Surgical Principles: Rapid Sequence Intubation (RSI)

Rapid Sequence Intubation (RSI)

Definition

  • Definition: A Technique to Induce Immediate Unresponsiveness & Muscular Relaxation to Facilitate Rapid Endotracheal Intubation
  • The Fastest & Most Effective Technique to Gain Control of an Emergency Airway
  • Mediation Administration is Rapid & Virtually Simultaneous with No Titration
  • Generally Done Outside of the Operating Room

Rapid Sequence Intubation (RSI) Process (“9 P’s”)

  • Plan
  • Prepare – Equipment, Medications, etc.
  • Protect the C-Spine
  • Preoxygenation (Before Drug Administration)
  • Pretreatment – Used to Prevent Complications of Airway Manipulation
    • Optional for Select Patients
  • Paralysis & Induction
    • Induction Given BEFORE Paralysis
  • Position & Cricoid Pressure
  • Placement & Proof
  • Postintubation Management

Endotracheal Intubation & Rescue Techniques

Pretreatment Medication in RSI

General Indications Mn

  • High Airway Pressures
  • High Intracranial Pressures (ICP)
  • Select Cardiovascular Conditions

Medications

  • Aerosolized Beta-2 Agonist (Albuterol)
    • If Presenting with Acute Bronchospasm
  • Lidocaine
    • Reduce Risk of Bronchospasm if Beta-2 Agonist Not Given
    • Dose: 1.5 mg/kg IV Given 3 Minutes Before Induction
      • *120 mg for an Average 80 kg Male
    • Onset of Action: 45-90 Seconds
    • Contraindication: High-Grade Heart Block – Can Cause Cardiac Arrest
  • Fentanyl
    • Reduce Cardiovascular Effects from Acute Sympathetic Stimulation if Rapid Blood Pressure Rise Would Be Dangerous (High ICP or Cardiovascular Disease)
    • Dose: 3 mcg/kg IV Given 3 Minutes Before Induction
      • *240 mcg for an Average 80 kg Male
  • Vasopressors (Alpha-Adrenergic Agents)
    • Given to Patients in Shock to Maintain Blood Pressures
    • Dose:
      • Epinephrine 5-20 mcg
      • Phenylephrine 50-200 mcg
  • Atropine
    • Used to Prevent Vagally-Induced Bradycardia in Infants (< 1 Year Old)
    • Dose: 0.02 mg/kg IV (Maximum 1 mg)
  • Small (Defasciculating) Dose of Neuromuscular Blocker
    • Given Prior to the Use of Succinylcholine to Reduce Rise in ICP from Succinylcholine-Induced Fasciculations
    • No Longer Recommended – No Evidence to Support

Approach

  • High Airway Pressures – Albuterol or Lidocaine
  • High ICP – Fentanyl
  • Cardiovascular Conditions:
    • Prevent Hypertension (ACS or Aortic Dissection) – Fentanyl
    • Prevent Hypotension (Shock) – Vasopressors

Induction & Paralytic Medication in RSI

Induction Agents

  • Etomidate
    • Benefits: Minimal Hypotension
    • Can Suppress Adrenal Cortisol Production – Use Caution in Sepsis
    • Dose: 0.3-0.4 mg/kg
      • *24-32 mg for an Average 80 kg Male
  • Ketamine
    • Benefits: Stimulates Catecholamine Release & Bronchodilation
    • Dose: 1-2 mg/kg
      • *80-160 mg for an Average 80 kg Male
    • OK to Use in TBI – No Increase in ICP as per Dogma
  • Midazolam
    • Benefits: Added Amnesic Effects
    • Dose: 0.2-0.3 mg/kg – Commonly Underdosed
      • *16-24 mg for an Average 80 kg Male
  • Propofol
    • Benefits: Bronchodilation
    • Dose: 1.5-3 mg/kg
      • *120-240 mg for an Average 80 kg Male

Paralytic Agents

  • Succinylcholine
    • Many Contraindications: Hyperkalemia, Burns (> 3-5 Days), Rhabdomyolysis, Malignant Hyperthermia, Neuromuscular Disease
    • Dose: 1.5 mg/kg IV
      • *120 mg for an Average 80 kg Male
    • Onset of Action: 45-60 Seconds
    • Duration of Action: 10 Minutes
  • Rocuronium
    • Contraindication: Need for Rapid Recovery (Neuro Assessment or Elective Procedures)
    • Dose: 1.0-1.2 mg/kg IV
      • *80-96 mg for an Average 80 kg Male
    • Onset of Action: 45-60 Seconds
    • Duration of Action: 45 Minutes
  • *Most Other Paralytic Drugs Have Onset of Action Too Long for RSI

Mnemonics

Indications for RSI Pretreatment

  • ABC
    • A: Asthma
    • B: Brain
    • C: Cardiovascular