Rapid Sequence Induction

Rapid Sequence Induction - Why, When, Wow!

• Why perform RSI? For rapid airway control, crucially preventing pulmonary aspiration in high-risk patients.

  ⭐ Primary goal of RSI is to minimize the risk of pulmonary aspiration in patients with a full stomach.

• Key Indications:
  • Emergency surgery.
  • Full stomach (e.g., trauma, pregnancy, bowel obstruction, GERD, uncontrolled diabetes).
• Key Goals/Features:
  • Achieve swift, definitive airway.
  • Minimize time to intubation.
  • Avoid Bag-Mask Ventilation (BMV) pre-intubation to limit gastric insufflation.

Rapid Sequence Induction - Breathe Easy Now

• Aim: Rapid airway control, ↓ aspiration risk (full stomach, emergency).
• Core Sequence:
  • Preparation: Check equipment, drugs (e.g., Propofol, Suxamethonium/Rocuronium), suction.
  • Pre-oxygenation: 100% O₂ for 3-5 min.

    ⭐ Effective pre-oxygenation with 100% O₂ for 3-5 minutes can provide an apneic window of up to 8 minutes in a healthy adult.

  • Induction & Paralysis: Simultaneous IV push.
  • Intubation: No/gentle Bag-Mask Ventilation (BMV) prior. Cricoid pressure (Sellick). Confirm placement.

Rapid Sequence Induction - The Knockout Crew

• Goal: Rapid unconsciousness & paralysis to secure airway, minimizing aspiration risk.
• Induction Agents (IV):
  • Propofol: 1.5-2.5 mg/kg. Rapid onset, short duration. ↓BP, apnea.
  • Etomidate: 0.2-0.3 mg/kg. Hemodynamically stable. Adrenal suppression. Myoclonus.
  • Ketamine: 1-2 mg/kg. Sympathomimetic (↑HR, ↑BP). Analgesic. Emergence delirium.
• Neuromuscular Blocking Agents (NMBAs):
  • Succinylcholine (SCh): 1-1.5 mg/kg. Depolarizing. Fastest onset (30-60s).

    ⭐ Succinylcholine, despite its side effects, remains the fastest onset NMBA, crucial for RSI, but contraindicated in severe burns after 24h and crush injuries due to hyperkalemia risk.

  • Rocuronium: 0.6-1.2 mg/kg. Non-depolarizing. Longer onset (60-90s). Reversible with Sugammadex.
• 📌 P.L.S. (Please Let's Secure-airway): Preparation, Preoxygenation, Pretreatment, Paralysis with induction, Positioning, Placement of tube, Post-intubation management (not part of RSI itself but crucial follow-up).

Rapid Sequence Induction - The Swift Seven

📌 The 7 P's of RSI:

• Preparation: Equipment, drugs, team ready.
• Preoxygenation: 100% O₂ for 3-5 min or 8 vital capacity breaths/60s. Target ETO₂ >90%.
• Pretreatment (Optional): Lidocaine, fentanyl, atropine (if indicated).
• Paralysis & Induction: Co-administer:
  • Sedative: Propofol 1.5-2.5 mg/kg / Etomidate 0.2-0.3 mg/kg.
  • NMB: Succinylcholine 1-1.5 mg/kg / Rocuronium 1-1.2 mg/kg.
• Protection & Positioning: Cricoid pressure (Sellick's), sniffing position.

  ⭐ Cricoid pressure (Sellick's maneuver) involves applying 10N of force before LOC and 30N after LOC, aimed at occluding the esophagus.

• Placement & Proof: Intubate. Confirm: ETCO₂, chest rise, auscultation.
• Post-intubation Management: Secure ETT, ventilate, post-intubation care.

Rapid Sequence Induction - Trouble Shooters' Guide

• Hypotension: IV fluids, vasopressors.
• Hypoxemia: ↑FiO2, optimize PEEP, airway maneuvers, LMA.
• Difficult Airway: Follow algorithm; VL, SGA, bougie, surgical kit.
• Aspiration: Cricoid pressure (Sellick’s), immediate suction, consider antibiotics.
• Laryngospasm: 100% O2, PPV, Larson's maneuver, suxamethonium ($0.1 \text{ mg/kg}$ IV).
• Bradycardia: Atropine ($0.02 \text{ mg/kg}$).

⭐ In a 'Can't Intubate, Can't Oxygenate' (CICO) scenario during RSI, progression to a surgical airway (e.g., cricothyroidotomy) must be rapid and decisive.

High‑Yield Points - ⚡ Biggest Takeaways

• RSI aims to rapidly secure the airway in full stomach patients, minimizing aspiration risk.
• Preoxygenation with 100% O2 for 3-5 minutes or 4 vital capacity breaths is crucial.
• Cricoid pressure (Sellick’s maneuver) at 30N is applied before loss of consciousness until cuff inflation.
• Common induction agents: Propofol; Etomidate for hemodynamic stability; Ketamine for bronchospasm/hypotension.
• Paralytics: Succinylcholine (gold standard, rapid onset/offset) or high-dose Rocuronium.
• Traditionally, no bag-mask ventilation (BMV) before intubation to prevent gastric insufflation and aspiration.