eMedicine Specialties > Clinical Procedures > Respiratory Management

Tracheal Intubation, Rapid Sequence Intubation

Author: Keith A Lafferty, MD, Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional Medical Center
Coauthor(s): Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: Oct 27, 2008

Introduction

Airway management is the most important skill for an emergency physician to master because failure to secure an adequate airway can quickly lead to death or disability.¹ Endotracheal intubation using rapid sequence intubation (RSI) is the cornerstone of emergency airway management.^2,3

The decision to intubate is sometimes difficult and requires clinical experience to recognize signs of impending respiratory failure. Patients who require intubation have at least one of the following 3 indications: 1) inability to maintain airway patency or protect the airway against aspiration, 2) ventilatory compromise or failure to adequately oxygenate pulmonary capillary blood, 3) anticipation of a deteriorating course that will eventually lead to the inability to maintain airway patency or protection, ventilate, or oxygenate.

RSI is the preferred method of endotracheal intubation in the emergency department (ED) because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). This is important in patients who have not fasted and are at much greater risk for vomiting and aspiration. To this end, the goal of RSI is to intubate the trachea without having to use bag-valve-mask (BVM) ventilation, which is often necessary when attempting to achieve intubating conditions with sedative agents alone (eg, midazolam, diazepam). Instead of titrating to effect, RSI involves administration of weight-based doses of an induction agent (eg, etomidate) immediately followed by a paralytic agent (eg, succinylcholine, rocuronium) to render the patient unconscious and paralyzed within 1 minute. This method has been proven safe and effective in EDs over the past 2 decades, and it is considered the standard of care.

RSI is not indicated in a patient who is unconscious and apneic. This situation is considered a "crash" airway and immediate BVM ventilation and endotracheal intubation without pretreatment, induction, or paralysis is indicated.

RSI should be approached with caution in a patient with a suspected difficult airway. If difficulty is anticipated, then an awake technique or the use of airway adjuncts (eg, fiberoptic intubation) is recommended.

Certain clinical scenarios call for pretreatment medications prior to induction/paralysis to optimize physiologic parameters for intubation, such as blunting the sympathetic response to laryngoscopy, preventing upward or downward spikes in blood pressure, avoiding increased intracranial pressure, and facilitating bronchodilation. These conditions include suspected high intracranial pressure (eg, intracranial hemorrhage or trauma), severe asthma or COPD, hypovolemic shock, aortic emergencies, and pediatric considerations among others.

Indications

• Failure to maintain airway patency
  • Swelling of upper airway as in anaphylaxis or infection
  • Facial or neck trauma with oropharyngeal bleeding or hematoma
  • Decreased consciousness and loss of airway reflexes
• Failure to protect airway against aspiration - Decreased consciousness that leads to regurgitation of vomit, secretions, or blood
• Failure to ventilate (ie, deliver air to the lungs/alveoli)
  • End result of failure to maintain and protect airway
  • Prolonged respiratory effort that results in fatigue or failure, as in status asthmaticus or severe COPD
• Failure to oxygenate (ie, transport oxygen to pulmonary capillary blood)
  • End result of failure to maintain and protect airway or failure to ventilate
  • Diffuse pulmonary edema
  • Acute respiratory distress syndrome (Click here to complete a Medscape CME activity on managing acute respiratory failure.)
  • Large pneumonia or air-space disease
• Anticipated clinical course or deterioration (eg, need for situation control, tests, procedures)
  • Uncooperative trauma patient with life-threatening injuries who needs painful procedure (eg, chest tube) or immediate CT scanning
  • Stab wound to neck with expanding hematoma
  • Septic shock with high minute-ventilation and poor peripheral perfusion
  • Intracranial hemorrhage with altered mental status and need for close blood pressure control

Contraindications

• Absolute
  • Total upper airway obstruction, which requires a surgical airway
  • Total loss of facial landmarks, which requires a surgical airway
• Relative
  • Anticipated "difficult" airway, in which endotracheal intubation may be unsuccessful, resulting in reliance on successful bag-valve-mask (BVM) ventilation to keep an unconscious patient alive (In this scenario, techniques for awake intubation and difficult airway adjuncts can be used.)
  • The "crash" airway, in which the patient is in an arrest situation, unconscious and apneic (In this scenario, no time is available for preoxygenation, pretreatment, or induction and paralysis. BVM ventilation, intubation, or both should be performed immediately without medications.)

• Search for CME/CE on This Topic »

• Tracheal Intubation, Surgical Airway Techniques (Clinical Procedures)
• Tracheal Intubation, Medications (Clinical Procedures)
• Tracheal Intubation, Laryngeal Mask Airways (Clinical Procedures)
• Ventilator Management (Clinical Procedures)

• Rocuronium vs. Succinylcholine in the Emergency Department: A Critical Appraisal
• Neuromuscular Blocking Agents Dosing for Rapid Sequence Intubation
• Ketamine and Etomidate: Good Choices for RSI in Critically Ill Patients