Rapid Sequence Intubation (RSI) Procedure in Emergency Situations
Rapid Sequence Intubation (RSI) is 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, which is the standard approach for most emergency intubations, particularly indicated for patients at risk of aspiration. 1
Definition and Indications
- RSI is indicated for critically ill adult patients in emergency departments, ICUs, or other locations outside the operating room requiring emergency airway management 1
- RSI is the most common and preferred method for intubation of patients presenting to the emergency department 2
Step-by-Step Procedure
1. Positioning
- Use head and torso inclined (semi-Fowler) position during RSI to reduce aspiration risk and improve first-pass intubation success 1
2. Preoxygenation
- Provide standard preoxygenation for cooperative patients 1
- Use high-flow nasal oxygen (HFNO) when laryngoscopy is expected to be challenging 1
- Apply noninvasive positive pressure ventilation (NIPPV) for patients with severe hypoxemia 1
- For agitated, delirious, or combative patients who cannot tolerate preoxygenation devices, use medication-assisted preoxygenation (sometimes called delayed sequence intubation) 1
3. Gastric Decompression
- Consider nasogastric tube decompression when the benefit outweighs the risk in patients at high risk of regurgitation of gastric contents 1
4. Medication Selection and Administration
- A sedative-hypnotic induction agent must be administered when a neuromuscular-blocking agent is used for intubation 1
- Common induction agents include etomidate and ketamine, which have more favorable hemodynamic profiles 2
- For neuromuscular blocking agents, either rocuronium or succinylcholine is recommended when there are no contraindications to succinylcholine 1
- Rocuronium dosing for RSI is 0.6 to 1.2 mg/kg IV, with most patients having excellent or good intubating conditions within 2 minutes 3
- Succinylcholine dosing is typically 1 to 1.5 mg/kg IV 3
5. Intubation Technique
- Attempt intubation within 60-90 seconds after administration of medications 3
- Clinical studies show excellent or good intubating conditions are achieved in 99% of patients receiving rocuronium and 98% receiving succinylcholine 3
6. Post-Intubation Management
- Confirm tube placement using primary and secondary methods 4
- Initiate appropriate post-intubation sedation and analgesia 2
Special Considerations
Patient-Specific Dosing
- For obese patients, dose medications based on actual body weight rather than ideal body weight 3
- Obese patients dosed according to ideal body weight had longer time to maximum block, shorter clinical duration, and inadequate intubating conditions compared to those dosed on actual body weight 3
Medication Selection Based on Clinical Scenario
- For hemodynamically unstable patients, ketamine may be preferred as an induction agent 4
- When succinylcholine is contraindicated, use rocuronium at doses of 1.0-1.2 mg/kg 1, 3
- Have sugammadex readily available when using high-dose rocuronium to reverse neuromuscular blockade if needed 4
Common Pitfalls and How to Avoid Them
Inadequate Preoxygenation
- Ensure proper preoxygenation technique to prevent desaturation during intubation 1
- Consider medication-assisted preoxygenation for uncooperative patients 1
Hemodynamic Instability
- Select appropriate induction agents based on the patient's hemodynamic status 2
- Be prepared for potential hypotension, especially in volume-depleted patients 4
Delayed Recognition of Failed Intubation
- Have backup airway equipment immediately available 5
- Standardized protocols have been shown to facilitate efficient airway management with fewer complications 5
Awareness During Paralysis
- Always administer a sedative-hypnotic agent before or concurrently with the neuromuscular blocking agent 1
- When using rocuronium, be aware of its longer duration of action compared to succinylcholine 4