Rapid Sequence Intubation in Adults For Emergency Medicine and Critical Care - UpToDate

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Rapid sequence intubation in adults for emergency

medicine and critical care
AUTHORS: Calvin A Brown, III, MD, John C Sakles, MD
SECTION EDITOR: Ron M Walls, MD, FRCPC, FAAEM
DEPUTY EDITOR: Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Nov 16, 2023.
INTRODUCTION
Rapid sequence intubation (RSI) is the preferred method for securing the airway in the
critically ill or injured patient. RSI involves the administration of an anesthetic induction
agent followed quickly by a neuromuscular blocking agent (NMBA) to create optimal
intubating conditions and minimize both the duration of the patient's apnea and the time
the airway is unprotected. RSI presupposes the patient is at risk for aspiration of gastric
contents and incorporates medications and techniques to minimize this risk. Use of RSI also
helps to mitigate the potential adverse effects of airway manipulation.
This topic reviews the central concepts and techniques needed to perform RSI in adults in
the emergency setting outside the operating room. RSI for anesthesia, RSI in children, the
medications used for emergency RSI, and other subjects related to emergency airway
management are reviewed separately:
● Medications used for RSI in adults (see "Induction agents for rapid sequence intubation
in adults for emergency medicine and critical care" and "Neuromuscular blocking
agents (NMBAs) for rapid sequence intubation in adults for emergency medicine and
critical care")
● RSI in children (see "Rapid sequence intubation (RSI) in children for emergency
medicine: Approach" and "Rapid sequence intubation (RSI) in children for emergency
medicine: Medications for sedation and paralysis")
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● Basic and advanced airway management (see "Basic airway management in adults"
and "Extraglottic devices for emergency airway management in adults" and "Direct
laryngoscopy and endotracheal intubation in adults" and "Video laryngoscopes and
optical stylets for airway management for anesthesia in adults")
DEFINITION AND KEY CONCEPTS
RSI is the virtually simultaneous administration of an induction agent and a neuromuscular

blocking agent to induce unconsciousness and paralysis to facilitate rapid tracheal
intubation. The technique is designed to maximize the likelihood of successful intubation
and minimize the risk of aspiration. Maximal preoxygenation and hemodynamic
optimization are essential prior to drug administration. (See "Induction agents for rapid
sequence intubation in adults for emergency medicine and critical care" and
"Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults for
emergency medicine and critical care".)
RSI is associated with increased first-pass success rates (ie, successful endotracheal tube
[ETT] placement on the first intubation attempt) and reduced incidence of complications [1-
3]. Maximizing first-pass success hinges primarily on:
● Robust preoxygenation
● Correct dosages and timing of intubation medications
● Use of a videolaryngoscope
Adequate preoxygenation allows maximal time for successful tube placement without
hypoxemia. Administering the right doses of induction agent and NMBA, and allowing
sufficient time for the drugs to distribute and exert their effects, ensures that the patient is
unconscious and has adequate muscle relaxation to permit intubation. In a large meta-
analysis involving many thousands of intubations, videolaryngoscopy was found to improve
first-pass success and reduce complications [4]. This meta-analysis included findings from
over 200 studies, including 21 conducted outside the operating room (six prehospital, seven
emergency department, and eight intensive care unit). A study from the National Emergency
Airway Registry demonstrated that the advantage of videolaryngoscopy over direct
laryngoscopy for first-pass intubation success extends from novice to experienced
intubators [5].
Preoxygenation creates a large intrapulmonary and tissue reservoir of oxygen that allows
patients to tolerate a period of apnea without clinically significant oxygen desaturation. This
avoids the need for positive-pressure ventilation during the apneic phase of RSI, during
which the patient is not breathing spontaneously but is not yet sufficiently paralyzed to
facilitate intubation. Patients undergoing emergency intubation are presumed to have full
stomachs and are therefore considered at high risk for aspiration. Accordingly, interposed
face mask ventilation is generally avoided to help prevent gastric insufflation and the risk of
aspiration. When the risk and consequences of desaturation are judged to exceed those of
aspiration, oxygenation may be provided using gentle face mask ventilation between the
time of drug administration and initiation of laryngoscopy. (See 'Preoxygenation' below.)
Induction agents are given by rapid intravenous (IV) push during RSI, putting critically ill
patients at risk for developing hypotension. When circumstances allow, such risk can be
mitigated by the choice and dose of the induction agent, as well as by optimization of
cardiovascular status, as clinically indicated, using crystalloids, blood products, vasopressors,
or inotropes prior to administering RSI drugs. (See 'Physiologic optimization' below.)
When performing RSI in a patient with a predicted difficult airway, the clinician must have a
backup plan to execute in the event intubation is unsuccessful, including immediate access
to the equipment necessary to restore oxygenation. Such equipment generally includes a
bag and mask device, extraglottic airway, and instruments for providing a surgical airway.
(See "Approach to the difficult airway in adults for emergency medicine and critical care" and
"Basic airway management in adults" and "Extraglottic devices for emergency airway
management in adults" and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)
INDICATIONS
RSI is the most common and preferred method for securing control of the airway in critically
ill patients when not contraindicated by the presence of significant anatomic or physiologic
abnormalities. [6-12].
RSI may also be the preferred approach in the patient with an anatomically difficult airway if
the intubator is confident that gas exchange can be maintained, either by successful
intubation or by use of a bag and mask or extraglottic airway. In a registry study of
emergency department intubations, 80 percent of patients with predicted anatomically
difficult airways were managed with RSI using a videolaryngoscope with a high first-pass
success rate [13]. (See "Approach to the difficult airway in adults for emergency medicine
and critical care".)
CONTRAINDICATIONS AND PRECAUTIONS
Contraindications to RSI are relative. The most important contraindication to RSI is

