Rapid Sequence Intubation

Assisting in Rapid Sequence Intubation

 The most common protocol used for rapid sequence intubation (RSI) includes use of the drug succinylcholine for induction. Succinylcholine is absolutely contraindicated in patients who have a family history of malignant hypertension, burn injuries that are more than 24 hours old, or crush injuries more than 7 days old. These patients are at risk for developing life-threatening hyperkalemia.11 Penetrating eye injuries are considered relative contraindications to RSI because of the increased intraocular pressure resulting from some of the medications; alternatives may need to be considered.2,6

The administration of neuromuscular blocking agents (NMBAs), such as succinylcholine, should only be performed by those who are educated about the indications, side effects, and complications of NMBAs. Some states only allow specific personnel to administer these medications. Anyone without adequate airway training should never administer these medications.

Alternative airways such as a Combitube or cricothyrotomy equipment should always be available.

Administer premedications as prescribed: 

1.  Give lidocaine to attenuate the increase in intracranial pressure associated with intubation. Lidocaine is usually used for patients with head injuries. Administer the lidocaine approximately 90 seconds before administering succinylcholine.
2.  Give atropine to minimize the bradycardic impact of succinylcholine for children younger than 10 years of age.
3.  Give vecuronium or another nondepolarizing paralytic agent at one tenth of the paralytic dose. This is a defasciculating dose and may be used when succinylcholine is the prescribed paralytic.
4.  As soon as the defasciculating dose is administered or the patient begins to lose consciousness, apply cricoid pressure as directed by the intubator.
5.  Maintain cricoid pressure throughout the procedure until ETT placement is verified and the cuff is inflated.
6.  Administer the induction agent of choice as directed.
7.  Administer the NMBA of choice as directed.
8.  The patient will be orally intubated by the physician or intubator.
9.  Verify ETT placement, inflate the cuff, and ventilate the patient with 100% oxygen while manually maintaining tube placement.
10. Release cricoid pressure as directed.
11. Have suction immediately available in case of regurgitation when cricoid pressure is released.
12. Secure the ETT.
13. Administer long-acting paralytic agents as prescribed. Patients in whom pharmacologic neuromuscular blockade has been achieved also require sedation and/or analgesia.
14. Decompress the stomach with a gastric tube.
15. If intubation is unsuccessful and an alternative airway must be established, be prepared for the use of an alternative airway.