Rapid Sequence Intubation (RSI) is a medical procedure used to secure the airway in patients who are at risk of aspiration or cannot maintain adequate oxygenation or ventilation. It is a highly controlled and time-sensitive technique that minimizes the risk of aspiration by combining rapid administration of a sedative (induction agent) and a neuromuscular blocking agent, allowing for prompt and safe endotracheal intubation.
Indications
Airway Protection
Inability to protect the airway: Due to altered mental status, coma, or neurologic conditions (e.g., stroke, traumatic brain injury).
Risk of aspiration: Present in patients with a full stomach (recent meal, gastrointestinal bleed, or bowel obstruction) or those vomiting.
Oxygenation or Ventilation Failure
Severe hypoxemia: Despite high-flow oxygen or non-invasive ventilation (e.g., ARDS, pneumonia).
Hypercapnia with respiratory acidosis: Typically seen in advanced COPD or other causes of respiratory failure.
Imminent respiratory arrest: Fatigue or failure of respiratory muscles in conditions like status asthmaticus or myasthenia gravis.
Anticipated Clinical Deterioration
Trauma patients with airway compromise: Facial trauma, neck hematoma, or burns causing swelling.
Anaphylaxis or angioedema: Involving airway structures, leading to potential obstruction.
Smoke inhalation injuries: That may cause airway edema.
Neurologic Indications
Increased intracranial pressure (ICP): To prevent secondary brain injury and facilitate hyperventilation if indicated.
Seizures: Refractory status epilepticus requiring airway protection and sedation.
Contraindications
Known Allergy to RSI Medications:
Allergy or hypersensitivity to any of the medications planned for induction or paralysis (e.g., succinylcholine, etomidate, or rocuronium).
Severe Anticipated Difficulty with Airway Management:
Patients with a high likelihood of failed intubation and where alternative airway strategies (e.g., awake intubation or surgical airway) may be safer.
Severe Cardiovascular Instability:
Hemodynamic instability or conditions where induction agents could worsen hypotension, making the risks outweigh the benefits without prior optimization.
Difficult Airway Anticipation:
Trauma, swelling, tumors, or anatomical abnormalities. Ensure airway adjuncts (e.g., video laryngoscopy, bougie, cricothyrotomy kits) and skilled personnel are available.
Increased Risk of Aspiration:
Severe gastrointestinal bleeding or active vomiting where preoxygenation and suctioning may need modification.
Outcomes
Equipment’s
Laryngoscope
Endotracheal Tubes (ETT)
Stylet
Supraglottic Airway Devices (SGA)
Bag-Valve-Mask (BVM)
Oxygen Source
Nasal Cannula
Patient Preparation
Medication Preparation
Premedication (optional, based on clinical situation):
Atropine: For bradycardia prevention in pediatrics.
Lidocaine: For suspected intracranial hypertension or reactive airway disease.
Fentanyl: For blunting hemodynamic response.
Induction Agent (choose based on patient condition):
Etomidate: Hemodynamically stable patients.
Ketamine: Hypotension or bronchospasm.
Propofol: Contraindicated in hypotension but preferred in stable patients.
Neuromuscular Blocker:
Succinylcholine: Rapid onset, short duration (contraindicated in hyperkalemia, crush injuries, or burns).
Rocuronium: Alternative with longer duration.
Patient position:
Place the patient in the sniffing position for adequate visualization; flex the neck and extend the head. This position helps to align the axes and facilitates visualization of the glottic opening.
Technique
Step 1-Preparation:
Equipment:
Airway tools: Laryngoscope (with appropriate blade), endotracheal tubes (ETT) of different sizes, stylet, bougie.
Oxygenation: Bag-valve mask (BVM), high-flow nasal cannula, and suction.
Monitoring: Pulse oximetry, ECG, capnography, and blood pressure monitoring.
IV access: Ensure functional and patent IV/IO lines.
Step 2-Pre-intubation assessment:
Evaluate airway using tools like LEMON (Look externally, Evaluate 3-3-2, Mallampati score, Obstruction/Obesity, Neck mobility).
