Rapid Sequence Intubation (RSI), Adult

Special Note

[high-risk procedure]

no 'gold standard' RSI protocol available; drugs, doses, and techniques vary widely; multiple patient factors may complicate RSI and should be used to guide drug and dose selection

1) Pre-event Preparation

[evaluate patient]

review patient history, assess for possible difficult airway; consider need for surgical airway; formulate backup plan for failed RSI

[prepare equipment]

oxygen, pulse oximeter, suction, bag valve mask (BVM), free-flowing IV, BP cuff, cardiac monitor, laryngoscope handles, laryngoscope blades, endotracheal tubes, stylets, cuff syringe, CO2 detector, end-tidal CO2 monitor, tape or tube holder, alternative airway devices, consider video laryngoscope

[assign personnel]

leader, intubator, airway equipment, medication administration, c-spine stabilization, cricoid pressure, monitoring and documentation

[prepare medications]

opioid, IV fluid, bolus pressor, induction agent, paralytic, post-intubation sedation and analgesia

2) Preoxygenation/Positioning

[100% oxygen 10-15 L/min]

maintain manual c-spine stabilization if patient in cervical collar, otherwise head and neck in sniffing position; if obese patient, head and neck in ramped position; use tight-fitting face mask (BVM or anesthesia circuit), ventilate gently if minute ventilation decreased or SpO2 <95%; consider applying cricoid pressure if unconscious; optimize cardiovascular system

3) Premedication/Pretreatment

[consider ultrashort-acting opioid]

fentanyl 1-3 mcg/kg/dose IV x1

[consider IV fluid and bolus dose pressor]

Info: for patients with shock or hypotension signs/symptoms during intubation

phenylephrine 50-100 mcg IV x1; Max: 200 mcg/total dose

epinephrine 5-20 mcg IV x1

4) Induction then Paralysis

[wait 3min after premedications]

[STEP 1: INDUCTION with one of the following:]

etomidate 0.3 mg/kg/dose IV x1

ketamine 1-2 mg/kg/dose IV x1

midazolam 0.1-0.3 mg/kg/dose IV x1

propofol 1-3 mg/kg/dose IV x1

[STEP 2: PARALYZE with one of the following:]

succinylcholine 1-2 mg/kg/dose IV x1

rocuronium 1-1.2 mg/kg/dose IV x1

5) Protection

[consider applying cricoid pressure]

apply just after induction and paralytic agents injected, maintain until placement confirmed; release earlier if difficulty with laryngoscopy or tracheal tube passage

[wait 60sec after paralytic agent]

assess adequacy of paralysis by mandibular mobility

6) Placement/Confirmation

[perform laryngoscopy, intubate]

monitor BP, HR, ECG, pulse oximetry, continuous waveform capnography, appearance of patient; if bradycardia develops or SpO2 <90% interrupt attempt and gently ventilate with 100% oxygen via BVM; inflate cuff when tube in place

[primary placement confirmation]

direct visualization of tube passing through vocal cords; chest rise and fall bilaterally with each ventilation; 5 point chest auscultation

[secondary placement confirmation]

use continuous waveform capnography or end-tidal CO2 detector; monitor SpO2 and end-tidal CO2 levels after intubation

7) Postintubation Management

[oxygenate, ventilate]

secure tube with commercial holder (preferred) or tape; continue c-spine immobilization if c-spine not cleared; obtain x-ray confirmation of tube depth

[consider ongoing sedation, analgesia, paralysis]

consider additional sedation and analgesia if short-acting induction agents used; consider longer duration paralytic if succinylcholine used