anticipation of difficult or impossible rescue oxygenation. In patients who cannot tolerate
apnea (eg, refractory hypoxemia or severe metabolic acidosis is present), neuromuscular
blockade may be undesirable, and an "awake" intubation approach (ie, use of topical
anesthesia and light sedation) is preferred to minimize the likelihood of precipitous

deterioration.
Medications and doses for induction and neuromuscular blockade should be selected to
achieve airway management goals while minimizing side effects. Particular drugs used for
RSI are discussed in detail separately. (See "Neuromuscular blocking agents (NMBAs) for
rapid sequence intubation in adults for emergency medicine and critical care" and
"Induction agents for rapid sequence intubation in adults for emergency medicine and
critical care".)
Many critically ill patients experience significant hypoxemia or hypotension during the peri-
intubation period. To minimize the risk of these complications, patients should be
physiologically optimized prior to intubation whenever time allows. (See 'Physiologic
optimization' below.)
Properly performed preoxygenation using the most appropriate methods given clinical
circumstances is the most important measure to prolong safe apnea time and prevent
desaturation during intubation. However, hypoxemic patients may have severe
intrapulmonary shunting and refractory hypoxemia despite supplemental oxygen.
Optimization in patients with high shunt fractions includes preoxygenation with high-flow
nasal oxygen (HFNO) or noninvasive positive-pressure ventilation (NIPPV). If oxygen
saturation (SpO2) ≥93 percent cannot be achieved with these methods, the risk of severe
hypoxemia during RSI is high, and an "awake" technique maintaining spontaneous
ventilation may be preferred. In patients with hypotension and shock, RSI remains the
preferred approach provided deranged hemodynamics are mitigated with fluid or blood
administration and norepinephrine [14,15].
PERFORMANCE OF RSI
The updated "seven Ps of RSI" is a mnemonic that outlines the key steps of RSI planning and
performance ( table 1) [16-18]:
● Preparation
● Preoxygenation
● Physiologic optimization
● Paralysis with induction
● Positioning
● Placement with proof
● Postintubation management
Pretreatment with medications to reduce the effects of laryngoscopy and intubation on the
nervous system should be viewed as a supplementary (ie, nonessential) step in RSI to be
performed in specific clinical circumstances if time permits. The role of such pretreatment is
reviewed separately. (See "Pretreatment medications for rapid sequence intubation in adults
for emergency medicine and critical care".)
Preparation — The goal of preparation is to maximize the chances for successful intubation
on the first attempt without adverse events [19]. Studies suggest that the risk of an adverse
event during emergency tracheal intubation (eg, hypoxemia, hypotension, esophageal
intubation) increases significantly with the number of attempts [20-22]. An observational
emergency department study of 1828 intubations reported that 14 percent of patients
intubated on the first pass experienced an adverse event compared with 47 percent of those
intubated on the second attempt and 64 percent of those intubated on the third attempt
[20].
Basic preparation steps — Preparation for RSI includes:
● Assessing the patient's airway for potential anatomic or physiologic difficulty (see
'Identifying anatomic or physiologic difficult airways' below)
● Developing an airway management plan (including a backup strategy)
● Assembling all necessary personnel, equipment, and medications
The following table summarizes these steps ( table 2). A detailed discussion of the steps
needed to prepare for intubation is provided separately. (See "Direct laryngoscopy and
endotracheal intubation in adults", section on 'Preparation'.)
Prior to proceeding with RSI, at least one, but preferably two, functioning intravenous (IV)
lines should be in place, as should cardiac and blood pressure monitors, pulse oximetry, and
capnography. (See "Pulse oximetry" and "Carbon dioxide monitoring (capnography)".)
Patients undergoing airway management should be in an appropriate clinical area where all
necessary airway and resuscitation equipment is available. The airway manager should have
easy access to the head of the bed and should adjust the height of the bed and position of
the patient to facilitate intubation. The equipment and steps necessary to prepare for and
perform tracheal intubation are reviewed separately. (See "Direct laryngoscopy and
endotracheal intubation in adults" and "Video laryngoscopes and optical stylets for airway
management for anesthesia in adults", section on 'Videolaryngoscopy'.)
Identifying anatomic or physiologic difficult airways — Once the need for intubation is
determined, and prior to committing to RSI as the method of intubation, the clinician
assesses the patient for anatomic features and clinical findings that indicate the patient may
be difficult to intubate or to ventilate using a bag-mask, or in whom it may be difficult to use
a rescue airway, such as an extraglottic device. (See "Approach to the difficult airway in
adults for emergency medicine and critical care".)
Although the presence of markers for difficult intubation or difficult bag-mask ventilation is
not an absolute contraindication to RSI, if such features are identified, alternatives to RSI
may be preferred. If the clinician chooses to proceed with RSI in the presence of such
markers, comprehensive backup plans are required, and all resources needed to enact each
plan must be available at the bedside.
In addition, an assessment must be performed for the presence of any physiologic

