Rapid Sequence Intubation

Rapid sequence intubation (RSI) is the (emergency) non-elective endotracheal intubation of a patient using an induction agent, neuromuscular blocking agent, and (if indicated) pre-induction medications using an algorithm. It is a critical skill for any physician who has the responsibility for caring for unstable or potentially unstable patients. It is a skill that builds on those learned in Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, and Advanced Trauma Life Support.

The skill of rapid sequence intubation can be learned and practiced in a course like The Difficult Airway Course. (1) It can also be learned through textbooks like The Manual of Emergency Airway Management. (2)

The best introductory article for RSI is the 2005 article in Chest written to introduce intensivists to the procedure. (3)

The steps in RSI include: Evaluation of the likely difficulty of ventilation; evaluation of the likely difficulty of endotracheal intubation; give (perhaps) pre-induction drug (e.g. lidocaine, fentanyl, esmolol, and others), give induction drug (etomidate, ketamine, or propofol), give neuromuscular blocking agent (succinylcholine or rocuronium), perform endotracheal intubation, perform post entubation management (confirm tube placement, ventilate, and consider additional sedation and/or paralysis as indicated).

If the patient is unconscious and apneic, he or she does not need RSI and you will ventilate patient with bag mask (two person technique is best) while you make preparation for intubation.

For the patient who is spontaneously breathing but requires intubation, if evaluation suggests that the patient may be difficult to ventilate with a bag-mask or that the patient may be difficult to intubate, then you should consider an awake intubation. (4 and 5)

The 2005 Chest article has an outstanding Table 5 example of an RSI and is worth reviewing. (6)

The three e-medicine articles on RSI are a brief and fast reads. (7, 8, and 9) They cover the same ground as the Chest article but are worth reading for additional slants.

(1) The Difficult Airway Course available at https://www.theairwaysite.com/pages/page_content/Airway_home.aspx

(2) The Manual of Emergency Airway Management. 4th ed, 2012, Walls and Murphy.

(3) Airway Management of the Critically Ill Patient: Rapid Sequence Intubation. Chest, 2005. Available at https://chestjournal.chestpubs.org/content/127/4/1397.full.pdf

(4) How to Do An Awake Intubation—Two Outstanding Videos available at https://www.tomwademd.net/2012/03/23/an-outstanding-video-on-how-to-do-an-awake-intubation/

(5) More Details On Awake Intubation available at https://www.tomwademd.net/2012/03/26/more-details-on-awake-intubation/

(6) Airway Management of the Critically Ill Patient: Rapid Sequence Intubation. Chest, 2005. Table 5, Schematized Example of an RSI, p. 1408 Available at https://chestjournal.chestpubs.org/content/127/4/1397.full.pdf

(7) Rapid Sequence Intubation from emedicine-medscape available athttps://emedicine.medscape.com/article/80222-overview.

(8) Medications Used In Tracheal Intubation from emedicine-medscape available at  https://emedicine.medscape.com/article/109739-overview#showall.

(9) Video Laryngoscopy and Fiberoptic Assisted Tracheal Intubation from emedicine-medscape available at https://emedicine.medscape.com/article/110880-overview#showall.

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