Rapid sequence intubation (RSI) is a critical process that combines preparation, sedation, and paralysis for safe emergency tracheal intubation. The document outlines the medications, techniques, and equipment needed for effective intubation, emphasizing the importance of patient assessment and careful selection of sedatives and paralytics based on individual clinical scenarios. Additionally, it discusses potential complications associated with RSI and provides dosage recommendations for various sedatives and paralytics.

1. Rapid Sequence Intubation (RSI)
By Turki M. Alanazi

2. Introduction
RSI describes a coordinated, sequential process of preparation, sedation, and paralysis to facilitate safe, emergency
tracheal intubation.
Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform
laryngoscopy and tracheal intubation.
The goal of RSI is to intubate patients quickly and safely using sedation and paralysis.
RSI is generally recommended because it is more successful and safer than intubation without sedation and paralysis
for patients with varying levels of consciousness, active protective airway reflexes, and/or a full stomach.
Sedation and paralysis are unnecessary prior to intubation for some patients, such as those who are in cardiac arrest
or already deeply comatose.

4. Preparation:
Providers;
● Primary laryngoscopist
● Back-up laryngoscopist
● Respiratory therapist
● Registered nurse

5. Airway equipment for pediatric patients
Supplemental oxygen :
● Nasal cannulae (infant, child, and adult)
● Clear oxygen masks (standard and nonrebreathing - infant & child)
Suction :
● Suction catheters (6 through 16 French)
● Yankauer suction tip (two sizes)
Bag-mask ventilation :
● Masks (neonate, infant, child, adult)
● Self-inflating resuscitator bag (450 and 1000 mL)

6. Intubation equipment :
● Endotracheal tubes (uncuffed and
cuffed)
● Stylets
● Laryngoscope handle
● Laryngoscope blades: straight (sizes 0, 1,
2, and 1.5 Wis-Hipple) and curved (sizes
2 and 3)

7. ----------------------------------
Use formula for children 2 years of age and older. Use 3.5 mm internal diameter cuffed
endotracheal tube for children 1 to <2 years of age and a 3.0 mm internal diameter cuffed
endotracheal tube for children <1 year of age.

8. Depth of ETT = ETT size X 3

9. Rescue airway devices
● Laryngeal mask airway
Miscellaneous
● End-tidal CO2 detector
● Bulb suction

10. Physical assessment to identify signs of a difficult airway
in children

12. Preoxygenation — ( 5 minutes Before Intubation )
● Preoxygenation with 100 percent inspired oxygen should begin as soon as possible once the need for
endotracheal intubation becomes evident:
Spontaneously breathing patients :
● Apply a nonrebreather mask for a minimum of three minutes. From a practical viewpoint, oxygen should be
administered at the highest concentration available as soon as RSI is potentially needed.

13. Pretreatment (optional)
Atropine: Although not routinely recommended, many experts suggest atropine as pretreatment
for:
■ Children ≤1 year
■ Children in shock
■ Children <5 years receiving succinylcholine
■ Older children receiving a second dose of succinylcholine
Dose: 0.02 mg/kg IV without a minimum dose (maximum single dose 1 mg; if no IV access, can be
given IM).

14. Induction (sedation)
Etomidate:
■ Safe with hemodynamic instability, neuroprotective, transient adrenal cortico-suppression. Do not use routinely in
patients with septic shock.
■ Dose: 0.3 mg/kg IV.
Ketamine:
■ Safe with hemodynamic instability if patient is not catecholamine depleted. Use in patients with bronchospasm and
septic shock. Use with caution in hypertensive patients with increased intracranial pressure.
■ Dose: 1 to 2 mg/kg IV (if no IV access, can be given IM dose: 3 to 7 mg/kg).
Propofol:
■ Causes hypotension. May use in hemodynamically stable patients with status epilepticus.
■ Dose 1 to 1.5 mg/kg IV.
Midazolam:
■ May use in hemodynamically stable patients with status epilepticus. Time to clinical effect is longer; inconsistently
induces unconsciousness. May cause hemodynamic instability at doses required for sedation.
■ Dose: 0.2 to 0.3 mg/kg IV (maximum dose 10 mg; onset of effect requires 2 to 3 minutes).
Fentanyl:
■ Optional for cardiogenic shock or catecholamine-depleted shock (eg, persistent hypotension despite vasopressor
therapy). Limited evidence in children.
■ Dose 1 to 5 mcg/kg titrated to effect. Start at lower end of range in hypotensive patients. Give over 30 to 60
seconds to avoid respiratory depression or chest wall rigidity.
Pretreatment

15. Paralytic
Selection of paralytic agent — Paralytic agents provide complete muscle relaxation, which facilitates rapid tracheal
intubation. They do not provide sedation, analgesia, or amnesia. Thus, a sedative agent must also be used both for RSI
and when paralysis is maintained after intubation.
Rocuronium:
■ Use for children with contraindication for succinylcholine or as primary paralytic if sugammadex is immediately
available.
■ Dose: 1 mg/kg IV.*
Succinylcholine:
■ Do not use with extensive crush injury with rhabdomyolysis, chronic skeletal muscle disease (eg, Becker
muscular dystrophy) or denervating neuromuscular disease (eg, cerebral palsy with paralysis); 48 to 72 hours
after burn, multiple trauma, or denervating injury; patients with history or malignant hyperthermia; or pre-
existing hyperkalemia.
■ Dose: Infants and children ≤2 years: 2 mg/kg IV, older children and adolescents: 1 to 1.5 mg/kg IV (if IV access
unobtainable, can be given IM, dose: 4 mg/kg)¶.