derangements that increase the risk of cardiovascular collapse after the administration of
RSI medications and transition to positive-pressure ventilation. The strongest predictors of
peri-intubation circulatory arrest are hypotension (systolic blood pressure <100 mmHg),
elevated shock index (heart rate divided by systolic blood pressure >0.8), and hypoxemia
(oxygen saturation [SpO2] <93 percent) [23-25]. Therefore, these must be recognized and,
whenever possible, corrected before RSI medications are given. (See 'Physiologic
optimization' below.)
Right ventricular failure and severe metabolic acidosis are less common conditions, but they
too can cause rapid physiologic deterioration with RSI [14]. Patients with profound metabolic
acidosis may experience a precipitous deterioration even during brief periods of apnea when
compensatory elimination of carbon dioxide is halted. Severe asthma, active myocardial
ischemia, tachydysrhythmias, and all forms of shock require a tailored approach that results
in successful tube placement and minimal risk of hypoxic insult or circulatory collapse.
Choosing between RSI and awake intubation — If an anatomically difficult airway is

predicted, rapid desaturation is anticipated, or refractory hemodynamic instability is present,
RSI may not be the safest way to achieve airway control. Instead, an "awake intubation," in
which topical anesthesia is applied to the upper airway, sometimes in combination with light
sedation, may be preferred [26,27]. The benefit of the awake intubation is that the patient
maintains spontaneous ventilation, thereby avoiding the dangers of apnea and
hemodynamic compromise associated with RSI medications. However, awake intubation has
potential drawbacks. It may be poorly tolerated, requires adequate time for topical
anesthesia to take effect, and takes longer to achieve intubation. In rare cases, awake
intubation can precipitate complete airway obstruction, emphasizing the importance of a
rescue plan in the event this occurs [28].
Choosing between RSI and awake intubation can be difficult, and the clinician must carefully
consider the pros and cons of each approach in the individual patient, including available
equipment, medications, and personnel, to determine the best course. Discussions of how
to determine the need for intubation and to identify airways that are potentially difficult to
intubate or ventilate are provided separately. (See "The decision to intubate" and "Approach
to the difficult airway in adults for emergency medicine and critical care".)
With RSI as the chosen technique, the clinician selects the appropriate induction and
neuromuscular blocking agents (NMBAs) to be used and determines the doses. The
medications to be used are drawn up into labeled syringes, and standard closed-loop
communication protocols are used to ensure proper dosing. (See "Induction agents for rapid
sequence intubation in adults for emergency medicine and critical care" and
"Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults for
emergency medicine and critical care".)
Preoxygenation
General guidelines and common scenarios — Preoxygenation increases the safety of RSI.
Any patient requiring urgent tracheal intubation ideally should be preoxygenated for a
minimum of three minutes using oxygen delivered at the highest flow rate available (ideally
at flush rate: 40 to 70 liters per minute) via a nonrebreather mask [29,30]. Using the flush
rate (wide open) should be encouraged and is advantageous compared with the "standard"
10 to 15 liters per minute commonly used with nonrebreather masks in other circumstances.
Preoxygenation replaces the nitrogen in the gas-exchanging portions of the lung (functional
residual capacity) with oxygen, thereby creating a large oxygen reservoir. This significantly
prolongs the safe apneic period of RSI [31,32]. Common conditions that cause oxygen
desaturation or exacerbate hypoxemia during RSI and interventions to help prevent or
manage them are summarized in the following table ( table 3).
Researchers have characterized the expected time to desaturation below 90 percent after
apnea is induced in properly preoxygenated patients of various ages and comorbid
conditions ( figure 1) [33]:
● Healthy 70-kg male: 6 to 8 minutes

● Young children (10 kg): <4 minutes
● Adults with chronic illness or obesity: <3 minutes
● Patient at near full-term pregnancy: <3 minutes
Critically ill patients in the emergency department or intensive care unit often desaturate
even more quickly.
The important concept is that preoxygenation provides a longer period before clinically
significant desaturation, regardless of the patient's condition, age, and body habitus.
Continuous monitoring of oxyhemoglobin saturation by pulse oximetry is essential during
RSI. This task should be assigned to an individual who can reliably track and regularly report
the information without other tasks or distractions. When assessing SpO2, remember that
pulse oximetry readings obtained with a finger probe may lag behind the central arterial
circulation, particularly in critically ill patients [29,34].
There are multiple ways to perform preoxygenation in the critically ill depending on the
clinical scenario:
● Inadequate spontaneous ventilation ‒ In the patient with inadequate spontaneous

