What is Rapid Sequence Intubation (RSI)?

Rapid Sequence Intubation (RSI)

Rapid Sequence Intubation (RSI) is a standardized procedure for emergency airway management that involves the sequential administration of an induction agent and neuromuscular blocking agent to facilitate rapid endotracheal intubation while minimizing the risk of aspiration and complications. 1, 2

Definition and Purpose

RSI is the most common method for intubation in emergency settings, designed to:

• Secure a definitive airway rapidly
• Minimize the risk of aspiration
• Optimize intubation conditions
• Reduce complications during emergency airway management

Key Components of RSI

1. Patient Preparation

• Position the patient in a semi-Fowler position (head and trunk elevated) to improve preoxygenation and laryngeal view 2
• Verify all airway equipment is functional and ready
• Prepare medications in appropriate doses
• Ensure monitoring equipment is connected and functioning

2. Preoxygenation

• Administer high-flow oxygen for 3-5 minutes before RSI to prevent hypoxemia 2
• For patients with severe hypoxemia (PaO₂/FiO₂ < 150), use non-invasive ventilation with positive pressure 2
• Consider high-flow nasal oxygen (HFNO) for patients with anticipated difficult airway 2

3. Medication Administration

• Induction Agents:

  • Etomidate: 0.2-0.3 mg/kg IV
  • Ketamine: 1-2 mg/kg IV
  • Propofol: Use with caution in hemodynamically unstable patients 2, 3

• Neuromuscular Blocking Agents:

  • Succinylcholine: 1.5 mg/kg IV (first-line for patients with signs of difficult airway)
  • Rocuronium: 0.9-1.2 mg/kg IV (when succinylcholine is contraindicated) 2, 4

4. Intubation

• Perform laryngoscopy and intubation after onset of neuromuscular blockade
• Confirm tube placement with end-tidal CO2 detection and chest auscultation
• Secure the endotracheal tube and initiate mechanical ventilation

5. Post-Intubation Management

• Confirm correct tube placement
• Initiate appropriate sedation and analgesia
• Maintain full monitoring
• Address any hemodynamic changes 2

Special Considerations

Difficult Airway

• Have difficult airway equipment immediately available
• Consider alternative approaches such as video laryngoscopy
• Be prepared for rescue techniques if intubation fails 2

Risk of Aspiration

• Consider nasogastric decompression in high-risk patients 2
• Maintain cricoid pressure during the procedure (though this remains controversial)

Hemodynamic Instability

• Choose induction agents based on hemodynamic status
• Etomidate may produce less hypotension than ketamine in patients with shock or sepsis 3
• Have vasopressors readily available 2

Rescue Techniques

• If mask ventilation fails, consider inserting a laryngeal mask airway (LMA)
• If LMA ventilation fails, proceed to invasive rescue techniques such as emergency cricothyrotomy 2

Alternative Approaches

When standard RSI is not optimal, consider:

• Delayed sequence intubation: Using ketamine to allow airway preparation and preoxygenation in agitated patients 5
• Ketamine-only breathing intubation: Using ketamine without a paralytic to facilitate intubation while the patient continues breathing spontaneously 5

Common Pitfalls to Avoid

• Inadequate preoxygenation leading to rapid desaturation
• Inappropriate medication selection for patient's condition
• Underdosing of medications, especially in obese patients
• Failure to anticipate difficult airway
• Delayed recognition of esophageal intubation
• Inadequate post-intubation sedation and analgesia

RSI requires experienced clinicians or adequately trained individuals supervised by an experienced clinician familiar with neuromuscular blocking agents and their complications 4. The procedure should be performed with all necessary equipment and medications immediately available to manage potential complications.