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, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: Dec 17, 2009

Introduction

Airway management is the most important skill for an emergency practitioner 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; clinical experience is required to recognize signs of impending respiratory failure. Patients who require intubation have at least one of the following 5 indications: 1) inability to maintain airway patency, 2) inability to protect the airway against aspiration, 3) ventilatory compromise, 4) failure to adequately oxygenate pulmonary capillary blood, 5) anticipation of a deteriorating course that will eventually lead to the inability to maintain airway patency or protection.

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 may 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.

This article focuses on direct laryngoscopy using a traditional laryngoscope.

Indications

  • Failure to maintain airway patency/tone
    • 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)
  • Anticipated clinical course or deterioration (eg, need for situation control, tests, procedures)
    • Uncooperative trauma patient with life-threatening injuries who needs procedures (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
    • Cervical spine fracture with concern for edema and loss of airway patency

Contraindications

  • Absolute
    • Total upper airway obstruction, which requires a surgical airway
    • Total loss of facial/oropharyngeal 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.
      • Multiple methods can be used to evaluate the airway and the risk of difficult intubation (eg, LEMON rule, 3-3-2, Mallampati class, McCormack and Lehane grade). Please refer to the Difficult Airway Assessment section below for details.
    • The "crash" airway, in which the patient is in an arrest situation, unconscious and apneic
      • In this scenario, the patient is already unconscious and may be flaccid; further, no time is available for preoxygenation, pretreatment, or induction and paralysis.
      • BVM ventilation, intubation, or both should be performed immediately without medications.

More on Tracheal Intubation, Rapid Sequence Intubation

Overview: Tracheal Intubation, Rapid Sequence Intubation
Treatment & Medication: Tracheal Intubation, Rapid Sequence Intubation
Multimedia: Tracheal Intubation, Rapid Sequence Intubation
References
[ CLOSE WINDOW ]

References

  1. Reynolds SF, Heffner J. Airway management of the critically ill patient: Rapid-sequence intubationhttp://www.chestjournal.org/cgi/content/full/127/4/1397. Chest [serial online]. 2005; 127:1397-412. Available at http://www.chestjournal.org/.

  2. Bair AE, Filbin MR, Kulkarni RG, et al. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med. Aug 2002;23(2):131-40. [Medline].

  3. Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. Oct 2005;46(4):328-36. [Medline].

  4. Walls RM. Rapid-sequence intubation in head trauma. Ann Emerg Med. Jun 1993;22(6):1008-13. [Medline].

  5. Walls RM. Management of the difficult airway in the trauma patient. Emerg Med Clin North Am. Feb 1998;16(1):45-61. [Medline].

  6. Airway. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2004:11.

  7. Windsor J, Varon AJ. Fentanyl should be used with caution in patients with severe brain injury. J Trauma. Dec 1998;45(6):1103. [Medline].

  8. de Nadal M, Munar F, Poca MA, Sahuquillo J, Garnacho A, Rossello J. Cerebral hemodynamic effects of morphine and fentanyl in patients with severe head injury: absence of correlation to cerebral autoregulation. Anesthesiology. Jan 2000;92(1):11-9. [Medline].

  9. de Nadal M, Ausina A, Sahuquillo J, Pedraza S, Garnacho A, Gancedo VA. Effects on intracranial pressure of fentanyl in severe head injured patients. Acta Neurochir Suppl. 1998;71:10-2. [Medline].

  10. Sperry RJ, Bailey PL, Reichman MV, Peterson JC, Petersen PB, Pace NL. Fentanyl and sufentanil increase intracranial pressure in head trauma patients. Anesthesiology. Sep 1992;77(3):416-20. [Medline].

  11. Weinstabl C, Spiss CK. Fentanyl and sufentanil increase intracranial pressure in head trauma patients. Anesthesiology. Mar 1993;78(3):622-3. [Medline].

  12. Sperry RJ, Bailey PL, Reichman MV, Peterson JC, Petersen PB, Pace NL. Fentanyl and sufentanil increase intracranial pressure in head trauma patients. Anesthesiology. Sep 1992;77(3):416-20. [Medline].

  13. Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. Oct 2004;20(10):651-5. [Medline].

  14. Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. Feb 2006;18(1):37-44. [Medline].

  15. Adnet F, Baillard C, Borron SW, et al. Randomized study comparing the "sniffing position" with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology. Oct 2001;95(4):836-41. [Medline].

  16. Mace SE. Challenges and advances in intubation: airway evaluation and controversies with intubation. Emerg Med Clin North Am. Nov 2008;26(4):977-1000, ix. [Medline].

  17. Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology. Jul 2003;99(1):60-4. [Medline].

  18. Butler J, Sen A. Best evidence topic report. Cricoid pressure in emergency rapid sequence induction. Emerg Med J. Nov 2005;22(11):815-6. [Medline].

  19. Werner SL, Smith CE, Goldstein JR, Jones RA, Cydulka RK. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med. Jan 2007;49(1):75-80. [Medline].

  20. Walz JM, Zayaruzny M, Heard SO. Airway management in critical illness. Chest. Feb 2007;131(2):608-20. [Medline].

  21. Kelly JJ, Eynon CA, Kaplan JL, et al. Use of tube condensation as an indicator of endotracheal tube placement. Ann Emerg Med. May 1998;31(5):575-8. [Medline].

  22. Mace SE. Challenges and advances in intubation: airway evaluation and controversies with intubation. Emerg Med Clin North Am. Nov 2008;26(4):977-1000, ix. [Medline].

  23. [Best Evidence] Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. Apr 16 2008;CD002788. [Medline].

  24. Walls RM. The decision to intubate. In: Walls RM, ed-in-chief; Murphy MF, Luten RC, Schneider RE, eds. Manual of Emergency Airway Management. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:1-7.

  25. Walls RM. Rapid sequence intubation. In: Walls RM, ed-in-chief; Murphy MF, Luten RC, Schneider RE, eds. Manual of Emergency Airway Management. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:22-31.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

tracheal intubation, endotracheal intubation, oral intubation, orotracheal intubation, intubation, rapid sequence intubation, RSI, anesthesia and intubation, emergency airway management, emergency intubation, rapid tracheal intubation, difficult airway

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Keith A Lafferty, MD, Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional Medical Center
Keith A Lafferty, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Medical Editor

Michael R Filbin, MD, Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital
Michael R Filbin, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.