The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Rapid Sequence Induction

by Kevin Martinez
with Patrick Hymel

Indications
Procedure
Complications

Indications

• RSI is indicated in patients who require incubation and have recently ingested food or have an uncertain history.
  
• This technique couples sedation to induce unconsciousness (induction) with muscular paralysis.
  
• Common circumstances include head trauma, intoxication, cardiac emergency, multiple trauma, seizures and respiratory failure.

Procedure

1. Preoxygenate the patient for 5 minutes with 100% oxygen by facemask or 4 tidal volume breaths of 100% oxygen if patient is conscious.
   
2. Prepare equipment for intubation.
   
3. Pretreatment
   • Lidocaine (1.0-1.5 mg/kg IV) to possibly reduce rise in intracranial pressure in head trauma patients may be considered.
     
   • Defasciculate with a nondepolarizing agent if succinylcholine is used as paralytic.
     • Vecuronium (0.02 mg/kg IV) OR
       
     • Succinylcholine (0.1 mg/kg IV)
   • Atropine (0.01-0.02 mg/kg IV) for pediatric or bradycardic patients.

   *If possible, wait, 2 minutes for pretreatment to take effect

4. Induction.
   • Thiopental (3-5 mg/kg IV) reduces intracranial pressure in head injury. Dose is 0.5-1.0 mg/kg in a hypotensive patient. Contraindicated in asthmatics. For patients needing analgesia in addition to induction consider opiates (fentanyl 2-10 micrograms/kg IV) OR
     
   • Etomidate (0.2-0.3 mg/kg IV) OR
     
   • Ketamine (1 -2 mg/kg IV) increases cardiac output, vasoconstriction in hypotensive patient; bronchodilates in asthmatic patient.
5. Apply cricoid pressure (Sellick maneuver)
   Important in preventing aspiration.
   
6. Paralysis
   • Succinylcholine (1.0-1.5 mg/kg IV) contraindicated in bum patients or patients with preexisting paralysis because of resultant hyperkalemia. OR
     
   • Vecuronium (0.2 mg/kg) for patients with increased intracranial pressure or those in status asthmaticus
7. Intubate (see endotracheal intubation)
   
8. Release cricoid pressure once ETT placement is confirmed via auscultation or end tidal CO2

Complications

• Complications secondary to intubation or inability to secure an airway.
  
• Succinylcholine may cause fasciculations and increased intracranial pressure, both of which may be prevented by defasiculation. It may also cause malignant hyperthermia, hyperkalemia, and dysrrythmias.
  
• Ketamine is associated with emergence phenomenon hallucinations and dysphoria upon emergence from sedation. Treat with benzodiazipines.
  
• Thiopental may cause hypotension, laryngospasm, or bronchospasm (contraindicated in reactive airway disease).