Rapid sequence intubation (RSI) is the virtually simultaneous administration of a sedative and a neuromuscular blocking (paralytic) agent to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation and to minimize the risk of aspiration.

The Goals of RSI

1. Facilitate Intubation via sedation and paralysis
2. Prevent Aspiration (by minimizing positive pressure ventilation)
3. Reduce the psychological trauma of intubation
4. Decrease the adverse physiologic consequence of intubation

Who Gets RSI? (Hint, It’s Not For Everyone)

While RSI is the most common approach to patients requiring emergent intubation in the Emergency Department, that DOES NOT mean it is always the correct choice. Intubation and RSI are not synonymous! The key factors that determine whether RSI is appropriate for your patient are TIME & DIFFICULTY.

1. Time: If your patient is apneic and unresponsive, then you’re out of time, and this is a crash intubation scenario where RSI is not indicated. Maintain oxygenation by all means necessary until a definitive airway is secured.
2. Difficulty: You have some amount of time (based on your gestalt of the patient and their physiologic parameters) but you predict a difficult airway. While RSI may still be the right choice, entering the difficult airway pathway requires a higher level of preparation and a review of all options BEFORE proceeding with RSI.

Remember the Third Rail of Intubation

A third factor should always modify your decision to use RSI.  How sick is your patient? The “resuscitate before you intubate” mantra applies to all patients requiring intubation. Unless you have a crash airway, or a patient already in cardiac arrest, use the time you have prior to intubation to address your patient’s critically ill physiology and prepare for the complications associated with the intersection of intubation and critically ill physiology by going here.

The Steps of RSI

There are many mnemonics and other cognitive tools to help you be consistent with the steps of RSI.  The most well known being the 7Ps:

1. Preparation
2. Pre-oxygenation
3. Pretreatment
4. Paralysis with induction
5. Positioning
6. Placement with proof
7. Post-intubation Management

While that seems easy enough, within each of these are nested plenty of critical actions essential for safe and successful RSI.  Which is why I think the 7p approach is inadequate for the task, and why coming up with a simple checklist has been so challenging. So far I think the best cognitive tool available is the one by Scott Weingart, who organizes his approach into four main categories including your:

1. Plan
2. Patient
3. Equipment
4. Team

The simplicity of this list belies the real-world genius embedded within it: by dividing the checklist tasks into buckets that make up the four essential parts of any procedure. This checklist asks you to focus first on you and your approach, then the patient, the equipment you need, and your team. Here it is:

The EMCrit RSI Checklist v 2.0

Here is a great video by Ruben Strayer @emupdates on the details of this approach:

Dosing & Choosing Your Medications

Part of the planning for RSI includes choosing your RSI medications.

Induction Agents & Paralytics

from Medzcool

Ketamine

Etomidate

Paralytics

Rocuronium

Succinylcholine

Mobile Tools – Resources reviewed by our airway team, and available for rapid use in clinical settings. All resources are FOAM when possible. There are no conflicts of interest with any paid airway tools. 

The Difficult Airway App Created by Ron M. Walls, MD, Michael F. Murphy, MD and Robert C. Luten, MD. Provides you with rapid weight-based RSI meds on your mobile device. It’s not FOAM ($2.99) but well worth the cost.

The RSI Checklist @EMCRIT  – By Dr Scott Weingart