analgesia
3. Thiopentone 3-5 mg/kg IVP (Barbiturate)
 Advantages: Most rapid onset of action and predictable dose-dependent effect
 Onset of Action: < 30 seconds
 Effects: Vasodilator (↓BP), Negative cardiac inotrope, Histamine release,
Immunosuppressant (decreases WBC recruitment, activation, and activity)
 Use: Hemodynamically patients with conditions that can elevate ICP including
seizures, intracranial bleeding, or trauma
 AVOID: Patients prone to hypotension (elderly), reactiveairway disease (histamine
causes bronchospasm), sepsis
 Drawbacks: High rate of anaphylaxis (1 in 20,000), tissuenecrosis if extravasation
occurs, potentially life-threatening side effects (muscle twitching/jerking, must NOT
be injected intra-arterially will causeburning pain, severe arterial spasm/ischemia
 Does NOT provide analgesia
4. Etomidate 0.3 mg/kg IVP
 Advantages: Hemodynamically neutral
 Use: Hemodynamically unstable patients (hypo/hyper-tensive)with severe
cardiovascular disease, or with high intracranial pressure, shock, sepsis
 Drawbacks: Reversible adrenal suppression, myoclonus, pain on injection,
 AVOID: Patients with adrenal insufficiency(Addison’s disease)
 Does NOT provide analgesia

3. 5. Midazolam 0.1-0.2 mg/kg IVP (Benzodiazepine)
 Effects: Anticonvulsant, decreasesblood pressure
 Use: Patients with status epilepticus, hypertension, anxiety, or bronchospasm
 Drawbacks: Patients with Hypovolemia/shock, or respiratory depression
 Does NOT provide analgesia
6) Paralyze
Eliminates muscle tone of the airway optimizing laryngoscopy and preventing vomiting/aspiration.
Ideal paralytic agent is to have a rapid onset of action and rapid recovery to ventilation if intubation fails.
Commonly Used Neuromuscular Blocking Agents:
1. Succinylcholine 1.5 mg/kg IVP (Depolarizing)
 Onset of Action: 45-60 seconds (rapid)
 Duration: 6-10 minutes (rapid)
 Use: Widely used unless contraindicated, ideal if needed to extubate rapidly
following an elective procedure or to assess neurology in an intubate patient, patients
with myasthenia gravis
 Contraindications: History of malignant hyperthermia, risk of developing severe
hyperkalemia
 Drawbacks: Life-threatening side effects (hyperkalemia, muscle pains, bradycardia,
malignant hyperpyrexia, high incidence of anaphylaxis and histamine release,
fasciculations, elevated intraocular pressure)
 AVOID: Patients with muscular dystrophy or rhabdomyolysis, stroke >72 hours old,
burn over 72 hours old, or significant hyperkalemia
2. Rocuronium 1.2 mg/kg IVP (Non-depolarizing)
 Onset of Action: 45-60 seconds
 Duration: ~30 minutes
 Use: If succinylcholine is contraindicated or if longer paralysis is required
 Advantages: Can be reversed by neostigmine (AChesterase inhibitor) or
Sugammadex returning neuromuscular function in emergent settings
3. Vecuronium 0.15 mg/kg IVP (Non-depolarizing)
 Onset of Action: 75-100 seconds
 Duration: ~45-60 minutes
 Use: Not recommended for RSI, if succinylcholine or rocuronium cannot be used
 Drawbacks: Slow onset, long duration
 Advantages: Can be reversed by neostigmine or Sugammadex returning
neuromuscular function in emergent settings
7) Pass the Tube
Pass the tube as gently as possible after there is full relaxation of the airway muscles
8) Post-Intubation Care
Tube placement should be confirmed objectively with end-tidalCO2. As soon as the tube is confirmed in
the trachea, cricoid pressure may be released. The tube should be secured with tape or a commercial device.
The patient should receive sedation and analgesia as soon as possible and be placed on a ventilator.