The following is an example of a Rapid Sequence Intubation from an article for intensivists in Chest. (1)
Time: Minus Ten Minutes (Prepare)
Predict difficult intubation: stop if not RSI candidate
Hypotensive patient:
1. Good vascular access
2. Vasopressors readily available
We use as needed Phenylephrine 10 mg in 100 mL NS (100 #g/mL)—and give 1 mL aliquots prn
Or Ephedrine, 5–10 mg boluses as needed
If patient is hypotensive, ensure good vascular access, and have available drugs.
Note: The Resident ICU Course from the Society of Critical Care Medicine notes that– “There is a potential for hypotension in Cardiac Dysfunction, Hypovolemia, and Sepsis.” And [you] “may need to consider awake intubation with topical (aersolized lidocaine) as sedation may precipitate hemodynamic compromise and even arrest.” (2)
Mnemonic “Y BAG PEOPLE” Indicates the Necessary Preparations and Equipment for Intubation (2)
Y = Yankauer suction
B = Bag-valve-mask
A = Access vein
G = Get your team together and get help if difficult airway is predicted
E = Assemble the correctly sized ET tubes and check that the cuffs work
O = Prepare and check oxygen equipment and have oropharyngeal airways available
P = Pharmacy: draw up adjunctive medications, induction agent, and neuromuscular blocker
L = Laryngoscopes and blades: ensure a variety and that they are working
E = Evaluate for difficult airway: look for obstruction, assess thyromental distance of less than three fingers breath, interincisor distance of less than two fingers breath, neck immobilization
Time: Minus Five Minutes (Preoxygenate)
Provide 100% with nonrebreather mask or BVM
No PPV unless patient’s Spo2 is less than 90%
If PPV required, then provide cricoid pressure (Sellick maneuver)
Time: Minus Two Minutes (Pretreat)
Suspected intracranial hypertension, myocardial ischemia, or hypertensive emergency: Fentanyl with or without lidocaine (more commonly we use fentanyl alone)
Asthma lidocaine
It is not our practice to use defasciculating doses of rocuronium or other nondepolarizing NMBAs
Time: Zero (Paralysis)
Induction:
1. Etomidate (default induction agent) or
2. Propofol or
3. Ketamine or
4. Scopalamine
Sellick maneuver with administration of induction agent
Neuromuscular blockade:
1. Succinylcholine
2. Rocuronium
Time: Plus 30 to 45 Seconds (Pass the Tube)
Intubate
Observe ETT pass between vocal cords
If problems with visualization remember to “BURP”: 1. Backwards, 2. Upward, and 3. Rightward, 4. Pressure on the thyroid cartilage
If patient Spo2 is less than 90% during attempt, stop and provide PPV and oxygenation until Spo2 is greater than 90%
Time: Plus 45 Seconds (Postintubation Management)
Confirm placement after inflation of cuff: 1. Auscultate abdomen, then hemithoraces for air entry;
2. Detect Etco2 color change or waveform; 3. Reassess oxygenation status; 4. Once ETT placement confirmed, cease Sellick maneuver; 5. Secure tube
Consider placement of OGt or NG
Post ETI, ABG analysis and CXR
As many of the drugs used in RSI have short half-life consider continued sedation with or without paralysis
Abbreviations
ABG = arterial blood gas; SCI = spinal cord injury; BVM = bag-valve-mask ventilation; CXR = chest radiograph; ETco2 = end-tidal CO2; ETI = endotracheal intubation; NG = nasogastric tube;
OG = orogastric tube; PPV = positive-pressure ventilation; SPo2 = pulse oximetry oxygen saturation; ETT = endotracheal tube.
(1) 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
(2) Airway Management in The Emergency Department and ICU. The Resident ICU Course from the Society of Crtical Care Medicine, 2008. Available at
https://www.slideshare.net/fergua/airway-management.
