What is the step‑by‑step procedure for performing endotracheal intubation with rapid‑sequence induction in an adult patient?

Rapid Sequence Intubation Procedure in Adults

For rapid sequence intubation in adults, administer ketamine 1-2 mg/kg IV (or etomidate 0.3 mg/kg IV in hemodynamically unstable patients) followed immediately by rocuronium 1.0-1.2 mg/kg IV (or succinylcholine 1-1.5 mg/kg IV if no contraindications), then intubate after 60 seconds of neuromuscular blockade, confirming placement with waveform capnography. 1

Pre-Intubation Preparation

Patient Positioning and Preoxygenation

• Position the patient in semi-Fowler position (head and trunk elevated 20-30 degrees) to improve first-pass success and reduce aspiration risk 1
• Perform preoxygenation with FiO₂ 1.0 and oxygen flow >10 L/min for 3-5 minutes using a completely sealing mask with capnography, targeting FetO₂ >0.9 2
• Use high-flow nasal oxygen (HFNO) when challenging laryngoscopy is anticipated 1
• In patients with severe hypoxemia (PaO₂/FiO₂ <150), use noninvasive positive pressure ventilation (NIPPV) during preoxygenation 1

Equipment and Team Preparation

• Ensure waveform capnography is immediately available—this is mandatory for confirming intubation 3
• Have a front-of-neck access (FONA) set immediately to hand before the first laryngoscopy attempt 3
• Assign a dedicated team member to note the time as induction commences 3
• Summon senior help after the first failed attempt 3
• Prepare suction equipment with catheter connected and turned on 2, 4
• Have videolaryngoscopy available as it improves laryngeal view, reduces trauma, and decreases failure rates 3

Medication Administration Sequence

Step 1: Induction Agent Selection and Dosing

Ketamine is the preferred first-line agent:

• Ketamine 1-2 mg/kg IV provides sympathomimetic properties that maintain hemodynamic stability 1
• In hemodynamically compromised patients, consider using the lower end of the dosing range (1 mg/kg) 1

Etomidate is an alternative in hemodynamically unstable patients:

• Etomidate 0.3 mg/kg IV has a favorable hemodynamic profile 1
• Do not exceed 0.3 mg/kg in patients >55 years due to increased risk of oxygen desaturation requiring bag-valve-mask ventilation 1
• Corticosteroid administration following etomidate is not recommended as multiple RCTs showed no mortality benefit 1

Step 2: Neuromuscular Blocking Agent Administration

Rocuronium is increasingly preferred:

• Rocuronium 1.0-1.2 mg/kg IV provides similar intubating conditions to succinylcholine 3, 1
• Administer rocuronium as early as practical after induction to minimize apnea time 1
• Have sugammadex available for reversal when using high-dose rocuronium (≥0.9 mg/kg) 1
• Critical awareness risk: Rocuronium's 30-60 minute duration outlasts ketamine's dissociative effects, creating a window where patients may be paralyzed but inadequately sedated 1

Succinylcholine is an alternative when no contraindications exist:

• Succinylcholine 1-1.5 mg/kg IV produces paralysis within 30-45 seconds, lasting 5-10 minutes 1
• Contraindications include malignant hyperthermia history, severe burns/crush injury, spinal cord injury, and hyperkalemia risk 1
• Succinylcholine has numerous side effects including life-threatening hyperkalemia and its short duration can hamper intubation if difficulty prolongs the attempt 3

Laryngoscopy and Intubation Technique

Optimal Conditions for First Attempt

• Ensure adequate neuromuscular relaxation—wait at least 60 seconds after rocuronium administration before attempting intubation 1
• Position head and neck in "sniffing" position (head extension and neck flexion) 3
• Apply optimal external laryngeal manipulation (OELM) or BURP (backward, upward, rightward pressure on thyroid cartilage) with the operator's right hand 3

Laryngoscopy Attempt Limits and Modifications

• A blade entering the oral cavity constitutes one attempt at laryngoscopy 3
• Limit to maximum 3 attempts—repeated attempts are associated with trauma, airway deterioration, and progression to "can't intubate, can't ventilate" (CICV) situations 3
• After the first failed attempt, declare "get FONA set" and summon senior help 3

Between attempts, modify technique:

• Use a different device or blade 3
• Try a different operator 3
• Apply suction 3
• Reduce or release cricoid force if applied, as it can compromise laryngoscopy and facemask ventilation 3
• Use a bougie or stylet when the laryngeal opening is poorly seen (Cormack-Lehane Grade 2b or 3a views) 3
• Avoid blind efforts to pass a tracheal tube in Grade 3b and 4 views as they are potentially traumatic 3

Cricoid Pressure Considerations

• Cricoid pressure should be reduced or removed if there is difficulty with laryngoscopy, passage of the tracheal tube, facemask ventilation, or active vomiting 3
• Successful supraglottic airway (SGA) insertion requires removal of cricoid force 3

Confirmation of Intubation

Mandatory Confirmation Method

• Waveform capnography is mandatory to confirm intubation 3
• Absence of a recognizable waveform trace indicates failed intubation unless proven otherwise 3

Failed Intubation Algorithm

After 3 Failed Attempts: Declare "This is a Failed Intubation"

Plan B/C: Maintain Oxygenation

• Attempt supraglottic airway (second-generation LMA) for temporary oxygenation 3, 2
• Revert to face mask ventilation if SGA fails 3
• Consider awakening the patient if oxygenation can be maintained and surgery is not immediately life-threatening 3

Plan D: "Can't Intubate, Can't Ventilate" (CICV) Situation

• Proceed immediately to emergency front-of-neck access (cricothyroidotomy) 3

Post-Intubation Management

Critical Sedation Protocol

• Implement protocolized post-intubation analgosedation immediately after RSI with rocuronium to prevent awareness during the prolonged paralysis period 1
• Assign a dedicated team member (preferably a clinical pharmacist) to manage timing of post-intubation analgosedation 1
• Use standardized order sets that automatically trigger sedation protocols after rocuronium administration 1
• The initial ketamine dose of 1-2 mg/kg does not provide adequate sedation throughout the entire duration of rocuronium-induced paralysis 1

Common Pitfalls to Avoid

• Do not perform more than 3 intubation attempts without declaring failed intubation and moving to rescue plans 3
• Do not use etomidate doses >0.3 mg/kg in patients >55 years due to high risk of oxygen desaturation 1
• Do not forget post-intubation sedation when using rocuronium—the incidence of explicit recall is approximately 2.6% in emergency intubations, substantially reduced with protocolized analgosedation 1
• Do not delay FONA in a true CICV situation—have the equipment immediately available after the first failed attempt 3
• Do not apply cricoid pressure rigidly—be prepared to reduce or release it if it impairs laryngoscopy or ventilation 3