Rapid Sequence Intubation

Preoxygenation, hemodynamic optimisation, the equipment, and the drugs that sedate and paralyse.

What Is RSI? Rapid Sequence Intubation (RSI) is an airway management technique in which a patient is quickly sedated and paralyzed to allow for the rapid placement of an endotracheal (ET) tube. The tube is then connected to a ventilator to take over the patient's breathing. RSI is commonly performed in patients experiencing respiratory failure, or those who are unable to protect their airway, such as those with a Glasgow Coma Scale (GCS) score < 8.

Preoxygenation: The Most Important Step

The most critical part of preparing for RSI is preoxygenation—the process of delivering oxygen to the patient to build an oxygen reserve before they become apneic during intubation. This helps prevent oxygen desaturation and cardiac arrest during the procedure. How to preoxygenate: • Ensure a working oxygen tank is on the gurney • Apply a nasal cannula at 6 L/min • Use a non-rebreather mask (NRB) at 15 L/min OR more commonly: o Use a bag-valve mask (BVM) over the patient's mouth and nose If the patient is still breathing spontaneously: • Hold the mask tightly over their face without squeezing—this allows for passive preoxygenation. If the patient is not breathing adequately: • Use a 3-C grip for a tight seal and bag the patient every 5–6 seconds. Preoxygenate for at least 3 minutes to maximize oxygen reserves.

Hemodynamic Optimization Before RSI

If the patient is unstable (low BP, low SpO2, or acidotic), address this before intubation to reduce the risk of deterioration during the procedure.

Management:

• IV fluids if hypotensive (unless contraindicated, such as in CHF) • Push-dose pressors (e.g., epinephrine or phenylephrine)—administered by providers • Discuss options with your team if you notice instability before RSI Remember, after giving a paralytic, the patient becomes apneic, CO2 builds up, and acidosis worsens—this can crash an already unstable patient. Preparation is everything.

Equipment Preparation

Ensure the following equipment is ready: • Suction • Nasal cannula, NRB, and bag-valve mask (BVM) • Cardiac monitor, SpO2, and blood pressure cuff connected • At least one good IV, ideally two Airway Equipment (often gathered by RT or the provider, but nurses should know): • Laryngoscope with blades: o Macintosh (curved) or Miller (straight) • ET tube with a stylet (blue insert for structure) • Colorimetric CO2 detector (purple to yellow = confirmed placement) • OPA (oropharyngeal airway) • Glidescope (video-assisted laryngoscope, if used)

Post-Intubation Care

After intubation: • Insert a Foley catheter for urine output monitoring • Place an NG or OG tube to decompress the stomach and reduce aspiration risk • Apply soft restraints as ordered, especially if the patient may become agitated • Confirm and follow hospital policies and provider orders IV pumps will be needed for: • Sedation and analgesia drips • Other continuous infusions related to the patient's condition Ask the provider in advance: "What medications will we be using for sedation and pain control?" Being prepared helps you set up medications ahead of time for post-intubation care.

Common RSI Medications

Sedation Agents:

• Etomidate – hemodynamically stable, fast-acting • Ketamine – useful in asthmatics or hypotensive patients • Propofol – not ideal for unstable patients (can cause hypotension) • Midazolam (Versed) – benzodiazepine option

Paralytics:

• Succinylcholine (Succs) – fast onset, short duration, but can cause hyperkalemia • Rocuronium – slower onset, lasts longer (up to 1 hour), preferred when Succs is contraindicated Example: Succinylcholine is preferred when rapid onset is critical, but avoid in patients with suspected hyperkalemia (e.g., burns, crush injuries, ESRD).

Rapid Sequence Intubation