Predict difficulty with bag-mask ventilation, laryngoscopy, and intubation.
Step 3-Preoxygenation:
To increase oxygen reserves and delay hypoxia during apnea.
Provide 100% oxygen using a non-rebreather mask, BVM, or high-flow nasal cannula for 3–5 minutes if possible.
In emergencies, perform 4–8 large tidal breaths with 100% oxygen.
Step 4-Pre-treatment (Optional):
Consider administering pre-treatment drugs for specific indications:
Lidocaine: To blunt intracranial pressure (ICP) rise in head injury.
Fentanyl: To mitigate sympathetic response in cases like hypertension.
Atropine: In pediatric patients to prevent bradycardia from vagal stimulation.
Step 5-Induction:
Administer the induction agent (e.g., etomidate for hemodynamic stability, ketamine for bronchodilation in asthma, or propofol for rapid onset but with caution in hypotension).
Onset: Agents typically work within 30–60 seconds.
Step 6-Paralysis with Sedation:
Administer a paralytic immediately after the induction agent:
Succinylcholine: Rapid onset (30–60 seconds) but contraindicated in hyperkalemia, burns, crush injuries, and neuromuscular diseases.
Rocuronium: Non-depolarizing alternative with a slightly slower onset (45–90 seconds).
Step 7-Positioning:
Align the airway axes (oral, pharyngeal, and laryngeal) using the “sniffing position”:
Extend the neck and elevate the head.
For obese patients, use a ramped position with the external auditory meatus aligned to the sternal notch.
Ensure the suction device is readily available and functional.
Step 8-Intubation:
Rapid sequence intubation
Perform direct or video laryngoscopy:
Visualize the glottis and vocal cords.
Pass the endotracheal tube (ETT) through the cords until the cuff is just beyond the cords.
Inflate the ETT cuff with air to achieve a seal.
Confirm placement using end-tidal COâ‚‚ (capnography), chest rise, and auscultation (bilateral breath sounds).
Rapid Sequence Intubation (RSI) is a medical procedure used to secure the airway in patients who are at risk of aspiration or cannot maintain adequate oxygenation or ventilation. It is a highly controlled and time-sensitive technique that minimizes the risk of aspiration by combining rapid administration of a sedative (induction agent) and a neuromuscular blocking agent, allowing for prompt and safe endotracheal intubation.
Airway Protection
Inability to protect the airway: Due to altered mental status, coma, or neurologic conditions (e.g., stroke, traumatic brain injury).
Risk of aspiration: Present in patients with a full stomach (recent meal, gastrointestinal bleed, or bowel obstruction) or those vomiting.
Oxygenation or Ventilation Failure
Severe hypoxemia: Despite high-flow oxygen or non-invasive ventilation (e.g., ARDS, pneumonia).
Hypercapnia with respiratory acidosis: Typically seen in advanced COPD or other causes of respiratory failure.
Imminent respiratory arrest: Fatigue or failure of respiratory muscles in conditions like status asthmaticus or myasthenia gravis.
Anticipated Clinical Deterioration
Trauma patients with airway compromise: Facial trauma, neck hematoma, or burns causing swelling.
Anaphylaxis or angioedema: Involving airway structures, leading to potential obstruction.
Smoke inhalation injuries: That may cause airway edema.
Neurologic Indications
Increased intracranial pressure (ICP): To prevent secondary brain injury and facilitate hyperventilation if indicated.
Seizures: Refractory status epilepticus requiring airway protection and sedation.
Known Allergy to RSI Medications:
Allergy or hypersensitivity to any of the medications planned for induction or paralysis (e.g., succinylcholine, etomidate, or rocuronium).
Severe Anticipated Difficulty with Airway Management:
Patients with a high likelihood of failed intubation and where alternative airway strategies (e.g., awake intubation or surgical airway) may be safer.
Severe Cardiovascular Instability:
Hemodynamic instability or conditions where induction agents could worsen hypotension, making the risks outweigh the benefits without prior optimization.
