Rapid Sequence Intubation (RSI)

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Rapid Sequence Intubation (RSI)

Immediately place LMA/SGA, call for advanced airway provider

Contraindications to NG/OG tube placement?

#2 intubation attempt

  • Must modify at least one core approach to intubation technique
  • Surgical airway supplies should be open and at the bedside

Place surgical airway, off pathway

Confirmation of placement checklist (minimum)

  • Visualization of tube through cords
  • Chest rise
  • Auscultate
  • End tidal CO2 (Inline or Cap) present
  • Oxygen saturation rises appropriately
  • Chest x-ray

Concern for COPD or asthma?

IV access established x2?

C-Collar present?

Inclusion Criteria
  • Clinically requires urgent intubation
Exclusion Criteria
  • Delayed sequence or awake intubation candidates
  • Severe facial trauma or anatomical abnormalities (including morbid obesity)
  • Do not resuscitate / Do not intubate directive
  • Place patient on cardiorespiratory monitor with pulse oximeter
  • BP cycling Q1 min
  • Place nasal cannula AND non-rebreather on patient at 15 L/min (goal: minimum of 3 min)
  • Move the head of bed to 30 degrees or other techniques to optimize airway

< 2 months old?

Patient requires positive pressure ventilation?

2 attempts by trained provider at peripheral IV access (max time 60 seconds)

Select sedation/induction agent

Status epilepticus or < 1 years old?

Concern for COPD or asthma?

Catecholamine depleted shock?

Select paralytic medication

< 1 years old?

NG/OG tube placement

Obstructive strategy

  • I:E ratio: goal of 1:4, titrate as needed
  • Assure that expiratory phase is complete prior to initiation of inspiration. Adjust rate or inspiratory time accordingly.
  • Permissive hypercapnia (Goal to keep pH above 7.25; may rarely need a bicarb drip)

< 10 years?

Optimize oxygenation (PEEP + FiO2)

Goal PaO2 55-80 mmHg or SpO2 88-95% Use a minimum PEEP of 5 cm H2O































Post-intubation care

  • Secure tube, return head of bed to 30 degrees if not present
  • Maintenance fluids
  • Vitals Q15 min and continuous EtC02 monitoring
  • VBG 10 min after intubation, then as needed
  • Vecuronium 0.1 mg/kg IV available in case of movement (consider giving preemptively to prevent self-extubation if patient to be relatively unsupervised - e.g. imaging)

Contraindications to Succinylcholine?

Successful bag-mask ventilation?

Bag-mask ventilation with PEEP valve

Intraossous line placement

Ketamine Injection

Etomidate injection

Midazolam injection

Consider intubation without paralytics. May consider adding analgesia such as morphine. Also may consider placing OG tube prior to intubation to evacuate stomach.

In-line stabilization

Optimize panoxygenation (preoxygenation + apnic oxygenation)

Complete timeout and checklist

< 1 yrs or < 5 yrs with SCh?

2 mg/kg (< 2 years), 1.5 mg/kg (> 2 years) - max 200 mg

Succinylcholine injection

Atropine injection

#1 intubation attempt

Consider video larnygoscopy (especially VL/DL combination devices)

Checklist verbalized, give sedation and paralytic medications

Signs of potential difficult airway

  • Short neck (Turners syndrome, etc.)
  • Thick neck
  • Protruding upper incisors
  • Receding or small mandible
  • Facial trauma
  • Blood in airway
  • Expanding hematoma
  • Swelling of intra-oral structures
  • Laryngeal edema
  • Obesity
  • Facial hair
  • C-spine collar or other devices

Indications for RSI

  • Failure to oxygenate
  • Failure to ventilate
  • Loss of airway tone
  • Decreased consciousness/loss of airway reflexes
  • Increased work of breathing likely leading to clinical deterioration
  • Airway protection
  • Combative patients at risk of harm to self or others

Fentanyl 2 mcg/kg bolus then 1 mcg/kg/hr

Fentanyl injection
Fentanyl infusion

Any one of the following

  • Status epilepticus
  • Requires frequent neuro checks
  • Bradycardia

Head positioning to optimize airway (sniffing position with ear canals level with sternal notch)

  • Infant: Due to large occiput, add a shoulder roll
  • Child: Often optimized with no additional support
  • Adult: Support with towels or pillow under patient's head
  • Obesity: May require more support under patient's head and neck

Midazolam injection

Admit to ICU

Dexmedetomidine infusion

If patient has g-tube, consider venting prior to intubation attempts.

