Emergency Rapid Sequence
Intubation:
A “How and When To”
Guide
Pat Melanson, MD, FRCPC
Department of Emergency Medicine
Division of Critical Care Medicine
Royal Victoria Hospital
Emergency RSI
Rapid Sequence Intubation :
Definition
•
The near simultaneous administration
of a sedative-hypnotic agent and a
neuromuscular blocker in the presence
of continuous cricoid pressure to
facilitate endotracheal intubation and
minimize risk of aspiration
•
modifications are made depending
upon the clinical scenario
Emergency RSI
A Brief History of Emergency RSI
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intubation of the newly/nearly dead
(prehistoric)
techniques adapted from anesthetists in Case
Room and “crash” full-stomach induction's
(exploration)
rapid dissemination of RSI teaching to
emergency physicians (proselytism)
evidence-based research supporting safety and
advantages of emergency RSI (enlightenment)
increasingly sophisticated techniques and
methodology critically evaluated (postmodern)
Emergency RSI
Intubation Dilemmas:
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Intubate Awake or Asleep
Oral or Nasal
Laryngoscopy or Blind Intubation
To Paralyze or Not
Emergency RSI
Oral Intubation Without Drugs
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•
Emergency RSI
Reserved for the completely
unconscious, unresponsive, pulseless
and apneic
Arrest situations only
The “ CRASH AIRWAY”
Oral Intubation with Sedation
proponents argue use of BZ or opioids
–improves airway access
–decreases patient resistance
–avoids risks of NMB
• Generally obtunds patient to point of
loss of protective reflexes and
respiratory drive
• lower success rate, higher
complications compared with RSI
Emergency RSI
•
Oral Intubation with Sedation
•
Emergency RSI
“ In
general, the technique of
administering a potent sedative agent
to obtund the patient’s responses and
permit intubation in the absence of
NMB is hazardous and to be
discouraged… is not an appropriate
alternative to properly conducted RSI
and affords neither the success rate or
the minimal complication rate of RSI.”
– RM Walls, page 4, Chapter 1, Rosen
Oral Intubation with Sedation

“ The avoidance of NMB actually creates
a more hazardous situation for the
patient and this practice should no longer
be considered an appropriate method for
emergency department ET intubation.”

Emergency RSI
RM Walls, page 8, Chapter 1, Rosen
Oral Intubation with Sedation:Use for
the Anticipated Difficult Airway
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Emergency RSI
if time permits
–topical anesthesia
–careful titrated sedation
–avoid obtundation
‘Awake” intubation technique
Blind Nasal Intubation
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Emergency RSI
success rates 65 - 80 % in most series
high complication rates
–epistaxis
–pharyngeal/ esophageal perforations
–increased incidence of O2 desats
Considered second line approach only
reserved for when RSI contraindicated
The “ DIFFICULT AIRWAY”
Approach to Airway Management:
Algorithms
Is
intubation indicated ?
Is this a Crash Airway situation ?
Is this a potentially Difficult Airway?
Difficult laryngoscopy ?
Difficult Bag -Mask Ventilation?
 Is RSI appropriate ?
 Is this a Failed Airway?
Emergency RSI
Emergency Airway Concerns
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“full” stomach
minimal respiratory reserve
hemodynamic instability
acute myocardial ischemia
increased intracranial pressure
C-spine injury
The “Difficult” Airway
 Laryngoscopy
 bag-mask
Emergency RSI
difficulty
Advantages of RSI
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facilitates and expedites endotracheal
intubation
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increased success rate
decreased time to intubation
minimizes trauma during laryngoscopy
minimizes hypoxia and hypercapnia
minimizes risk of aspiration
minimizes hemodynamic effects of
intubation
Emergency RSI
Disadvantages of RSI
operator assumes complete
responsibility for oxygenation,
ventilation and airway patency
 irreversible commitment

 (burnt
bridges)
adverse effects of medications
 ?? increases surgical airway rate

 no evidence
Emergency RSI
Rapid Sequence Intubation:
Principles
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Emergency intubation is indicated
The patient has a “full” stomach
Intubation is predicted to be successful
If intubation fails, ventilation is
predicted to be successful
Consists of a series of planned discrete
steps
Emergency RSI
Principles of RSI
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Competing demands:
 Minimizing risk of aspiration vs. risk of hypoxia
Preoxygenation:
 ideally avoid BMV-PPV to minimize aspiration
 adequate N2 washout (5 min 100% O2 ) gives
oxygen reservoir providing several minutes of
O2 supply despite apnea
 4 assisted PPV breaths prior to paralysis
 pulse oximetry essential
 ANTICIPATE the O2 trend!
