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

Rapid Sequence Intubation (RSI) Procedure in Emergency Situations

Rapid Sequence Intubation (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, which is the standard approach for most emergency intubations, particularly indicated for patients at risk of aspiration. 1

Preparation and Positioning

• Position the patient in a head and torso inclined (semi-Fowler) position during RSI to reduce aspiration risk and potentially improve first-pass intubation success 1
• Consider nasogastric tube decompression when the benefit outweighs the risk in patients at high risk of regurgitation of gastric contents 1

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

Medication Selection and Administration

Sedative-Hypnotic Agents

• A sedative-hypnotic induction agent must be administered when a neuromuscular-blocking agent is used for intubation 1
• Options include etomidate, ketamine, propofol, or midazolam 1, 2
• No significant difference exists between etomidate and other induction agents with respect to mortality or hypotension 1

Neuromuscular Blocking Agents (NMBAs)

• Strongly recommended to administer an NMBA when a sedative-hypnotic induction agent is used for intubation 1
• Either rocuronium or succinylcholine is suggested for RSI when there are no contraindications to succinylcholine 1
• Rocuronium dosing for RSI: 0.6 to 1.2 mg/kg IV 3
• Succinylcholine dosing: 1 to 1.5 mg/kg IV 3

Intubation Procedure

1. Administer sedative-hypnotic agent first 1, 2
2. Immediately follow with NMBA 1, 2
3. Attempt intubation within 60-90 seconds of NMBA administration 3
4. Most patients should have intubation completed within 2 minutes 3

Special Considerations

Obese Patients

• Dose rocuronium based on actual body weight (ABW) rather than ideal body weight (IBW) 3
• Obese patients dosed according to IBW had longer time to maximum block, shorter clinical duration, and did not achieve comparable intubating conditions to those dosed based on ABW 3

Medication-Assisted Preoxygenation (Delayed Sequence Intubation)

• For agitated, delirious, or uncooperative patients who cannot tolerate standard preoxygenation methods 1
• Involves administering a sedative-hypnotic agent (commonly ketamine) to facilitate preoxygenation before administering the NMBA 1
• Can increase oxygen saturation by approximately 8.9% before NMBA administration 1

Common Pitfalls and How to Avoid Them

• Inadequate preoxygenation: Ensure proper technique and consider medication-assisted preoxygenation for uncooperative patients 1
• Hemodynamic instability: Include a cardiovascular component in the intubation protocol with defined parameters for fluid challenges and early vasopressor use 1
• Delayed post-intubation analgosedation: When using rocuronium, be aware that its longer duration may delay provision of post-intubation analgosedation, potentially increasing risk of awareness 1
• Inappropriate dosing in obese patients: Dose based on actual body weight rather than ideal body weight 3

Efficacy and Success Rates

• Clinical studies show excellent or good intubating conditions achieved in 99% of patients receiving rocuronium and 98% receiving succinylcholine 3
• Most patients can be successfully intubated within two attempts (97% success rate) 4
• Major immediate adverse events are rare (1.4%), including hypotension, hypoxemia, and dysrhythmias 4