Rapid Sequence Intubation (RSI)

Preparation

Patients without a pulse do not require medications to facilitate intubation.

Maximize your chances for first-pass success with:

1. Preparation: Room, airway equipment, suction, monitor, IV access, personnel
2. Pre-oxygenation: NRB mask for spontaneously breathing patient, ventilate if hypoxic
3. Positioning: Ear above sternum or ramp
4. Plan A: Share your laryngoscopy and intubation plan (bougie?, video?)
5. Plan B: Share your rescue ventilation and rescue intubation plan (LMA?, cric kit?)
6. Paralysis: Optimize laryngoscopic view with muscle relaxants
7. Post-intubation: Secure and confirm tube placement, sedation and vent orders

Avoid paralysis without sedation.

Avoid paralysis when difficulty laryngoscopy is anticipated. Consider awake intubation strategy, alternatively.

1. Distortion (of upper or lower airway ie: trauma, anaphylaxis)
2. Disproportion (small jaw, large tongue)
3. Dysmobility (neck stiffness, c-collar, rheumatoid arthritis)
4. Dentition (large teeth = small mouth opening)

Medications

Pre-treatment

Medication	Weight-based dose	80 kg / 180 lbs dose	Indications
Lidocaine	1.5 mg/kg	120 mg	Head, lung
Fentanyl	3 mcg/kg	250 mcg	Head, heart

Sedation

Medication	Weight-based dose	80 kg / 180 lbs dose	Indications
Etomidate	0.3 mg/kg	24 mg
Propofol	1.5 mg/kg	120 mg
Thiopental	3 mg/kg	250 mg
Ketamine IV	1.5 mg/kg	120 mg	Asthma
Ketamine IM	3.0 mg/kg	240 mg	No IV access
Midazolam	0.3 mg/kg	24 mg

Paralytics

Medication	Weight-based dose	80 kg / 180 lbs dose	Indications
Succinylcholine	1.5 mg/kg	120 mg
Rocuronium	1.0 mg/kg	80 mg
Vecuronium	0.2mg/kg	16 mg

References

• Airway Cam Pocket Guide to Intubation, 2nd Edition [Source]
• “The Airway Card”, The Airway Course [Source]