What is the step‑by‑step procedure for rapid sequence intubation in an adult patient who requires immediate airway control and cannot be safely ventilated with bag‑mask techniques?

Rapid Sequence Intubation: Step-by-Step Procedure

Rapid sequence intubation involves the near-simultaneous administration of a sedative-hypnotic agent and a neuromuscular-blocking agent followed by immediate endotracheal tube placement without assisted ventilation between drug administration and intubation. 1

Pre-Intubation Preparation

Assessment and Planning

• Conduct airway assessment to identify potential difficulties including mouth opening, thyromental distance, neck mobility, and Mallampati score 2
• Declare anticipated difficulty and brief the entire team on the primary plan and backup strategies (Plans A through D) before induction 2, 3
• Position the patient optimally with head elevation (ramping in obese patients) and ear-to-sternal-notch alignment to improve laryngoscopic view 2

Preoxygenation

• Deliver 100% oxygen for 3-5 minutes via tight-fitting facemask or use 8 vital capacity breaths over 60 seconds if time-critical 2
• Consider apneic oxygenation techniques (nasal cannula at 15 L/min) in high-risk patients to extend safe apnea time 4
• Maximize oxygen delivery continuously throughout the procedure to prevent critical hypoxemia 2

The Seven Steps of RSI

Step 1: Preparation

• Ensure all equipment is immediately available: functioning laryngoscope (video laryngoscope preferred), endotracheal tubes (multiple sizes), suction, bag-valve-mask, rescue airway devices, and cricothyroidotomy kit 2, 3
• Draw up and label all medications before starting 1
• Assign team roles explicitly (airway operator, medication administrator, cricoid pressure if used, documentation) 2

Step 2: Preoxygenation (as detailed above)

Step 3: Pretreatment

• Administer pretreatment medications if indicated (though evidence is limited for routine use) 1
• This step is increasingly de-emphasized in modern practice 1

Step 4: Paralysis with Induction

• Administer sedative-hypnotic agent first (etomidate, ketamine, propofol, or midazolam depending on hemodynamic status) 1
• Immediately follow with neuromuscular-blocking agent (succinylcholine 1-1.5 mg/kg or rocuronium 1.2 mg/kg) 1
• The combination of both agents defines RSI and optimizes intubating conditions while reducing aspiration risk 1, 5

Step 5: Protection and Positioning

• Avoid positive pressure ventilation between drug administration and intubation in traditional RSI to minimize aspiration risk 1
• However, if oxygen saturation falls critically, provide gentle bag-mask ventilation with careful pressure control, as preventing hypoxemia takes priority over theoretical aspiration risk 4
• Cricoid pressure (Sellick maneuver) is no longer routinely recommended due to lack of evidence and potential interference with intubation 1

Step 6: Placement with Proof

• Use video laryngoscopy as first-line approach when available, as it improves first-pass success rates compared to direct laryngoscopy 2, 3
• Limit intubation attempts: if first attempt fails with optimal positioning and equipment, declare difficulty and progress through the algorithm 2, 3
• Confirm tube placement immediately with waveform capnography (mandatory, not optional) 2
• Limit total airway interventions to prevent trauma and edema that complicate rescue attempts 3

Step 7: Post-Intubation Management

• Secure the tube and reconfirm position with capnography and clinical assessment 2
• Initiate post-intubation sedation and analgesia immediately 1
• Obtain chest radiograph to verify tube depth 6

Failed Intubation Algorithm

Plan A Failure (Cannot Intubate)

• After one failed optimal attempt, call for help immediately 2, 3
• Optimize positioning, use video laryngoscopy if not already employed, consider bougie or stylet 2, 3
• Maximum 3-4 attempts total before declaring Plan A failure 3

Plan B (Supraglottic Airway Device)

• Insert second-generation supraglottic airway device (i-gel, LMA Supreme) to restore oxygenation 2, 3
• Confirm ventilation with capnography 2
• Reassess options: wake the patient (default), attempt fiberoptic intubation through device, or proceed to surgery if cannot delay 3

Plan C (Facemask Ventilation)

• If supraglottic device fails, attempt optimized facemask ventilation with two-person technique, oral/nasal airways, and consider early neuromuscular blockade if not already given 4

Plan D (Emergency Front-of-Neck Airway)

• If cannot intubate AND cannot oxygenate (SpO2 falling despite Plans A-C), proceed immediately to cricothyroidotomy 2, 3
• Scalpel cricothyroidotomy is the recommended technique: horizontal incision through cricothyroid membrane, bougie insertion, railroaded tube placement 3
• Do not delay with ineffective interventions once this scenario is recognized 4

Critical Pitfalls to Avoid

• Multiple intubation attempts without changing approach: each attempt worsens conditions through trauma, edema, and hypoxemia 3
• Failure to recognize and declare difficulty early: delays appropriate escalation and team mobilization 2
• Inadequate preoxygenation: rushing through this step eliminates your safety margin 2
• Persisting with failed techniques: blind bougie passes and repeated direct laryngoscopy after failure are outdated and dangerous 3
• Delaying cricothyroidotomy in cannot intubate-cannot oxygenate scenarios: this is a time-critical emergency requiring immediate action 3