Rapid sequence intubation for adults outside the operating room
- Aaron E Bair, MD, MSc, FAAEM, FACEP
Aaron E Bair, MD, MSc, FAAEM, FACEP
- Professor of Emergency Medicine
- University of California, Davis
- Section Editor
- Ron M Walls, MD, FRCPC, FAAEM
Ron M Walls, MD, FRCPC, FAAEM
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Adult Resuscitation
- Neskey Family Professor of Emergency Medicine
- Harvard Medical School
- Brigham and Women's Hospital
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
The first task of any clinician managing an acutely unstable patient is to secure the airway. In most circumstances, emergency clinicians use rapid sequence intubation (RSI) to accomplish this task. RSI incorporates a rapidly acting sedative (ie, induction) agent and a neuromuscular blocking (ie, paralytic) agent to create optimal intubating conditions and enable rapid control of the airway. RSI presupposes the patient is at risk for aspiration of stomach contents and incorporates medications and techniques to minimize this risk. Use of RSI also helps to mitigate the potential adverse effects of airway manipulation.
This topic reviews the central concepts and techniques needed to perform rapid sequence intubation in adults in the emergency setting outside the operating room. RSI for anesthesia, RSI in children, the medications used for emergency RSI, and other subjects related to emergency airway management are reviewed separately. (See "Rapid sequence intubation (RSI) outside the operating room in children: Approach" and "Induction agents for rapid sequence intubation in adults outside the operating room" and "Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults outside of the operating room" and "Pretreatment medications for rapid sequence intubation in adults outside the operating room" and "Basic airway management in adults" and "Rapid sequence induction and intubation (RSII) for anesthesia".)
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 emergency endotracheal intubation and to minimize the risk of aspiration. Preoxygenation is required to permit a longer period of apnea without clinically significant oxygen desaturation. Bag-mask ventilation is avoided during the interval between drug administration and endotracheal tube placement, thereby minimizing gastric insufflation and reducing the risk of aspiration.
Indications — RSI is the standard of care in emergency airway management for intubations not anticipated to be difficult [1-7]. Multiple large prospective observational studies confirm that the implementation of RSI has led to improved success and decreased complication rates for emergency intubations [1-6].
Precautions — Contraindications to RSI are relative. Circumstances exist where neuromuscular blockade is undesirable due to the high likelihood of intubation or mechanical ventilation failure. Depending on clinical circumstances, particular sedative or neuromuscular blocking agents may be relatively contraindicated, due to the risk of potential side effects. The effects of particular drugs used for RSI are described separately. (See "Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults outside of the operating room" and "Induction agents for rapid sequence intubation in adults outside the operating room" and "Approach to the difficult airway in adults outside the operating room".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46:328.
- Li J, Murphy-Lavoie H, Bugas C, et al. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999; 17:141.
- Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325.
- Walls RM. Rapid-sequence intubation in head trauma. Ann Emerg Med 1993; 22:1008.
- Dronen SC, Merigian KS, Hedges JR, et al. A comparison of blind nasotracheal and succinylcholine-assisted intubation in the poisoned patient. Ann Emerg Med 1987; 16:650.
- Bair AE, Filbin MR, Kulkarni RG, Walls RM. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med 2002; 23:131.
- Brown CA 3rd, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015; 65:363.
- Walls RM. Rapid Sequence Intubation. American College of Emergency Physicians Scientific Assembly, San Francisco, CA 1987.
- The mnemonics for difficult airway identification cited in this review are reproduced with permission from The Difficult Airway Course™: Emergency.
- Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013; 20:71.
- Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2012; 59:165.
- Groombridge C, Chin CW, Hanrahan B, Holdgate A. Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. Acad Emerg Med 2016; 23:342.
- Lane S, Saunders D, Schofield A, et al. A prospective, randomised controlled trial comparing the efficacy of pre-oxygenation in the 20 degrees head-up vs supine position. Anaesthesia 2005; 60:1064.
- Ramkumar V, Umesh G, Philip FA. Preoxygenation with 20º head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth 2011; 25:189.
- Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg 2003; 13:4.
- Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth 2010; 22:164.
- Taha SK, Siddik-Sayyid SM, El-Khatib MF, et al. Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Anaesthesia 2006; 61:427.
- Wimalasena Y, Burns B, Reid C, et al. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med 2015; 65:371.
- Sakles JC, Mosier JM, Patanwala AE, et al. First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department. Acad Emerg Med 2016; 23:703.
- Pavlov I, Medrano S, Weingart S. Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Am J Emerg Med 2017; 35:1184.
- Delay JM, Sebbane M, Jung B, et al. The effectiveness of noninvasive positive pressure ventilation to enhance preoxygenation in morbidly obese patients: a randomized controlled study. Anesth Analg 2008; 107:1707.
- Baillard C, Fosse JP, Sebbane M, et al. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med 2006; 174:171.
- Herriger A, Frascarolo P, Spahn DR, Magnusson L. The effect of positive airway pressure during pre-oxygenation and induction of anaesthesia upon duration of non-hypoxic apnoea. Anaesthesia 2004; 59:243.
- Mort TC, Waberski BH, Clive J. Extending the preoxygenation period from 4 to 8 mins in critically ill patients undergoing emergency intubation. Crit Care Med 2009; 37:68.
- Pandit JJ, Duncan T, Robbins PA. Total oxygen uptake with two maximal breathing techniques and the tidal volume breathing technique: a physiologic study of preoxygenation. Anesthesiology 2003; 99:841.
- Baraka A, Haroun-Bizri S, Khoury S, Chehab IR. Single vital capacity breath for preoxygenation. Can J Anaesth 2000; 47:1144.
- Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997; 87:979.
- Ding ZN, Shibata K, Yamamoto K, et al. Decreased circulation time in the upper limb reduces the lag time of the finger pulse oximeter response. Can J Anaesth 1992; 39:87.
- Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med 2007; 50:653.
- Algie CM, Mahar RK, Tan HB, et al. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev 2015; :CD011656.
- Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med 2006; 47:548.
- Butler J, Sen A. Best evidence topic report. Cricoid pressure in emergency rapid sequence induction. Emerg Med J 2005; 22:815.
- McNelis U, Syndercombe A, Harper I, Duggan J. The effect of cricoid pressure on intubation facilitated by the gum elastic bougie. Anaesthesia 2007; 62:456.
- Oh J, Lim T, Chee Y, et al. Videographic analysis of glottic view with increasing cricoid pressure force. Ann Emerg Med 2013; 61:407.
- Zeidan AM, Salem MR, Mazoit JX, et al. The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: an experimental and observational glidescope study. Anesth Analg 2014; 118:580.
- Green R, Hutton B, Lorette J, et al. Incidence of postintubation hemodynamic instability associated with emergent intubations performed outside the operating room: a systematic review. CJEM 2014; 16:69.
- Baraka AS, Taha SK, Aouad MT, et al. Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques. Anesthesiology 1999; 91:612.
- Ramez Salem M, Joseph NJ, Crystal GJ, et al. Preoxygenation: comparison of maximal breathing and tidal volume techniques. Anesthesiology 2000; 92:1845.
- Koh KF, Chen FG. Rapid tracheal intubation with atracurium: the timing principle. Can J Anaesth 1994; 41:688.
- Culling RD, Middaugh RE, Menk EJ. Rapid tracheal intubation with vecuronium: the timing principle. J Clin Anesth 1989; 1:422.
- Silverman SM, Culling RD, Middaugh RE. Rapid-sequence orotracheal intubation: a comparison of three techniques. Anesthesiology 1990; 73:244.
- DESCRIPTION OF THE TECHNIQUE
- Paralysis with induction
- - Induction agents
- - Neuromuscular blocking agents
- Protection (cricoid pressure) and positioning
- Placement with proof
- Postintubation management
- VARIATIONS OF TECHNIQUE
- Accelerated sequence
- Timing principle
- SUMMARY AND RECOMMENDATIONS