ventilation, preoxygenation should be performed using gentle positive-pressure
ventilation with a bag mask at flush-flow rate with a synchronous bag-assist technique
(ie, clinician delivers ventilations simultaneously with the patient's inhalation). It is
important to ventilate these patients with pressures less than 20 cm H2O to avoid
gastric insufflation. However, in patients with high intrinsic airway pressures (eg,
morbid obesity, severe asthma), greater force may be required to ventilate. In such
patients, we recommend that cricoid pressure be applied during bag-mask ventilation.
This maneuver compresses the cervical esophagus, thereby minimizing gastric
insufflation and reducing the risk of aspiration [35,36]. (See 'Cricoid pressure (Sellick
maneuver)' below.)
● Adequate spontaneous ventilation and cooperative ‒ In cooperative patients with

adequate spontaneous ventilation, preoxygenation can be performed with a
nonrebreather mask with flush-flow rate oxygen. Flush-flow rate oxygen is obtained by
opening the knob on the flow meter completely (ie, until it won't turn any farther in the
"open" direction).
Traditional flow rates of 15 liters per minute provide inadequate preoxygenation since leak
around the margin of the mask limits the fraction of inspired oxygen (FiO2) to approximately
65 percent. Flush rate oxygen (40 to 70 liters per minute depending on the oxygen source
and flow meter type) attenuates entrainment of room air around the margin of the mask
and increases the FiO2 to 90 percent or more, thereby providing maximal nitrogen washout
and, thus, a larger oxygen reservoir [37]. However, flush rates of oxygen vary considerably
among hospitals. Flush rates as low as 20 liters per minute have been reported [38,39]. If
circumstances do not allow for three minutes of preoxygenation, eight full, vital-capacity
breaths (the deepest breaths the patient can be coached to take) can provide adequate
preoxygenation in cooperative patients within one minute.
● Adequate spontaneous ventilation but uncooperative ‒ In patients who are

uncooperative and unable to tolerate any preoxygenation efforts, some advocate using
a delayed sequence intubation (DSI) technique. DSI involves the administration of a
dissociative dose of ketamine (1 mg/kg IV or 3 to 5 mg/kg intramuscularly [IM])
intended to sedate the patient sufficiently to allow effective preoxygenation without
depressing respiratory drive. Once ketamine takes effect, preoxygenation is performed
as for a cooperative patient with adequate spontaneous ventilation.
Great care must be taken when using DSI, as even a small dose of ketamine in the
critically ill can cause apnea or hypotension. The clinician should be ready to assume
complete control of the airway and manage hypotension as soon as ketamine is
administered.
There are few reports or studies of DSI, and the safety of this technique has not been
demonstrated, nor is it known whether this approach reduces adverse events
compared with RSI in such patients. Specifically, it is not known whether DSI is superior
to simply providing oxygenation via positive pressure using a bag mask beginning
immediately after induction. (See 'Adjunct strategies to maximize preoxygenation'
below.)
In a small observational study in intensive care unit and emergency department

patients, those managed with DSI showed improvements in preoxygenation [40]. A
before-and-after prehospital study reported that the implementation of a multi-
interventional airway "bundle," including routine administration of ketamine to
facilitate preoxygenation, reduced the rate of peri-intubation hypoxemia from 44 to 4
percent [41]. The bundle also required that oxygenation targets (>93 percent SpO2 for
three minutes) be met before RSI could be performed. Therefore, the direct impact of
ketamine was difficult to determine.
Right-to-left intrapulmonary shunting — When airspace disease (eg, pneumonia, acute

respiratory distress syndrome) causes significant right-to-left intrapulmonary shunting, the
above methods of preoxygenation may not be effective. Patients with such shunts require
positive end-expiratory pressure (PEEP) to promote alveolar recruitment and maximize the
efficacy of preoxygenation efforts. Although a bag mask with a PEEP valve may be used, we
recommend noninvasive ventilation in this setting [42-44]. The use of noninvasive ventilation
for acute respiratory failure and the benefits of positive-pressure ventilation to improve
preoxygenation are reviewed separately. (See "Noninvasive ventilation in adults with acute
respiratory failure: Benefits and contraindications".)
If a patient cannot tolerate noninvasive ventilation for preoxygenation, the use of a high-
flow nasal oxygen (HFNO) system (eg, Optiflow or Vapotherm) is a reasonable alternative
( figure 2) [45-47]. Studies on HFNO for preoxygenation in the critically ill are mixed, but
some have demonstrated favorable results [48,49]. (See "Heated and humidified high-flow
nasal oxygen in adults: Practical considerations and potential applications" and
"Preoxygenation and apneic oxygenation for airway management for anesthesia".)
Adjunct strategies to maximize preoxygenation — Additional strategies to prevent or