Modifiable intubation techniques for each attempt

Attempt defined as any time the laryngoscope enters the mouth

  • Change of airway provider
  • Manipulation of head, neck, larynx or device
  • Adjunct devices (LMA, SGA, bougie, etc.)
  • Size/type of device
  • Suction/O2 flow
  • Pharyngeal muscle tone

Drug (IV)




30 sec

5-10 min


30-60 sec (peak 1 min)

3-5 min


< 60 sec

4-6 min


1-2 min (peak 4 min)

30 min


2-3min (peak 3-5 min)

25-40 min


30 sec

30 min - 1 hour


3-5 min

< 2 hours

If at any point ventilation becomes severely compromised, immediately progress to surgical airway

Propofol 0.5 mg/kg bolus then 20 mcg/kg/min, titrate to adequate sedation

Propofol injection
Propofol infusion

Consult advanced airway provider

Obtain primary equipment

  • Oxygen (2 sources)
  • Suction (2 sources tested and active)
  • Bag-valve mask with PEEP valve (tested)
  • Proper sized oral and nasopharyngeal airway (and lubricant)
  • Laryngoscope (video or direct) - check light source
  • Endotracheal tube (plus a size larger and smaller than expected) - test cuff
  • Stylet
  • Devices to secure endotracheal tube
  • Bougie
  • Monitors/Capnometer/Esophageal detection device
  • Broselow tape (for pediatric patients)

Obtain backup equipment

  • Secondary airway visualization device (video, direct, etc.)
  • Backup airway devices (supraglottic airway, laryngeal mask airway, etc.)
  • Code medications / Push dose pressors

Rocuronium injection

Contraindications to Succinylcholine

  • History of malignant hyperthemria
  • Renal failure or other known/risk for hyperkalemia
  • Myopathy/Muscular dystrophy
  • Neuromuscular junction diseases
  • Guillain-barré syndrome
  • Severe burns
  • Crush injuries
  • Stroke with hemiparisis > 72 hours old
  • Bedbound or prolonged immobility (including developmentally delayed individuals)

Off pathway, consider repositioning and surgical airway

Comparing Paralytics

  Rocuronium Succinylcholine
Depolarizing No Yes
Onset 30 sec 5-10 sec
Time to intubation 90 sec (at 1-1.2 mg/kg) 30-60 sec (at 1.5-2 mg/kg)
Fasciculations No Yes
Duration 45-60 min 8-15 min

Pretreatment medications


  • May be useful in patients < 1 year, or < 5 years if receiving Succinylcholine (SCh)


  • No evidence to support routine use


  • No evidence to support routine use

Defasciculating dose of paralytics

  • No evidence to support routine use

#3 intubation attempt

  • Must modify at least one core approach to intubation technique
  • Must be performed by most advanced airway provider immediately available

Suggested age specific ventilation rates (titrate as needed)

0 - 2 mo

30 bpm

2 mo - 1 yr

25 bpm

1 yr - 2 yrs

22 bpm

2 yrs - 10 yrs

20 bpm

> 10 yrs

18 bpm

Protective strategy

  • Mode: SIMV with pressure support
  • Tidal Volume: 7 ml/kg, assess for air entry and chest excursion
  • PEEP: Start at 5, titrate as needed
  • Rate (RR): Start at age appropriate rate (18 bpm for adults), titrate as needed
  • FiO2: start at 100% (unless contraindications), titrate down as possible
  • I:E ratio at 1:2 seconds

Richmond agitation-sedation scale (RASS) scoring system




  • Observe patient. Is patient alert and calm (score 0)?


  • Does patient have behavior that is consistent with restlessness or agitation?
  • Assign score +1 to +4 using the criteria listed above.


  • If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker.
  • Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1).
  • Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2).
  • Patient has any movement in response to voice, excluding eye contact (score -3)


  • If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response.
  • Patient has any movement to physical stimulation (score -4).
  • Patient has no response to voice or physical stimulation (score -5).





Combative, violent, immediate danger to staff


Very Agitated

Pulls to remove tubes or catheters; aggressive



Frequent non-purposeful movements, fights ventilator



Anxious, apprehensive, movements not aggressive


Alert & calm

Spontaneously pays attention to caregiver



Not fully alert, but has sustaind awakening to voice (more than 10 sec)


Light sedation

Briefly awakens to voice (less than 10 sec)


Moderate sedation

Movement or eye opening to voice


Deep sedation

No response to voice, but movement or eye opening to physical stimulation



No response to voice or physical stimulation

Calculate sedation score (RASS, N-PASS, COMFORT, etc.) and select post-intubation sedation

NOTE: All intubations should be approached as 'difficult' no matter what the underlying assumptions may be.

Intubation by advanced airway provider?

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