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
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) in children" and "Induction agents for rapid sequence intubation in adults" and "Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults outside the operating room" and "Pretreatment agents for rapid sequence intubation in adults" 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 emergent 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].
Contraindications — 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. (See 'Induction agents' below and 'Neuromuscular blocking agents' below and "The difficult airway in adults".)
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- 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