delay oxygen desaturation during emergency airway management include the following
[29]:
● Proper positioning ‒ When immobilization for possible spinal injury is not required,
preoxygenation is improved by placing the patient in at least a 30-degree head-up
position [50-52]. Alternatively, reverse Trendelenburg positioning (bed kept flat but
tilted at an angle with patient's head up ( figure 3)) may be used for patients
requiring spinal injury precautions. The benefits of the head-up or ramp position for
obese patients ( figure 4) are discussed separately. (See "Airway management in the
morbidly obese patient for emergency medicine and critical care", section on
'Preoxygenation'.)
● Continuous passive oxygenation during apnea ‒ During the apneic period of RSI, the
airway manager can provide oxygen via nasal cannula at a flow rate of 15 liters per
minute. As passive oxygenation (also known as apneic oxygenation) is a simple, low-
cost intervention, we encourage its routine use during emergency intubation,
particularly if intubation is anticipated to be difficult or prolonged, or the patient has
reduced oxygen reserves. HFNO can be used instead of standard nasal tubing when
higher levels of apneic oxygenation are needed due to hypoxemia or a high risk of
desaturation ( figure 2).
The evidence supporting the efficacy and safety of passive oxygenation during
emergency RSI comes from randomized trials and meta-analyses involving patients
undergoing RSI in the intensive care unit and emergency department settings [53-59].
In a meta-analysis of six trials including 1015 patients undergoing RSI in the intensive
care unit (five trials) or emergency department (one trial), mortality was lower for
patients who received passive oxygenation during RSI compared with those who did
not receive apneic oxygenation (24 versus 31 percent, respectively), a finding that was
of borderline statistical significance (RR 0.84, 95% CI 0.7-1.0) [59]. A possible mortality
benefit was observed in these trials despite lack of a clear difference in the incidence of
severe hypoxemia (defined as SpO2 <80 percent) during RSI in the two groups (17
versus 19 percent, respectively; RR 0.89, 95% CI 0.68-1.16).
Use of passive oxygenation in this setting is also supported by observational studies

[55,56,60-62]. In a meta-analysis that pooled the results of four of the trials above plus
four observational studies (1834 patients in total), the incidence of clinically significant
hypoxemia (variably defined as SpO2 <90 or <93 percent) was lower in the group who
received passive oxygenation during RSI compared with those who did not (20 versus
28 percent, RR 0.70, 95% CI 0.59-0.82) [55].
Additional support for passive oxygenation comes from studies involving patients
undergoing elective intubation in the operating room. These data are discussed in
detail separately. (See "Preoxygenation and apneic oxygenation for airway
management for anesthesia".)
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● Gentle ventilation for patients who cannot tolerate apnea ‒ Many patients who are
physiologically deranged (eg, hypotension, acidosis, refractory hypoxemia from
intrapulmonary shunting) but require emergency intubation have a greatly reduced
tolerance for apnea [14,60]. In such cases, the clinician may wish to perform a modified
RSI technique that includes gentle, manual, positive-pressure ventilation during the
"apneic" period of RSI [61]. Alternatively, RSI can be avoided altogether and an awake
intubation performed, although this technique too can lead to hypoxemia [26].
Regardless of technique, it is essential to address underlying physiologic compromise
prior to beginning RSI. (See 'Physiologic optimization' below.)
A reasonable approach when deciding whether to provide mask ventilation during RSI
is to assess the patient’s relative risk for hypoxemia and aspiration. If the risk of
desaturation and hypoxemia is high, gentle mask ventilation can be performed during
induction; if the risk of aspiration is higher, mask ventilation should be avoided if
possible.
Bag-mask ventilation during the apneic period of RSI is most likely to benefit patients
with severe hypoxemia or those who are anticipated to desaturate rapidly following the
administration of RSI medications. These scenarios are more common among patients
with severe respiratory disease, who are often being treated in the intensive care unit.
Such patients are often hypoxemic at baseline and, although gastroparesis places
some at risk for aspiration, they are usually at lower risk for aspiration than emergency
department patients. Thus, the risk-benefit assessment often favors mask ventilation
during RSI. (See "Basic airway management in adults", section on 'Bag-mask
ventilation'.)
Conversely, it is best not to perform bag-mask ventilation during the apneic period of
RSI in patients at relatively high risk for aspiration. Such patients are more common in
the emergency department. They may include patients with active upper
gastrointestinal bleeding, hematemesis, or vomiting; victims of trauma with full
stomachs or blood in their airway; or patients who have deteriorated rapidly and
whose gastric contents are unknown. The risk-benefit assessment favors not
performing mask ventilation during RSI in these patients.
The efficacy of gentle mask ventilation in this setting is supported by a multicenter trial
performed in seven intensive care units across the United States [62]. In this trial, 401
patients requiring intubation were randomly assigned to RSI with or without assisted
ventilation using a bag mask during the induction phase. Patients in the ventilation
group received bag-mask ventilation using 15 liters per minute of oxygen, peak end-
expiratory pressure of 5 to 10 cm H2O, a rate of 10 breaths per minute, a two-handed
mask seal, an oropharyngeal airway, and the smallest volume necessary to generate
visible chest rise. The ventilation group experienced a significantly lower prevalence of
severe hypoxemia (SpO2 <80 percent) compared with the no ventilation group (10.9
percent [21 patients] versus 22.8 percent [45 patients], relative risk [RR] 0.48, 95% CI
0.30-0.77), while witnessed aspiration rates were similar (2.5 versus 4 percent). While
these findings support the approach described, it should be noted that the study
lacked standardized preoxygenation protocols or a flush-rate oxygen control group,
and patients identified as being at high risk for aspiration (eg, recent episodes of
emesis, hematemesis, hemoptysis) were excluded from the trial.
● Techniques to increase airway patency ‒ If necessary, patency of the upper airway

