What is the recommended protocol for Rapid Sequence Intubation (RSI) in the Emergency Room (ER)?

Recommended Protocol for Rapid Sequence Intubation (RSI) in the Emergency Room

The recommended protocol for RSI in the emergency room should include etomidate (0.2-0.3 mg/kg IV) or ketamine (1-2 mg/kg IV) as sedative agents, followed by succinylcholine (1.5 mg/kg IV) or rocuronium (0.9-1.2 mg/kg IV) as neuromuscular blocking agents, with appropriate pre-oxygenation and post-intubation care. 1

Medication Selection

Sedative-Hypnotic Agents:

• Etomidate (0.2-0.3 mg/kg IV):

  • First-line agent for most patients, especially those with cardiovascular compromise 1
  • Provides rapid onset and short duration with minimal cardiovascular depression
  • May cause adrenal suppression, though evidence suggests this doesn't significantly affect mortality outcomes 2

• Ketamine (1-2 mg/kg IV):

  • Preferred for patients with septic or hypovolemic shock 1
  • Maintains hemodynamic stability through sympathomimetic effects
  • Recent evidence suggests it may cause more hypotension than etomidate in septic patients 2

Neuromuscular Blocking Agents:

• Succinylcholine (1.5 mg/kg IV):

  • First-line agent for RSI in patients with vital signs of distress 2
  • Rapid onset (30-60 seconds) and short duration (5-10 minutes)
  • Contraindications: hyperkalemia, burns, crush injuries, neuromuscular disorders

• Rocuronium (0.9-1.2 mg/kg IV):

  • Alternative when succinylcholine is contraindicated 2
  • At higher doses (1.0-1.2 mg/kg), provides comparable intubating conditions to succinylcholine 3
  • Longer duration of action (30-40 minutes)
  • Sugammadex should be readily available when rocuronium is used 2

Pre-Intubation Preparation

1. Equipment Check:

   • Verify all airway equipment is functioning properly
   • Have backup devices readily available
   • Prepare difficult airway equipment if indicated 1

2. Pre-oxygenation:

   • Non-invasive ventilation for hypoxemic patients 2, 1
   • High-flow nasal oxygen for non-severely hypoxemic patients 2, 1
   • Aim for 3-5 minutes of pre-oxygenation when possible 1

3. Hemodynamic Preparation:

   • Have vasopressors immediately available
   • Ensure continuous hemodynamic monitoring
   • Consider fluid bolus in hypovolemic patients 1

4. Adjunctive Medications (situation-dependent):

   • Atropine (0.01-0.02 mg/kg) for children aged 28 days to 8 years to prevent bradycardia 1
   • Consider fentanyl (1-3 mcg/kg) to blunt sympathetic response in select patients 1
   • Lidocaine (1-2 mg/kg IV) may be considered for patients with increased intracranial pressure 1

RSI Procedure

1. Position the patient in a semi-Fowler position with head elevation if not contraindicated 1

2. Administer sedative agent (etomidate or ketamine) at appropriate dose

3. Immediately follow with neuromuscular blocking agent (succinylcholine or rocuronium)

4. Apply cricoid pressure (Sellick maneuver) if trained personnel available, though evidence for this practice is mixed

5. Intubate when adequate muscle relaxation is achieved (typically 45-60 seconds after medication administration)

6. Confirm tube placement using multiple methods (capnography, chest rise, auscultation)

Post-Intubation Care

1. Initiate appropriate sedation/analgesia immediately after confirmation of tube placement 1

2. Consider post-intubation recruitment maneuver in hypoxemic patients 2

3. Apply PEEP of at least 5 cmH2O after intubation of hypoxemic patients 2

4. Monitor for complications:

   • Hypotension (especially with sedative agents)
   • Hypoxemia
   • Esophageal intubation
   • Aspiration

Special Considerations

Cardiovascular Compromise:

• Prefer etomidate (0.2-0.3 mg/kg) for hemodynamic stability 1
• Have norepinephrine immediately available 1
• Consider reduced doses of sedative agents

Septic Patients:

• Consider avoiding etomidate due to concerns about adrenal suppression, though evidence for clinical harm is limited 2, 1
• Recent evidence suggests etomidate may produce less hypotension than ketamine in septic patients 4

Increased Intracranial Pressure:

• Consider etomidate (0.2-0.3 mg/kg) as the preferred sedative 1
• Avoid ketamine if possible due to potential ICP effects (though this concern is increasingly questioned)

Difficult Airway:

• Have specialized equipment readily available
• Consider awake intubation techniques if appropriate
• Ensure backup plans are in place before administering paralytic agents

Clinical Pitfalls to Avoid

1. Inadequate pre-oxygenation: Ensure thorough pre-oxygenation to maximize safe apnea time

2. Inappropriate medication selection: Match sedative agent to patient's hemodynamic status

3. Inadequate dosing: Underdosing can lead to awareness during paralysis or inadequate intubating conditions; standardized protocols reduce this risk 5

4. Failure to anticipate complications: Have vasopressors and difficult airway equipment readily available

5. Omitting neuromuscular blockade: Evidence shows significantly higher complication rates (including aspiration and airway trauma) when intubation is attempted without paralysis 6

6. Delayed post-intubation sedation: Ensure ongoing sedation after initial RSI medications wear off to prevent paralysis without sedation 1

The implementation of a standardized RSI protocol has been shown to facilitate airway management, reduce the need for medication redosing, and decrease medication-related complications 5.