Emergency RSI
Principles of RSI (cont)
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Minimizing gastric distention
 avoidance of BMV-PPV
 cricoid pressure
–caudal to thyroid cartilage
–complete ring esophageal occlusion
–release if vomiting occurs
–maintain until ETT position confirmed
 minimize peak pressures if BMV-PPV
 immediate ID of esophageal
intubation
Emergency RSI
Typical Emergency RSI: Time Course
time
0:00
2:00
2:15
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3:00
3:20
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5:00
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Emergency RSI
100% O2, iv access, monitor, oximetry
assemble equipment, meds and team
thiopental 3mg/kg iv
succinylcholine 1.5mg/kg iv
cricoid pressure with LOC; no bagging
laryngoscopy after fasciculations
tube position confirmed and secured
positive pressure ventilation begins
To CT/lavage/OR/etc.
O2 sat 100% throughout
Drugs used for RSI: Overview
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Essential:
 Paralytic
 Sedative/ Induction agent
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Optional:
 Defasciculant
 Modulators of
hemodynamics/ICP/etc.
Emergency RSI
Emergency RSI: Selecting the Patient
Is RSI contraindicated?
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Absolute:
 Cardiopulmonary arrest
present/imminent
 Operator inexperience
Relative:
 Anticipated technical difficulties with
laryngoscopy and/or intubation
 Anticipated difficulty with BVM
Emergency RSI
Emergency RSI: Selecting the Paralytic
Neuromuscular blocking agents
Depolarizing:
 Succinylcholine
 Non-depolarizing:
 Vecuronium
 Rocuronium
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Emergency RSI
Emergency RSI: Selecting the Paralytic
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Is succinylcholine contraindicated?
NO: choose succinylcholine
YES: choose rocuronium (or vecuronium)
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If using SUX, is atropine needed?
atropine 0.02mg/kg (.15mg-.5mg) 2min before
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If using SUX, is a defasciculant desired?
10% dose of non-depolarizing agent 2 min prior
Emergency RSI
Succinylcholine ( Anectine)
dose: 1.5 mg/kg
 onset : 45 - 60 seconds
 duration : 6 to 10 min (3 to 15)
 disadvantages :

 ACh
analog - bradycardia
 fasciculations
 hyperkalemia ( K+ release)
 malignant hyperthermia
Emergency RSI
Succinylcholine
: Contraindications
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Emergency RSI
Hyperkalemia - renal failure
Active neuromuscular disease with
functional denervation
• ( 6 days to 6 months)
Extensive burns, crush injuries
Malignant hyperthermia
Pseudocholinesterase deficiency
Organophosphate poisoning
Succinylcholine : Complications
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Emergency RSI
Inability to secure airway
Increased vagal tone ( second dose )
Histamine release ( rare )
Increased ICP/ IOP/ gastric pressure
Myalgias
Hyperkalemia with burns, NM disease
Malignant hyperthermia
Vecuronium ( Norcuron )
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dose : 0.1 - 0.2 mg/kg
action : 120 secs to 60 minutes
“prime” with 1/10 dose 2 min prior
• onset in 90 secs
advantages :
• non-depolarizing
• neutral hemodynamics
• hepatic clearance
Emergency RSI
Rocuronium ( Zemuron )
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dose : 0.6 - 1.2 mg/kg
onset : 60 -90 secs
advantages :
• almost as rapid as SUX
disadvantages
• less rapid in elderly
• long duration
Emergency RSI
Emergency RSI: Selecting the Sedative
?
?
Thiopental
Ketamine
?
Midazolam
(nothing)
Emergency RSI
?