can be maintained with adjuncts (nasal or oropharyngeal airways) and positioning
maneuvers (jaw thrust and/or chin lift). The chin lift is not used when spine injury
precautions are in place. (See "Basic airway management in adults", section on 'Airway
maneuvers'.)
Physiologic optimization — Historically, the concept of the difficult airway was related to
anatomic factors that made laryngoscopy and delivery of the ETT through the laryngeal inlet
difficult. Subsequently, greater emphasis has been placed on physiologic abnormalities that
complicate emergency airway management.
"The physiologically difficult airway" is one in which physiologic derangements place the
patient at great risk of cardiovascular collapse during the peri-intubation period [14,24,63-
66]. The most frequent derangements in patients requiring emergency intubation are
hypotension and hypoxemia. Physiologic optimization involves recognizing and addressing
areas of physiologic vulnerability that may complicate resuscitative efforts, even if tracheal
intubation goes quickly and smoothly.
● Common conditions that cause or exacerbate hypotension following RSI and

interventions to help prevent or manage them are summarized in the following table
( table 4).
● Common conditions that cause or exacerbate hypoxemia following RSI and

interventions to help prevent or manage them are summarized in the following table
( table 3).
Hemodynamic compromise should be managed aggressively to optimize conditions prior to

intubation whenever time permits. In patients with hypotension from volume depletion or
other clinical signs of hypovolemic shock, either isotonic fluid (20 to 30 mL/kg IV bolus) or
blood (1 to 2 units of packed red blood cells), tailored to the presumed cause, should be
rapidly administered. Patients unable to receive additional fluid (eg, acutely decompensated
heart failure), those who experience persistent hemodynamic derangements despite a fluid
challenge, and those who have vasodilatory shock are treated with a norepinephrine
infusion (starting dose 5 to 15 mcg/minute IV). The therapeutic target is normalization of the
systolic blood pressure, a mean arterial pressure of 65 mmHg, or resolution of clinical signs
of poor perfusion. In patients with cardiogenic shock, infusion of an inotrope (eg,
dobutamine or milrinone) can be initiated. (See "Treatment of severe hypovolemia or
hypovolemic shock in adults" and "Use of vasopressors and inotropes".)
Patients with hypoxemia due to significant air space disease and large right-to-left
physiologic shunts require aggressive preoxygenation incorporating positive-pressure
ventilation, as described above. (See 'Right-to-left intrapulmonary shunting' above.)
Noninvasive ventilation with high levels of PEEP helps to recruit alveoli and decrease the
shunt fraction, thereby increasing SpO2. The goal is an SpO2 >93 percent before induction
medications are administered. (See "Noninvasive ventilation in adults with acute respiratory
failure: Practical aspects of initiation" and "Mechanical ventilation of adults in the emergency
department", section on 'Approach to ventilated patient in distress'.)
Nearly all induction agents can cause peripheral vasodilation and myocardial depression.
Therefore, patients with reduced ejection fraction, depleted intravascular volume, or
ongoing bleeding can suffer circulatory collapse after RSI drugs are administered. The risk is
compounded by subsequent positive-pressure ventilation, which can further compromise
blood pressure through increased intrathoracic pressure and diminished venous return.
Several studies have investigated the prevalence of peri-intubation arrest associated with
critically ill patients in the emergency department and intensive care unit and report rates
ranging from 1 to 4 percent [23,67-70]. The two factors consistently found to be associated
with peri-intubation cardiac arrest were hypotension and hypoxemia, suggesting that
optimization of these two physiologic disturbances can help to reduce intubation-associated
morbidity and mortality.
A prospective observational study involving 244 intensive care unit intubations reported that
the introduction of a 10-point intubation care bundle resulted in the reduction of severe life-
threatening complications from 34 to 21 percent [15]. Three of the components of this
intubation bundle were aimed at optimization of physiology: preoxygenation with
noninvasive ventilation, IV fluid loading (in the absence of heart failure), and early
vasopressor use. In a multicenter trial of intensive care unit patients (n = 1065), those
randomized to receive a 500 mL IV bolus of isotonic fluid prior to intubation did not
experience lower rates of circulatory collapse compared with patients given no additional
fluid [71]. However, overall fluid status was not reported for enrolled patients, and some had
decompensated heart failure, limiting our ability to extrapolate from these results. While
these findings suggest that routine prophylactic fluid administration is not likely to be
helpful, targeted fluid resuscitation prior to RSI in hypotensive patients with volume
depletion remains a sensible intervention when time allows.
Paralysis with induction — The concept of RSI is based on the virtually simultaneous IV
administration of a rapidly acting induction agent and an NMBA (paralytic agent). Medication
selection and dosing are aimed at producing unconsciousness and complete muscular
relaxation quickly. RSI does not involve titration of either agent to reach this state. The dose
of each agent is precalculated to achieve the desired effect, and the drugs are administered
in sequence by rapid IV push. Onset of action after administration is variable depending on
the agent chosen, but the goal is to achieve unconsciousness and paralysis 45 to 60 seconds
after the drugs are given by IV push. A table summarizing RSI drug selection based upon the
clinical scenario is provided ( table 5).
Induction agents — The ideal induction agent for RSI acts quickly to provide a deep state
of unconsciousness without causing hemodynamic side effects. No available agent meets all
criteria. Drugs currently available include etomidate, ketamine, midazolam, and propofol.
The induction agents used for RSI are discussed in detail separately (see "Induction agents
for rapid sequence intubation in adults for emergency medicine and critical care"). A
summary table of induction agents is provided ( table 6).
While data about the safest induction agent are conflicting, what is certain is that all
induction agents can cause hypotension in the critically ill. Thus, we reduce the dose of the
induction agent in patients with hemodynamic instability. Fortunately, patients in shock have
compromised peripheral circulation, and lower doses reach the brain sufficiently to produce
unconsciousness.
Neuromuscular blocking agents — Use of an NMBA to produce rapid paralysis is the

