Emergency Medicine

RAPID SEQUENCE INDUCTION INTUBATION

468 Practical Procedures

2 Pre-oxygenation

(i) Provide high concentration oxygen via bag-valve-mask for

3–5 min prior to RSI, to maximize oxygen reserve in the lungs by

washing out nitrogen, to compensate for the impending period of

apnoea.

3 Pre-treatment

(i) Option to administer fluid bolus in hypotension, or additional

drugs such as atropine 10–20 g/kg in children.

4 Paralysis and induction

(i) Use an i.v. induction agent such as thiopentone (thiopental) 0.5–

5 mg/kg, etomidate 0.3 mg/kg, ketamine 0.75–2 mg/kg, propofol

0.5–2 mg/kg, or midazolam 0.1 mg/kg plus fentanyl 2.5–5 g/kg.

(ii) Follow with muscle relaxant suxamethonium 1.5 mg/kg, or

rocuronium 1 mg/kg, if suxamethonium contraindicated by

hyperkalaemia, neuromuscular disease.

5 Protection and positioning

(i) Provide in-line stabilization in trauma where a cervical spine

injury is possible.

(ii) Apply cricoid pressure (2 kg or 4.5 lb force) from the moment

the patient loses muscle tone and maintain pressure until the

endotracheal tube has been correctly placed, position verified and

the cuff inflated.

(a) request some relaxation of cricoid pressure if the glottic view

is worsened.

(iii) Use the BURP manoeuvre on the thyroid cartilage as necessary to

improve the view of the vocal cords.

6 Placement with proof

(i) Confirm tube placement by:

(a) capnography to measure end-tidal carbon dioxide (ETCO 2 ) –

most reliable

(b) direct visualization of endotracheal tube passing through the

cords

(c) auscultation over the lung fields and stomach.

(ii) Only release cricoid pressure once placement is confirmed.

7 Post-intubation management

(i) Tie the tube in place and watch for cardiorespiratory changes, as

a chest radiograph (CXR) is arranged.

COMPLICATIONS

1 Failure or delay to intubate, with critical hypoxia.

2 Misplaced tube, e.g. oesophagus, or right main bronchus.

3 Airway trauma.