Emergency Medicine

Practical Procedures 467

RAPID SEQUENCE INDUCTION INTUBATION

The objective of rapid sequence induction (RSI) intubation is to secure the airway
as rapidly as possible and assumes that the patient has a full stomach and is at risk
of aspiration of gastric contents. Pre-determined doses of i.v. anaesthetic and a
rapid-acting paralysing drug are given to enable the intubation.

INDICATIONS

1 Failure of airway maintenance or protection:

(i) Loss of protective reflexes (e.g. severe head injury or drug overdose).

(ii) Prophylaxis (e.g. airway burns, epiglottitis, pre-transfer).

(iii) Prevention of aspiration of blood, mucus or gastric contents in

the comatose patient with reduced gag reflex.

2 Failure of oxygenation or ventilation:

(i) Treatment of inadequate oxygenation (hypoxaemic respiratory

failure).

(ii) Treatment of inadequate ventilation (hypercapnoeic respiratory

failure).

3 Therapeutic intervention:

(i) Provision of controlled mechanical ventilation.

(ii) Hyperventilation.

(iii) Pulmonary toilet, bronchoscopy.

CONTRAINDICATIONS

1 Unskilled or untrained operator.

2 Pre-arrest/moribund – proceed without drugs (see Endotracheal Intubation

above).

3 Obstructed air way, unless operator absolutely conf ident of success.

4 Difficult airway, unless operator absolutely confident of success, and or is

able to bag-mask ventilate.

TECHNIQUE

1 Preparation

(i) Resuscitation area with comprehensive non-invasive monitoring,

pre-checked intubation trolley with drugs drawn up, trained

personnel

(a) requires up to five people in a trauma intubation (intubator,

assistant, in-line manual stabilization, cricoid pressure, drug

administrator).

(ii) Two functioning laryngoscopes with choice of blades, introducer,

test endotracheal tube cuff inflation.