Propofol
Etomidate
Thiopental ( Pentothal )
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dose : 1- 5 mg/kg
action : 20 sec to 5 minutes
advantages
 ultrafast, short duration
 neuroprotective, anticonvulsant
 familiar
disadvantages
 hypotension ( myocardial depression, vd)
 ultrashort duration ( 3 - 5 minutes )
 demyelination in porphyria
 chemical endarteritis, thrombosis
Emergency RSI
Midazolam ( Versed )
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dose : 0.1 - 0.4 mg/kg
action : 2 min to 120 minutes
advantages:
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wide therapeutic index
amnesia
disadvantages
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Emergency RSI
variable dose response
slower onset
suboptimal effect at lower doses
negative inotrope, vasodilation
Ketamine ( Ketalar )
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dose : 1 - 2 mg/kg
action : 30 secs to 15 minutes
advantages :
 bronchodilation
 supports BP
disadvantages :
 increases ICP and IOP
 salivation
 emergence reactions
Emergency RSI
Propofol ( Diprivan )
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dose : 0.5 - 2.5 mg/kg (20-40mg q10 s)
action : 20 sec to 5 minutes
advantages :
 ultrarapid
 neuroprotective
disadvantages
 hypotension, bradycardia
 ultrashort duration
Emergency RSI
Etomidate ( Amidate )
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dose ; 0.3 mg/kg
action : 1 minute to 10 minutes
advantages :
 hemodynamically neutral
 neuroprotective
disadvantages :
 unfamiliar
 vomiting
 cortisol suppression
Emergency RSI
Emergency RSI: Selecting the Sedative
Identify Primary Concern:
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Hemodynamics: fentanyl, ketamine,
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Neuroprotection: thiopental, propofol
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etomidate
(midazolam)
Bronchodilation: ketamine
Speed: thiopental, propofol (ketamine)
Emergency RSI
Emergency RSI: Selecting the Sedative
Identify any Secondary Concerns:
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Hemodynamics: beware thiopental, propofol
(midazolam)
Neuroprotection: avoid ketamine (??)
Speed: beware midazolam
Patient given naloxone: avoid fentanyl
Specific contraindications (e.g. porphyria):
avoid drug
Emergency RSI
The “Intubation Reflex “
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Catecholamine release in response to
laryngeal manipulation
Tachycardia, hypertension, raised ICP
Attenuated by beta-blockers, fentanyl
ICP rise possibly attenuated by lidocaine
Midazolam and thiopental have no effect
Emergency RSI
Emergency RSI: Selecting optional
medications
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Increased ICP: Lidocaine
Bronchospasm : Lidocaine
Tachycardia harmful: fentanyl
(esmolol) 3 min before
atropine if child receiving Sux
defasciculant
“priming” dose of neuromuscular
blocking agent
topical/regional anesthetics
Emergency RSI
Emergency RSI Checklist: Flight planning
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Move patient to resuscitation suite
Assemble personnel
100% O2
Patient too unstable for RSI => intubate ASAP
Inadequate ventilation/sat <90% => BMV
Select drugs and doses, delegate “Drug Nurse”
Cardiac monitor, BP cuff, O2 sat continuously
IV running in limb contralateral to BP cuff
Cleared to taxi
Emergency RSI
Emergency RSI Checklist: Taxiing
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C-Spine?OK: pillow/folded sheet under head
?: designate assistant in-line stabilization
Check ETT and lubricate (+/- stylet)
Check laryngoscope (and other airway device prn)
Yankauer suction on and under mattress (to right)
Final neuro assessment (AVPU, posturing, pupils)
Baseline HR, BP, O2 sat
Review drugs, doses and sequence with Drug Nurse
Cleared for take-off
Emergency RSI
Emergency RSI Checklist: Take-off
time (mm:ss)
0:00
3:00
3:15
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4:00
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4:30
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5:0015:00
Emergency RSI
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administer optional drugs
administer sedative
