This document discusses tracheal intubation and rapid sequence intubation (RSI). RSI involves rapidly sedating and paralyzing a patient to facilitate endotracheal intubation. The key steps of RSI are preoxygenation, induction with sedatives, paralysis with neuromuscular blocking agents, protection of the airway with cricoid pressure during intubation, confirmation of proper endotracheal tube placement, and post-intubation management and securing of the airway. RSI aims to minimize risks of aspiration and facilitate safe and rapid intubation in emergency situations.

1. Tracheal Intubation

2. Why ?
 Primary objective – Adequate Ventilation and Oxygenation
 Protect Airway
 To decrease work of breathing

3. Indications;
Respiratory Failure
Unconscious patient / GCS < 8
Cardiac arrest
Maintenance or protection of an intact airway

4. Airway Anatomy

5. RSI – Rapid Sequence Intubation
 RSI is the virtually simultaneous administration of a sedative and a
neuromuscular blocking agent to render a patient rapidly unconscious
and flaccid in order to facilitate emergent endotracheal intubation and to
minimize the risk of aspiration.

6. Advantages of RSI
 Facilitates and expedites endotracheal intubation
1. Increase success rate
2. Decreased time for intubation
 Minimizes trauma during laryngoscopy
 Minimizes hypoxia and hypercapnia
 Minimizes risk of aspiration
 Minimizes hemodynamic effects of intubation

7. Seven “P” of RSI
1. Preparation
2. Pre oxygenation
3. Pre treatment
4. Paralysis with induction
5. Protection and positioning
6. Placement with proof
7. Post intubation management

8. Preparation
(10 mins before intubation )
 Prepare the Patient
 Prepare the equipment
 Prepare the team
 Prepare for difficulty

14. Preoxygenation/De nitrogenation
(5 mins before intubation)
 To replace all the nitrogen in the lungs with oxygen prior to intubation
 Act as a O2 reservoir during apneic period of RSI
 Maximal FiO2 for 3 – 5 mins
 Conscious patient 8 full vital capacity breaths
If SpO2 cannot increased > 93% after optimal preoxygenation We can use NPPV or
mask ventilation with a positive end expiratory pressure

15. PREOXYGENATION APNEIC OXYGENATION

16. Pre treatment ( 3 mins before intubation)
 Laryngoscopy can activate coughing ang gagging
 Infants – Bradycardia
Adults – Pressure response Change in BP , Increase ICP HR, Bronchospasm,
Dysrhythmias

17. Drugs
 Glycopyrolate – Anticholinergic decrease secretion and prevent aspiration
Dosage ; 5-10 micrograms / kg
 Atropine – Reduce incidence of bradycardia
Dosage ; 0.01 mg/kg or 10 micrograms / kg
 Fentanyl – Reduce pressor response and prevent rise in ICP
Dosage ; 2-3 microgram/kg given at a rate of 1-2 microgram/kg/min
 Lidocaine – 1.5-2 mg/kg iv over 30-60secs

18. Paralysis with induction
To induce loss of consciousness
Head injury or Stroke
we have to maintain adequate cerebral perfusion and maintain arterial pressure.
1. Etomidate 0.3 mg/kg – Excellent sedation, does not cause hypotension
2. Ketamine 1-2 mg/kg – Hypotensive patient with head injury, Septic shock,
Bronchospasm. Avoid in cerebral hemorrhage
3. Midazolam, Propofol can be used in head injury but risk of hypotension.

19. Paralysis with induction
Status Epilepticus – Midazolam (0.2-0.3mg/kg) can cause hypotension
use etomidate if hemodynamic compromise
do not use ketamine due to stimulant effect
Severe Bronchospasm
Hemodynamically stable – Ketamine, Propofol, Etomidate, Midazolam
Unstable- Ketamine or Etomidate
Cardiovascular – Etomidate
Shock – Etomidate or Ketamine

20. 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.

21. DEPOLARIZING PARALYTICS
SUCCINYLCHOLINE (1-2 mg/kg): Mostly preferred agent due to rapid onset (45-60
sec) and offset (6-10 mins). Better to overdose than under dose.
Absolute Contraindications:
SIGNIFICANT HYPERKALEMIA DEMONSTRATED BY ECG FINDING.
MALIGNANT HYPERTHERMIA (FAMILY OR PERSONAL Hx.)
RHABDOMYOLYSIS
STROKE OR BURN 72 HOUR OLD, DUE TO UPREGULATION OF Ach RECEPTORS
SIGNIFICANT NEUROMUSCULAR Dx OR MUSCULAR DYSTROPHY

22. NONDEPOLARIZING NEUROMUSCULAR BLOCKING
AGENTS (NMBAS)
USED WHEN DEPOLARIZING AGENTS ARE CONTRAINDICATED OR PROLONGED
BLOCKADE IS WARRANTED.
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

23. PROTECTION (CRICOID PRESSURE) AND
POSITIONING
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 preoxygenated.
A common error is to apply pressure to the thyroid cartilage
(Adam's apple).

24. SELLICK'S MANEUVER

25. 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).

27. ET Tube Size

30. POSTINTUBATION MANAGEMENT
RSI remains incomplete until the properly placed endotracheal tube is secured.
Several techniques are commonly used to secure the tube, including taping, tying
etc.
Hypotension can occur due to decreased venous return from increased
intrathoracic pressure due to mechanical ventilation or due to sedatives.

31. Other Technique
 Delayed sequence intubation
 Awake oral intubation
 Oral intubation without pharmacologic agent

32. Other devices – Video laryngoscopy
Indications;
 Routine emergency intubation
 Failed DL, Known or Suspected difficult airway
 Morbid obesity
 Trauma patient with C Spine immobilization
Contraindications;
 Limited mouth opening
 Severe kyphosis
 Copious blood or secretions
Complications;
 Dental trauma
 Oropharyngeal trauma

33. Airway scope Optical laryngoscope

34. Flexible fibreoptic intubation
Indications;
 Known or Suspected difficult airway
 Distorted airway anatomy; Swelling, Abscess,
Morbid obesity, Trauma, Previous radiation
therapy
Contraindications;
 Nasal approach; Severe midface trauma,
Coagulopathy
 Relative; Active airway bleeding, Vomiting
Complications;
 Hypoxia from prolonged attempt
 Vomiting, Laryngospasm
 Soft tissue trauma

35. Intubating LMA
Indications;
 Failed RSI
 Cannot intubate/Cannot ventilate
 Difficult mask ventilation
 Refractory hypoxemia despite preoxygenation
Contraindications;
 Unable to open mouth
 Awake patient
Complications;
 Laryngeal or Oesophageal injury
 Aspiration

36. Retrograde intubation
Indications;
 Need for definitive airway other failed
 Trismus, Maxillofacial trauma
 Upper airway mass
Contraindications;
 Inability to open mouth
 Rapid airway control
Complications;
 Haemorrhage
 Subcutaneous emphysema
Soft tissue infection
Failure to achieve intubation