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

Rapid Sequence Intubation (RSI) in Emergency Situations

Rapid sequence intubation requires administration of a sedative-hypnotic agent followed immediately by a neuromuscular blocking agent in rapid succession, with endotracheal tube placement before any assisted ventilation, specifically designed for critically ill patients requiring emergency airway management. 1

Patient Positioning

• Position the patient in semi-Fowler position (head and torso inclined) during RSI to reduce aspiration risk and improve first-pass intubation success. 1, 2

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 severe hypoxemia (PaO2/FiO2 < 150): Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation 1, 2
• For agitated, delirious, or combative patients: Use medication-assisted preoxygenation (delayed sequence intubation) with ketamine, which increases oxygen saturation by approximately 8.9% before administering the neuromuscular blocking agent 1, 2
• When difficult laryngoscopy is anticipated: Use high-flow nasal oxygen (HFNO) 1, 2

Gastric Decompression

• Consider nasogastric tube decompression in patients at high risk of regurgitation when benefits outweigh risks 1

Medication Selection Algorithm

Sedative-Hypnotic Induction Agents

You must administer a sedative-hypnotic agent when using a neuromuscular blocking agent to prevent awareness during paralysis. 1, 3

For hemodynamically unstable patients:

• Use etomidate 0.2-0.3 mg/kg as the preferred agent due to minimal cardiovascular depression 3, 2

For hemodynamically stable patients:

• Either etomidate or ketamine 1-2 mg/kg can be used 3, 2
• No significant mortality difference exists between etomidate and other induction agents (ketamine, midazolam, propofol) 1, 3
• Recent evidence suggests etomidate may produce less hypotension than ketamine in patients with shock or sepsis 4

For agitated patients requiring medication-assisted preoxygenation:

• Use ketamine 1-2 mg/kg before administering the neuromuscular blocking agent 3, 2

Neuromuscular Blocking Agents (NMBAs)

You must administer an NMBA when a sedative-hypnotic agent is used for intubation (strong recommendation). 1, 3

Choose between succinylcholine or rocuronium when no contraindications exist:

• Succinylcholine 1-1.5 mg/kg: Rapid onset with shorter duration; preferred for hemodynamically stable patients 3, 2
• Rocuronium 0.9-1.2 mg/kg for RSI: Provides intubating conditions in median 1 minute with 31 minutes clinical duration 3, 5
  • Critical requirement: Sugammadex must be immediately available when rocuronium is used for potential "cannot intubate/cannot oxygenate" scenarios 3, 2, 5
  • Be aware that rocuronium's longer duration may delay post-intubation analgosedation, potentially increasing awareness risk 1

Timing and Administration

• Administer both agents in rapid succession with immediate endotracheal tube placement before assisted ventilation begins to minimize aspiration risk 3, 2
• For rocuronium 0.6-1.2 mg/kg, excellent or good intubating conditions are achieved in most patients in less than 2 minutes 5
• Maximum neuromuscular blockade occurs within 3 minutes for most patients 5

Dosing for Rapid Sequence Intubation

Standard RSI dosing:

• Rocuronium 0.6-1.2 mg/kg provides excellent or good intubating conditions in less than 2 minutes 5
• The 0.6 mg/kg dose provides approximately 31 minutes of clinical relaxation under opioid/nitrous oxide/oxygen anesthesia 5

Special Population Considerations

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

Geriatric patients (65-80 years):

• Standard dose of 0.6 mg/kg provides excellent to good intubating conditions in median 2.3 minutes 5
• Recovery times are not prolonged compared to younger adults 5

Obstetric patients:

• Rocuronium is NOT recommended for rapid sequence induction in Cesarean section patients due to inadequate intubating conditions when used with lower thiopental doses 5

Common Pitfalls and How to Avoid Them

• Inadequate preoxygenation: Ensure proper technique and use medication-assisted preoxygenation for uncooperative patients 1, 2
• Failure to have backup airway equipment: Immediately available equipment is essential for "cannot intubate/cannot oxygenate" scenarios 2
• Inappropriate medication selection: Choose etomidate for hemodynamically unstable patients to avoid cardiovascular collapse 3, 2
• Delayed post-intubation sedation: When using rocuronium, anticipate its longer duration and plan for timely post-intubation analgosedation 1
• Medication errors: Store rocuronium with cap and ferrule intact to minimize wrong product selection, as accidental administration of neuromuscular blocking agents may be fatal 5

Post-Intubation Management

• Apply PEEP of at least 5 cmH₂O after intubation of hypoxemic patients 1
• Use post-intubation recruitment maneuvers in hypoxemic patients 1
• Include cardiovascular monitoring with defined parameters for fluid challenges and early vasopressor use to prevent hemodynamic instability 1