cornerstone of RSI. For RSI, the NMBA is given immediately following administration of the
induction agent. Only two NMBAs have onset times short enough for RSI: succinylcholine
(standard RSI dose 1.5 mg/kg IV) and rocuronium (standard RSI dose 1.5 mg/kg IV). NMBAs
do not provide analgesia or sedation. NMBAs for RSI by emergency and critical care
clinicians are discussed in detail separately. (See "Neuromuscular blocking agents (NMBAs)
for rapid sequence intubation in adults for emergency medicine and critical care".)
The onset of effect for rocuronium is dose dependent, but at higher doses (eg, 1.5 mg/kg),
onset and intubation conditions are comparable to those provided by succinylcholine,
without its numerous potential side effects. Rocuronium has a prolonged duration of effect
relative to succinylcholine, and clinicians must make certain that timely and adequate
longer-term sedation is given when rocuronium is used. Studies suggest that following RSI
performed with rocuronium, the administration of sedative medications is often delayed
[72]. (See 'Postintubation management' below.)
Positioning and protection — This phase of RSI refers to positioning the patient for
laryngoscopy and protecting against aspiration prior to placement of the ETT. This can be
accomplished in part by elevating the head of the bed to approximately 30 degrees. This
elevates the laryngeal inlet above the level of the stomach, thereby minimizing the risk of
passive regurgitation and aspiration. Proper positioning for direct laryngoscopy is discussed
separately. (See "Direct laryngoscopy and endotracheal intubation in adults", section on
'Positioning the patient'.)
Once drugs are administered, respiratory activity decreases and then ceases entirely. Bag-
mask ventilation is deliberately avoided for adequately preoxygenated patients. Interposed
bag-mask ventilation may be necessary for patients at risk for severe hypoxemia. We
routinely use continuous passive oxygenation during RSI. (See 'Preoxygenation' above.)
Cricoid pressure (Sellick maneuver) — Although cricoid pressure (Sellick maneuver) was
once widely used during RSI, we no longer recommend routine application of cricoid
pressure during laryngoscopy and intubation. The use of cricoid pressure during RSI for
anesthesia is discussed separately (see "Rapid sequence induction and intubation (RSII) for
anesthesia", section on 'Cricoid pressure during RSII').
Cricoid pressure has been shown to reduce gastric insufflation during bag-mask ventilation,
but there is no convincing evidence that it reduces the incidence of aspiration of gastric
contents during intubation [36,73-77]. Several studies suggest it may contribute to airway
obstruction and difficulty intubating in some cases, even when a video laryngoscope is used
[73,78-81]. However, it is reasonable to apply cricoid pressure during RSI if bag-mask
ventilation is necessary, and we encourage doing so if high pressures are needed to provide
adequate ventilation using a bag mask.
A systematic review of cricoid pressure studies noted the following [73]:
● Case series and retrospective reviews describe both the success and failure of cricoid
pressure to prevent aspiration.
● Cricoid pressure is often used inconsistently and applied improperly in all airway
management settings.
● Cricoid pressure may impair the function of the lower esophageal sphincter.
● Possible risks from cricoid pressure include movement of unstable cervical spine
fractures and esophageal injury.
Placement with proof — After complete neuromuscular blockade is achieved, as assessed

