What supplies are needed for a rapid sequence intubation (RSI)?

Essential Supplies for Rapid Sequence Intubation (RSI)

For a successful rapid sequence intubation, you must have a standardized set of equipment and medications that includes laryngoscopes, endotracheal tubes, neuromuscular blocking agents, sedative-hypnotic medications, and monitoring equipment. 1, 2

Airway Equipment

Basic Airway Equipment

• Video laryngoscope with disposable blades (preferred) or direct laryngoscope with standard and short handles, metallic blades of different sizes 1
• Endotracheal tubes:
  • Uncuffed (2.5,3.0,3.5,4.0,4.5.0,5.5, and 6.0 mm)
  • Cuffed (6.5,7.0,7.5,8.0, and 9.0 mm) 1
• Stylets (malleable material to shape endotracheal tubes) 1
• Oropharyngeal airways (sizes 0-5) 1
• Nasopharyngeal airways (12F through 30F) 1

Backup Airway Equipment

• Supraglottic airway devices (e.g., laryngeal mask airways) 1
• Disposable flexible video bronchoscope (if available) 1
• Cricothyroidotomy kit for emergency surgical airway 1

Monitoring Equipment

• Capnography device (essential to confirm correct endotracheal tube placement) 1
• Pulse oximeter with sensors appropriate for patient size 1
• Cardiorespiratory monitor 1
• Blood pressure monitoring equipment 1

Medications

Induction Agents (Sedative-Hypnotics)

• Etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg) - preferred for hemodynamically unstable patients 2, 3
• Alternative options: propofol, midazolam 2, 4

Neuromuscular Blocking Agents

• Succinylcholine (1-1.5 mg/kg) - first-line when no contraindications exist 2, 5
• Rocuronium (0.6-1.2 mg/kg) - alternative when succinylcholine is contraindicated 2, 5
• Note: If using rocuronium, sugammadex should be immediately available in case of "cannot intubate/cannot oxygenate" scenario 1, 2

Premedications (Used Selectively)

• Fentanyl (1-3 mcg/kg) - for blunting sympathetic response 3, 4
• Lidocaine (1-1.5 mg/kg) - for patients with increased intracranial pressure 3, 4
• Atropine - for pediatric patients to prevent bradycardia 4

Positioning and Preoxygenation Equipment

• Equipment to facilitate head and torso inclined (semi-Fowler) position 1, 2
• High-flow nasal oxygen (HFNO) device - especially for anticipated difficult laryngoscopy 1, 2
• Non-invasive positive pressure ventilation (NIPPV) equipment - for severely hypoxemic patients 1, 2
• Bag-valve-mask resuscitator with appropriate masks (neonatal through adult sizes) 1
• Oxygen source with flow regulators 1

Additional Essential Equipment

• Suction device with Yankauer and flexible suction catheters 1
• Nasogastric tubes (for gastric decompression in high-risk patients) 1, 2
• IV access equipment 1
• Syringes and needles for medication administration 1
• Difficult airway trolley with immediate access to all equipment 1

Organizational Considerations

• Equipment should be organized in a standardized manner for quick access 1
• Medications should be prepared in advance with appropriate dosing 1, 6
• A checklist should be used to ensure all necessary equipment is present 1
• Daily checks of difficult airway equipment should be performed 1

Common Pitfalls and Considerations

• Inadequate preoxygenation increases risk of desaturation - ensure proper technique and consider medication-assisted preoxygenation for uncooperative patients 2
• Failure to have backup airway equipment immediately available can lead to "cannot intubate/cannot oxygenate" scenarios 1
• Inappropriate medication selection or dosing can cause hemodynamic instability - choose induction agents based on patient's clinical condition 2, 3
• Lack of capnography to confirm tube placement is a significant safety risk 1
• Having a standardized protocol reduces medication redosing and complications 6

Remember that RSI should be performed by experienced providers, and repeated intubation attempts should be minimized to reduce risk of complications 1. The equipment and medications must be sufficient as visualization and access may be suboptimal during emergency situations 1.