Rapid Sequence Intubation

1. Indications

Rapid Sequence Intubation (RSI) should be considered in any patient that requires urgent or emergent endotracheal intubation but shows evidence of incomplete relaxation, or a patient who demonstrates a high probability of airway compromise during transport.

2. Contraindications

a. Absolute

i. Anticipated difficulty using “rescue” techniques

ii. Suspected hyperkalemia (e.g. dialysis patient)

b. Relative

i. Severe upper airway trauma

ii. Stridor or upper airway obstruction

iii. Morbid obesity

iv. Penetrating eye injuries

v. Renal failure

vi. History of Malignant Hyperthermia

vii. Small mouth, large tongue, or short neck (predicts difficulty)

viii. Age < 8

3. Procedure

a. Assemble all necessary equipment & medications so that there is a smooth, uninterrupted progression of the procedure

b. Preoxygenate the patient with high-flow O2 via non-rebreather mask OR have patient take 8 vital capacity breaths

i. Avoid using BVM in order to minimize gastric distention

c. Premedicate

i. Head injury patient

1. LIDOCAINE 1 mg/kg IV

d. Sedation

i. ETOMIDATE 0.3 mg/kg IV (“average” adult = 20 mg)

1. Option: MIDAZOLAM (Versed) 5 mg IV

2. Option: KETAMINE 1 mg/kg IV

ii. After adequate sedation:

1. Remove C-collar (if placed) & have assistant maintain in-line stabilization

2. Initiate apneic oxygenation by administering supplemental oxygen via nasal cannula at 10 liters per minute

e. Paralysis

i. SUCCINYLCHOLINE (Anectine) 1 – 1.5 mg/kg IV

ii. Option: ROCURONIUM (Zemuron) 1 mg/kg IV

f. Intubate

i. Verify via Endotracheal Intubation Protocol

ii. Discontinue apneic oxygenation

g. Ventilate patient at a “controlled” rate (Avoid excessive hyperventilation)

h. Resume C-spine precautions (& collar)

i. If patient becomes bradycardic hyperventilate the patient temporarily

ii. If bradycardia persists despite hyperventilation, administer ATROPINE 0.5 mg IV

j. If the patient begins moving or waking prior to arrival at medical facility, you must re-paralyze AND re-sedate. Administer:

i. VECURONIUM (Norcuron) 5 mg IV

1. Option: ROCURONIUM (Zemuron) 0.6 mg/kg IV

ii. MIDAZOLAM (Versed) 2 – 5 mg IV (hold if SBP < 80 mmHg)

1. Option: KETAMINE 1 mg/kg IV

2. Option: FENTANYL 50 – 100 mcg IV

Documentation

a. Indication for RSI

b. How patient was preoxygenated & O2 saturation during/after procedure

c. Complications during procedure

d. Method of ET tube placement verification

The emergent transport of the severely injured patient should NEVER be delayed to perform RSI.