Difficult Airway Anticipation:
Trauma, swelling, tumors, or anatomical abnormalities. Ensure airway adjuncts (e.g., video laryngoscopy, bougie, cricothyrotomy kits) and skilled personnel are available.
Increased Risk of Aspiration:
Severe gastrointestinal bleeding or active vomiting where preoxygenation and suctioning may need modification.
Equipment’s
Laryngoscope
Endotracheal Tubes (ETT)
Stylet
Supraglottic Airway Devices (SGA)
Bag-Valve-Mask (BVM)
Oxygen Source
Nasal Cannula
Patient Preparation
Medication Preparation
Premedication (optional, based on clinical situation):
Atropine: For bradycardia prevention in pediatrics.
Lidocaine: For suspected intracranial hypertension or reactive airway disease.
Fentanyl: For blunting hemodynamic response.
Induction Agent (choose based on patient condition):
Etomidate: Hemodynamically stable patients.
Ketamine: Hypotension or bronchospasm.
Propofol: Contraindicated in hypotension but preferred in stable patients.
Neuromuscular Blocker:
Succinylcholine: Rapid onset, short duration (contraindicated in hyperkalemia, crush injuries, or burns).
Rocuronium: Alternative with longer duration.
Patient position:
Place the patient in the sniffing position for adequate visualization; flex the neck and extend the head. This position helps to align the axes and facilitates visualization of the glottic opening.
Step 1-Preparation:
Equipment:
Airway tools: Laryngoscope (with appropriate blade), endotracheal tubes (ETT) of different sizes, stylet, bougie.
Oxygenation: Bag-valve mask (BVM), high-flow nasal cannula, and suction.
Monitoring: Pulse oximetry, ECG, capnography, and blood pressure monitoring.
IV access: Ensure functional and patent IV/IO lines.
Step 2-Pre-intubation assessment:
Evaluate airway using tools like LEMON (Look externally, Evaluate 3-3-2, Mallampati score, Obstruction/Obesity, Neck mobility).
Predict difficulty with bag-mask ventilation, laryngoscopy, and intubation.
Step 3-Preoxygenation:
To increase oxygen reserves and delay hypoxia during apnea.
Provide 100% oxygen using a non-rebreather mask, BVM, or high-flow nasal cannula for 3–5 minutes if possible.
In emergencies, perform 4–8 large tidal breaths with 100% oxygen.
Step 4-Pre-treatment (Optional):
Consider administering pre-treatment drugs for specific indications:
Lidocaine: To blunt intracranial pressure (ICP) rise in head injury.
Fentanyl: To mitigate sympathetic response in cases like hypertension.
Atropine: In pediatric patients to prevent bradycardia from vagal stimulation.
Step 5-Induction:
Administer the induction agent (e.g., etomidate for hemodynamic stability, ketamine for bronchodilation in asthma, or propofol for rapid onset but with caution in hypotension).
Onset: Agents typically work within 30–60 seconds.
Step 6-Paralysis with Sedation:
Administer a paralytic immediately after the induction agent:
Succinylcholine: Rapid onset (30–60 seconds) but contraindicated in hyperkalemia, burns, crush injuries, and neuromuscular diseases.
Rocuronium: Non-depolarizing alternative with a slightly slower onset (45–90 seconds).
Step 7-Positioning:
Align the airway axes (oral, pharyngeal, and laryngeal) using the “sniffing position”:
Extend the neck and elevate the head.
For obese patients, use a ramped position with the external auditory meatus aligned to the sternal notch.
Ensure the suction device is readily available and functional.
Step 8-Intubation:
Rapid sequence intubation
Perform direct or video laryngoscopy:
Visualize the glottis and vocal cords.
Pass the endotracheal tube (ETT) through the cords until the cuff is just beyond the cords.
Inflate the ETT cuff with air to achieve a seal.
Confirm placement using end-tidal COâ‚‚ (capnography), chest rise, and auscultation (bilateral breath sounds).
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