administer paralytic
cricoid pressure with loss of ciliary reflex
BMV if hypercapnia deleterious/sat <90%
laryngoscopy once fully relaxed
BURP to visualize larynx
Confirm ETT placement and secure
Ventilator settings
Treat fluctuations in VS as indicated
CXR
Rapid Sequence Intubation :
Procedure
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Emergency RSI
Pre-intubation assessment
Pre-oxygenate
Prepare
Premedicate
Paralyze with Induction
Pressure on cricoid
Place the tube
Post intubation assessment
Pre-oxygenate
( Time - 5 Minutes)
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Emergency RSI
100 % oxygen for 5 minutes
4 conscious deep breaths of 100 % O2
Fill FRC with reservoir of 100 % O2
Allows 3 to 5 minutes of apnea
Essential to allow avoidance of bagging
If necessary bag with cricoid pressure
Preparation
( Time - 5 Minutes )
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ETT, stylet, blades, suction, BVM
Cardiac monitor, pulse oximeter, ETCO2
One ( preferably two ) iv lines
Drugs
Difficult airway kit including cric kit
Patient positioning
Emergency RSI
Pre-treatment/ Prime
( Time - 2 Minutes )
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Emergency RSI
Lidocaine 1.5 mg/kg iv
Defasciculating dose of nondepolarizing NMB
Fentanyl 3- 5 mcg/kg
Atropine 0.02 mg/kg
( The above agents are optional and given if there is a
specific indication and time permits)
Induction agent
–Thiopental 3 - 5 mg/kg
–Midazolam 0.1 - 0.4mg/kg
–Ketamine 1.5 - 2.0 mg/kg
–Propafol 0.5 - 2.0 mg/kg
–Etomidate 0.2 - 0.3 mg/kg
Emergency RSI
Paralyze ( Time Zero )
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Emergency RSI
Succinylcholine 1.5 mg/kg iv
Allow 45 - 60 seconds for complete
muscle relaxation
Alternatives
–Vecuromium 0.1 - 0.2 mg/kg
–Rocuronium 0.6 - 1.2 mg/kg
Pressure
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Emergency RSI
Sellick maneuver
initiate upon loss of
consciousness
continue until ETT balloon
inflation
release if active vomiting
Place the Tube
( Time Zero + 45 Secs )
•
Wait for optimal paralysis
•
Confirm tube placement with
ETCO2
Emergency RSI
Post-intubation Hypotension
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Loss of sympathetic drive
Myocardial infarction
Tension pneumothorax
Auto-peep
Emergency RSI
Difficult Airway Kit
Multiple blades and ETTs
• ETT guides ( stylets, bougé, light
wand)
• Emergency nonsurgical ventilation
( LMA, Combitube, TTJV )
• Emergency surgical airway access
( cricothyroidotomy kit, cricotomes )
• ETT placement verification
• Fiberoptic and retrograde intubation
Emergency RSI
•
Amitriptyline tripper
27 year old overdose benzos +
TCAs 1 hour PTA.
Decreasing LOC (?ciliary reflex).
HR 140 wide-complex regular,
BP 90/50, RR 24,
O2 sat 99% on O2.
Emergency RSI
Walking at the scene
22 yr old multiple abdominal stab wounds
6” knife.
Evisceration, agitation and uncooperative.
HR 140, BP 90/50, RR 22,
O2 sat 99% on O2.
Emergency RSI
Status asthmaticus severus
50 yr old asthmatic x years, never
admitted O/N. SOB x 2d despite
prednisone, antibiotics, and
salbutamol q1h. Despite
continuous salbutamol, epi s/c x 2,
and SoluMedrol iv, begins to
fatigue.
pH 7.22, pCO2 70, pO2 140.
Emergency RSI
Collapse at bank
38 year old male, standing in line at
bank, complained of sudden severe
HA and collapsed.
On arrival, HR 55 BP 170/100 RR 12
decorticate posturing.
Emergency RSI
NOT renal colic
68 year old male, hypertensive, no past
history of urolithiasis, presents with R
flank pain and hematuria. While you
are booking the spiral CT, he complains
of increasing back pain, then vomits.
HR 140 BP 85/palp diaphoretic ++.
And then he gets worse.
Emergency RSI
Overdue for dialysis
68 yr old hemodialysis-dependent pt
in florid pulmonary edema and
decreasing LOC.
HR 120 reg, BP 220/120,
O2 sat 85% on non-rebreather
15L/min.
Emergency RSI
Too much Nintendo
14 year old known epileptic on
multiple meds, still seizing after
diazepam, phenobarb and over 30
minutes in the ED.
160 100/50 37.2 99% sat.
Small jaw.
Emergency RSI
“I
would especially commend the
physician who, in acute diseases, by
which the bulk of mankind are cutoff,
conducts the treatment better than
others.”
Hippocrates
Emergency RSI