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
 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:
• Intubate Awake or Asleep
• Oral or Nasal
• Laryngoscopy or Blind Intubation
• To Paralyze or Not

Emergency RSI
 Oral Intubation Without Drugs

• Reserved for the completely

unconscious, unresponsive, pulseless
and apneic
• Arrest situations only
• The “ CRASH AIRWAY”

Emergency RSI
 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

Emergency RSI
complications compared with RSI
 Oral Intubation with Sedation
• “ Ingeneral, 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
Emergency RSI
 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.”

 RM Walls, page 8, Chapter 1, Rosen

Emergency RSI
 Oral Intubation with Sedation:Use for
the Anticipated Difficult Airway

• if time permits
–topical anesthesia
–careful titrated sedation
–avoid obtundation
• ‘Awake” intubation technique

Emergency RSI
 Blind Nasal Intubation
• 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”
Emergency RSI
 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
• “full” stomach
• minimal respiratory reserve
• hemodynamic instability
• acute myocardial ischemia
• increased intracranial pressure
• C-spine injury
• The “Difficult” Airway
 Laryngoscopy
 bag-mask difficulty
Emergency RSI
 Advantages of RSI
 facilitates and expedites endotracheal
intubation
 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
• 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
 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)
 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  100% O2, iv access, monitor, oximetry
0:00  assemble equipment, meds and team
2:00  thiopental 3mg/kg iv
2:15  succinylcholine 1.5mg/kg iv
 cricoid pressure with LOC; no bagging
3:00  laryngoscopy after fasciculations
3:20  tube position confirmed and secured
 positive pressure ventilation begins
5:00  To CT/lavage/OR/etc.
 O2 sat 100% throughout

Emergency RSI
 Drugs used for RSI: Overview
 Essential:
 Paralytic
 Sedative/ Induction agent

 Optional:
 Defasciculant
 Modulators of
hemodynamics/ICP/etc.
Emergency RSI
 Emergency RSI: Selecting the Patient
Is RSI contraindicated?
 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

Emergency RSI
 Emergency RSI: Selecting the Paralytic

 Is succinylcholine contraindicated?
NO: choose succinylcholine
YES: choose rocuronium (or vecuronium)

 If using SUX, is atropine needed?

atropine 0.02mg/kg (.15mg-.5mg) 2min before

 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

• Hyperkalemia - renal failure

• Active neuromuscular disease with
functional denervation
• ( 6 days to 6 months)
• Extensive burns, crush injuries
• Malignant hyperthermia
• Pseudocholinesterase deficiency
• Organophosphate poisoning
Emergency RSI
 Succinylcholine : Complications
• 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

Emergency RSI
 Vecuronium ( Norcuron )
• 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 )

• 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
Propofol

(nothing)
? Etomidate

Emergency RSI
 Thiopental ( Pentothal )
 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 )
 dose : 0.1 - 0.4 mg/kg
 action : 2 min to 120 minutes
 advantages:
 wide therapeutic index
 amnesia
 disadvantages
 variable dose response
 slower onset
 suboptimal effect at lower doses
 negative inotrope, vasodilation
Emergency RSI
 Ketamine ( Ketalar )
 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 )
 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 )
 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:

 Hemodynamics: fentanyl, ketamine,

etomidate
 Neuroprotection: thiopental, propofol
(midazolam)
 Bronchodilation: ketamine
 Speed: thiopental, propofol (ketamine)

Emergency RSI
 Emergency RSI: Selecting the Sedative
Identify any Secondary Concerns:

 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 “
• 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
 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
 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
 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  administer optional drugs
3:00  administer sedative
3:15  administer paralytic
 cricoid pressure with loss of ciliary reflex
4:00  BMV if hypercapnia deleterious/sat <90%
 laryngoscopy once fully relaxed
4:30  BURP to visualize larynx
 Confirm ETT placement and secure
5:00-  Ventilator settings
15:00
 Treat fluctuations in VS as indicated
Emergency RSI  CXR
 Rapid Sequence Intubation :
Procedure
• Pre-intubation assessment
• Pre-oxygenate
• Prepare
• Premedicate
• Paralyze with Induction
• Pressure on cricoid
• Place the tube
• Post intubation assessment
Emergency RSI
 Pre-oxygenate
( Time - 5 Minutes)
• 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

Emergency RSI
 Preparation
( Time - 5 Minutes )
• 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 )
• Lidocaine 1.5 mg/kg iv
• Defasciculating dose of non-
depolarizing 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)

Emergency RSI
 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 )
• 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

Emergency RSI
 Pressure
• Sellick maneuver
• initiate upon loss of
consciousness
• continue until ETT balloon
inflation
• release if active vomiting

Emergency RSI
 Place the Tube
( Time Zero + 45 Secs )
• Wait for optimal paralysis

• Confirm tube placement with

ETCO2

Emergency RSI
 Post-intubation Hypotension
• 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