16. Protection and positioning :
● Maintain manual cervical spine immobilization during
intubation in the trauma patient.
● If cervical spine injury is not potentially present, put the
patient in the "sniffing position" (ie, head forward so that
the external auditory canal is anterior to the shoulder and
the nose and mouth point to the ceiling).
● Utilize external laryngeal manipulation or, in infants, gentle
cricoid pressure to optimize the view of the glottis during direct
laryngoscopy if the initial view is suboptimal or inadequate
despite correct laryngoscope blade positioning.

19. Tongue control during laryngoscopy.
A and B) Poor visualization of the cords due to incorrect positioning of the blade. Note how the tongue folds over the
blade and obscures the view.
C) Correct positioning of the blade to control and move the tongue to the left, providing an optimal view for
intubation.

20. Direct laryngoscopy with a straight blade

21. Direct laryngoscopy using a curved blade
● Selection of the appropriate laryngoscope blade
is especially important with this technique. A
blade that is too small will impinge on the
midportion of the tongue, potentially obscuring
the landmarks, whereas a blade that is too large
can displace the epiglottis posteriorly over the
glottic opening.
● The blade is inserted under direct vision until the
tip is positioned in the vallecula.
● Pulling upward on the laryngoscope handle at 45-
degree angle retracts the tongue and at the same
time elevates the epiglottis, revealing the vocal
cords and glottis.

22. A) After initial retraction of the tongue with a straight
blade, the epiglottis may remain draped posteriorly,
partially or completely covering the glottic opening.
(B) Retraction of the epiglottis with the tip of the
straight blade allows visualization of the glottis and
surrounding structures.

28. Positioning, with placement
● Initiate positive pressure ventilation — The laryngoscope can now be removed from the mouth while the
tube is held securely against the roof of the mouth, or by grasping the tube using the index finger and thumb
with the remaining three fingers holding the patient's face. If a cuffed tube is being used, the cuff should be
inflated at this time.
● Confirm tracheal tube placement with end-tidal CO2 detection.
● Clinical assessment for appropriate tube position includes:
○ Visible chest wall rise
○ Auscultation of breath sounds in both axillae and not heard over the stomach
○ Adequate oxygenation as demonstrated by continuous pulse oximetry
○ Mist should be present in the ETT
Postintubation management
● Obtain a chest radiograph to confirm the depth of tracheal tube insertion.
Provide ongoing sedation (eg, midazolam), analgesia (eg, fentanyl 1 mcg/kg), and, if indicated, paralysis.
● Gastric decompression – An orogastric or nasogastric tube should be placed following intubation to decompress the
stomach.

30. Complications;
Acute complications from laryngoscopy and intubation can occur at multiple points during the
procedure.
● During laryngoscopy/intubation:
○ Hypoxemia
○ Bradycardia
○ Increased intracranial pressure (ICP)
○ Mechanical trauma
○ Aspiration – Aspiration of oral or gastric contents during laryngoscopy or intubation can
occur.
● After intubation:
○ Esophageal or tracheal tube malposition.
○ Tube obstruction; hypoxemia and hypercapnia.
○ Barotrauma
○ Adverse events from medications

31. Sedative for Children with specific clinical features :
Hypotension other than septic shock –
● Etomidate. Fentanyl is preferred by some
experts for sedation of children with
cardiogenic shock.
Septic shock:
● Ketamine, unless otherwise contraindicated
(eg, suspected open globe injury or
catecholamine depletion [eg, hypotensive
despite receiving vasopressor medications.
Increased ICP :
● Etomidate or, in patients who are
hemodynamically stable, propofol or, in
countries where it is available, thiopental.
Hypotensive with head injury : Etomidate.
Status asthmaticus – Ketamine or etomidate.
Status epilepticus – Choice depends upon
hemodynamic status:
● Hemodynamically stable – Midazolam,
propofol, or, if available, thiopental.
● Hypotensive – Etomidate.

32. Summary of The doses
Following are the dosages of RSI medications:
Sedatives Used for Induction
1. Etomidate: 0.3 to 0.4 mg/kg
2. Fentanyl: 1 to 5 mcg/kg
3. Midazolam: 0.1 to 0.3 mg/kg
4. Propofol: 1 to 2.5 mg/kg
5. Thiopental 3 to 5 mg/kg
Paralytic Agents
1. Succinylcholine: 1 to 2 mg/kg
2. Rocuronium 0.6 to 1.2 mg/kg
3. Vecuronium 0.15 to 0.25 mg/kg

34. Any Questions ?