What is the recommended procedure for rapid sequence intubation (RSI) in emergency situations?

Recommended Procedure for Rapid Sequence Intubation (RSI) in Emergency Situations

Rapid Sequence Intubation (RSI) should be performed using a sedative-hypnotic agent and a neuromuscular-blocking agent in rapid succession with immediate placement of an endotracheal tube before assisted ventilation, particularly for patients at risk of aspiration. 1

Definition and Indications

• RSI is defined as the administration of a sedative-hypnotic agent and a neuromuscular-blocking agent in rapid succession with immediate placement of an endotracheal tube before assisted ventilation 2, 1
• RSI is indicated for critically ill adult patients in emergency departments, ICUs, or other locations outside the operating room requiring emergency airway management 2
• RSI is particularly indicated for patients at risk of aspiration 1

Positioning

• The American College of Critical Care Medicine suggests using the head and torso inclined (semi-Fowler) position during RSI (conditional recommendation, very low quality evidence) 2
• This positioning helps reduce the risk of aspiration and may improve first-pass intubation success 2

Preoxygenation

• High-flow nasal oxygen (HFNO) is suggested when laryngoscopy is expected to be challenging (conditional recommendation, low quality evidence) 2
• Noninvasive positive pressure ventilation (NIPPV) is suggested in patients with severe hypoxemia (PaO₂/FiO₂ < 150) 2
• For agitated, delirious, or combative patients who cannot tolerate preoxygenation devices, medication-assisted preoxygenation is suggested 2, 1

Gastric Decompression

• Nasogastric tube decompression is advised when the benefit outweighs the risk in patients undergoing RSI who are at high risk of regurgitation of gastric contents (best practice statement) 2

Medication Selection and Administration

Induction Agents

• A sedative-hypnotic induction agent must be administered when a neuromuscular-blocking agent is used for intubation (best practice statement) 2

• Common induction agents include:

  • Etomidate: Suggested for hemodynamically unstable patients 2, 3
  • Ketamine: Alternative for hypotensive patients 3, 4
  • Propofol: Has replaced thiopental as a common intravenous hypnotic, but may cause hypotension 3, 4

• The American College of Critical Care Medicine suggests there is no significant difference between etomidate and other induction agents with respect to mortality or hypotension (conditional recommendation, moderate quality evidence) 2

Neuromuscular Blocking Agents (NMBAs)

• The American College of Critical Care Medicine strongly recommends administering an NMBA when a sedative-hypnotic induction agent is used for intubation (strong recommendation, low quality evidence) 2
• Either rocuronium or succinylcholine is suggested for RSI when there are no contraindications to succinylcholine (conditional recommendation, low quality evidence) 2
• Succinylcholine is characterized by rapid onset and short duration 4
• Rocuronium (0.6-1.2 mg/kg) provides excellent or good intubating conditions in most patients in less than 2 minutes 5
• Higher doses of rocuronium (0.9-1.2 mg/kg) can be administered under opioid/nitrous oxide/oxygen anesthesia without adverse cardiovascular effects 5

Procedural Steps

1. Pre-oxygenation: Maximize oxygen saturation before intubation using appropriate methods based on patient condition 1, 3

2. Medication administration:

   • Administer sedative-hypnotic agent 2
   • Immediately follow with neuromuscular blocking agent 2

3. Intubation:

   • Perform laryngoscopy and intubation after onset of paralysis (typically 45-60 seconds with succinylcholine or 1-2 minutes with rocuronium) 5, 4
   • Most patients should have intubation completed within 2 minutes 5

4. Confirmation:

   • Verify correct endotracheal tube placement 3, 6

5. Post-intubation management:

   • Initiate appropriate ventilation and sedation 3, 6

Special Considerations

• Obese patients: Should be dosed based on actual body weight rather than ideal body weight 5
• Geriatric patients: No need for dose adjustment in most cases, but monitor carefully 5
• Cesarean section: RSI with rocuronium is not recommended for rapid sequence induction in Cesarean section patients due to inadequate intubating conditions 5
• Patients with shock or sepsis: Recent retrospective evidence suggests etomidate may produce less hypotension than ketamine 3

Potential Complications and Mitigation

• Hypoxemia: Ensure adequate preoxygenation and consider apneic oxygenation 3, 6
• Hypotension: Select appropriate induction agents based on hemodynamic status 3, 4
• Aspiration: Use proper positioning (semi-Fowler) and consider gastric decompression in high-risk patients 2

RSI requires familiarity with patient evaluation, airway management techniques, sedation agents, neuromuscular blocking agents, and post-intubation management to maximize successful endotracheal intubation while minimizing adverse physiologic effects 7, 6.