Rapid Sequence Intubation in Emergency Situations
Rapid sequence intubation (RSI) involves administering a sedative-hypnotic agent followed immediately by a neuromuscular blocking agent (NMBA) in rapid succession, with immediate endotracheal tube placement before assisted ventilation, and is the standard approach for emergency airway management in critically ill patients. 1
Patient Positioning
- Place the patient in semi-Fowler position (head and torso inclined) during RSI to reduce aspiration risk and improve first-pass intubation success 1, 2
- This positioning is particularly important for patients at risk of regurgitation 1
Preoxygenation Strategy
The preoxygenation approach depends on patient cooperation and severity of hypoxemia:
- For cooperative patients: Use standard preoxygenation with high-flow oxygen 1
- For severely hypoxemic patients (PaO2/FiO2 < 150): Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation 1, 2
- For agitated, delirious, or combative patients who cannot tolerate preoxygenation devices: Use medication-assisted preoxygenation (delayed sequence intubation) with ketamine, which increases oxygen saturation by approximately 8.9% before NMBA administration 1, 2
- When laryngoscopy is expected to be challenging: Use high-flow nasal oxygen (HFNO) 1, 2
Gastric Decompression
- Consider nasogastric tube decompression in patients at high risk of regurgitation of gastric contents when the benefit outweighs the risk 1
- Do not routinely use cricoid pressure (Sellick maneuver), as evidence does not support its effectiveness in preventing aspiration and it may impair laryngoscopy 2, 3
Medication Selection and Administration
Sedative-Hypnotic Induction Agent (Required)
A sedative-hypnotic induction agent must be administered when an NMBA is used for intubation 1, 2
Choose based on hemodynamic status:
- Etomidate (0.3 mg/kg IV): No significant difference in mortality or hypotension compared to other agents; recent evidence suggests it may produce less hypotension than ketamine in patients with shock or sepsis 1, 2, 4
- Ketamine (1-2 mg/kg IV): Preferred for hemodynamically unstable patients and may be particularly beneficial in head trauma as it maintains cerebral perfusion pressure 2, 3, 4
- Propofol (1.5-2.5 mg/kg IV): Alternative option but avoid in hemodynamically unstable patients 5, 4
Neuromuscular Blocking Agent (Strongly Recommended)
Administering an NMBA when a sedative-hypnotic induction agent is used for intubation is strongly recommended 1, 2
Choose between:
- Succinylcholine (1-1.5 mg/kg IV): First-line choice when no contraindications exist; provides rapid onset and shorter duration 1, 2, 5
- Rocuronium (0.9-1.2 mg/kg IV): Use when succinylcholine is contraindicated; provides comparable intubation conditions to succinylcholine at high doses but has longer duration of action 1, 2, 5, 4
- Sugammadex must be immediately available when rocuronium is used for potential "cannot intubate/cannot oxygenate" scenarios 2, 5
Timing for Intubation Attempt
- Attempt intubation within 60-90 seconds of medication administration 5
- With rocuronium 0.6 mg/kg: Neuromuscular block sufficient for intubation is attained in a median time of 1 minute, with most patients intubated within 2 minutes 5
- Maximum blockade is achieved in most patients in less than 3 minutes 5
Dosing for Rapid Sequence Intubation
- For standard RSI: Use rocuronium 0.6-1.2 mg/kg to provide excellent or good intubating conditions in less than 2 minutes 5
- For obese patients: Dose rocuronium based on actual body weight, not ideal body weight, as dosing by ideal body weight results in longer time to maximum block and shorter clinical duration 5
Post-Intubation Management
- Apply PEEP of at least 5 cmH₂O after intubation of hypoxemic patients 1
- Perform a post-intubation recruitment maneuver in hypoxemic patients 1
- Include a cardiovascular component in the protocol with defined parameters for fluid challenges and early vasopressor use to prevent hemodynamic instability 1
- Be aware that rocuronium's longer duration may delay post-intubation analgosedation, potentially increasing risk of awareness 1, 2
Critical Pitfalls to Avoid
- Inadequate preoxygenation: Ensure proper technique and consider medication-assisted preoxygenation for uncooperative patients 1, 2
- Failure to have backup airway equipment immediately available: Can lead to "cannot intubate/cannot oxygenate" scenarios 2
- Inappropriate medication selection or dosing: Can cause hemodynamic instability, particularly in shock or sepsis patients 2, 4
- Attempting intubation too early: Wait for adequate neuromuscular blockade before attempting laryngoscopy 5
Special Populations
Obstetric Patients
- Rocuronium is not recommended for rapid sequence induction in Cesarean section patients due to poor or inadequate intubating conditions when used with lower doses of thiopental 5