1. Rapid Sequence Intubation
Steven Podnos MD

2. RSI
• Definition: Using drugs that make emergent
intubation of conscious patients safer and
more controlled
• Process: Use of a sedative /hypnotic agent to
induce relaxation/sleepiness/amnesia
followed by a neuromuscular blocker to stop
any resistance to the intubation process

3. The Seven Ps of RSI
• Preparation
• Preoxygenation
• Pre treatment
• Paralysis
• Protection and Positioning
• Placement with Proof
• Post intubation management

4. Preparation
• Cardiac Monitor, O2 sat, IV access, BP monitor
• Suction, all meds ready and drawn up, crash
cart, bag valve mask
• Difficult airway assessment and alternate
airways available

5. Pre-oxygenation
• Done to avoid using Bag Valve mask
ventilation
• High flow O2 (usually at least 3-5 minutes)
given to “wash out” nitrogen and increases
body oxygen stores. Can extend time allowed
without ventilation for several minutes

6. Pretreatment
• In some cases, Lidocaine 1mg/kg IV or
Fentanyl is given to reduce the physiologic
increase in ICP in patients with head injuries

7. Paralysis and Induction
• RSI is designed to achieve paralytic and
sedated state within one minute. No titration-
use whole doses of drugs

8. Ideal Drugs
• Should have duration of very few minutes in
case intubation is not successful.
• Sedatives used: Etomidate, Midazolam
(Versed), Propofol
• Paralytics used: Succinylcholine (Anectine)

9. Sedative Drugs
• Etomidate-hemodynamically neutral,
• 0.3mg/kg bolus
• Midazolam-0.2mg/kg bolus, does often cause
hypotension
• Propofol-2mg/kg bolus, may cause
hypotension and CPP. Bronchodilator

10. Protection with Positioning
• Avoid Bag Mask Ventilation
• Cricoid pressure very controversial

11. Placement with proof
• MUST have EtCO2 proof , either colorimetric
or quantitative (monitor)
• In cardiac arrest may not see CO2 production.
Positive CO2 for six breaths is definitive
evidence of proper airway placement.
• Clinical and CXR evaluation is not definitive for
placement

12. Postintubation Management
• Fix the ETT location
• CXR for depth of tube
• Fluid bolus for transient hypotension