by absence of masseter muscle tone (ie, laxity of the jaw with no resistance to mouth
opening), laryngoscopy is performed. The time to muscular relaxation will vary depending
on the NMBA used and dosing. When used with an appropriate induction agent, both
succinylcholine and rocuronium at 1.5 mg/kg IV generally produce excellent intubating
conditions within 45 seconds. If full neuromuscular paralysis is not achieved by 45 seconds,
we recommend waiting an additional 15 to 30 seconds for this to occur, while continuing to
monitor oxyhemoglobin saturation.
The goal of laryngoscopy is full and clear visualization of the glottic aperture. Once the
glottis is visualized, the clinician places the ETT between the vocal cords, inflates the cuff,
withdraws the stylet, and confirms placement. The performance of laryngoscopy is
described in detail separately. (See "Direct laryngoscopy and endotracheal intubation in
adults" and "Devices for difficult airway management in adults for emergency medicine and
critical care" and "Video laryngoscopes and optical stylets for airway management for
anesthesia in adults", section on 'Videolaryngoscopy'.)
Confirmation of proper ETT placement is crucial; unrecognized esophageal intubation leads

to devastating complications [82]. Waveform capnography is the most accurate means of
confirming ETT placement, and we recommend it be used with every intubation. If not
available, then capnometry or colorimetric end-tidal carbon dioxide (EtCO2) devices can be
used. For clinicians experienced with ultrasound, this provides another accurate method for
confirming proper tube position [83].
Clinical indicators alone, such as visualization of the ETT through the cords, misting of the
tube with ventilation, and auscultation of breath sounds over both lung fields, cannot be
relied upon to confirm proper ETT placement. A single-view chest radiograph is only useful
to determine depth of placement (eg, supraglottic versus tracheal versus mainstem). It is not
useful for distinguishing tracheal from esophageal intubation.
The methods for proving proper ETT placement are discussed in greater detail separately.
(See "Direct laryngoscopy and endotracheal intubation in adults", section on 'Confirming
proper tracheal tube placement'.)
Postintubation management — RSI remains incomplete until the properly placed ETT is
secured. Several techniques are commonly used to secure the tube, including taping, tying,
and using proprietary tube-holders. The technique employed for emergency department
airway management should be readily available, easy to apply, and secure. A post-
procedural chest radiograph is obtained to confirm depth of tube placement and to evaluate
for evidence of barotrauma as a consequence of positive-pressure ventilation. Mechanical
ventilation is initiated. Ventilator settings may need modification according to clinical
circumstance. (See "Direct laryngoscopy and endotracheal intubation in adults", section on
'Post-intubation management' and "Mechanical ventilation of adults in the emergency
department", section on 'Disease-specific ventilatory management'.)
Minor reductions in SpO2 and blood pressure may be observed in the immediate post-
intubation period as a result of apnea and administration of the induction agent. If these do
not rebound quickly with fluids and positive-pressure ventilation, or if previously stable vital
signs suddenly deteriorate after tube placement, the clinician should quickly search for signs
of a peri-intubation adverse event. This may include tension pneumothorax, ETT cuff
rupture, mucus plugging, interruption of the oxygen circuit, or esophageal intubation. (See
"Mechanical ventilation of adults in the emergency department", section on 'Approach to

ventilated patient in distress'.)
If longer-term neuromuscular blockade is needed, the timing of subsequent doses of both

NMBA and sedative agents should be anticipated. Providing both longer-term analgesia and
sedation is crucial for all patients following RSI given the relatively short duration of action of
the agents frequently used and the inability of paralyzed patients to communicate pain or
distress. In a retrospective review of over 800 emergency intubations performed in the
emergency department, 66 patients (7.4 percent) reported being aware while paralyzed [84],
while a multicenter registry study reported that nearly 14 percent of patients who
underwent RSI in the emergency department did not receive additional sedation within 15
minutes following administration of the initial induction agent [85]. Lapses in providing
adequate sedation were associated with peri-intubation hypotension and the use of
rocuronium.
Increases in heart rate or blood pressure may be an indication of inadequate sedation while
paralyzed. Appropriate analgesia and sedation guided by a validated sedation scale (eg,
Richmond Agitation Sedation Scale [RASS] ( table 7)) often obviate the need for
neuromuscular paralysis to permit mechanical ventilation. (See "Sedative-analgesia in
ventilated adults: Management strategies, agent selection, monitoring, and withdrawal".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Airway management
in adults".)
SUMMARY AND RECOMMENDATIONS
● Definitions and basic concepts – Rapid sequence intubation (RSI) uses a rapidly acting
induction agent and a neuromuscular blocking agent (NMBA) to create optimal
intubating conditions and enable rapid control of the airway. RSI presupposes the
patient is at risk for aspiration of gastric contents and incorporates medications and
techniques to minimize this risk. The basic approach to RSI consists of the "seven Ps" as
outlined below and in the text.
● Preparation – Assess the patient for anatomic features and clinical findings that
indicate the patient may be difficult to intubate or to ventilate using a bag mask. Make
an airway management plan, including a backup approach, based on the clinical
scenario. Gather equipment and medications. (See 'Preparation' above.)
● Preoxygenation – Preoxygenation performed with the patient sitting upright or in

reverse Trendelenburg ( figure 3) using a face mask or flush-flow oxygen via
nonrebreather mask for at least three minutes, and passive oxygenation via high-flow
nasal cannula thereafter, is recommended for all patients managed with RSI. Strategies
to maximize preoxygenation are provided. (See 'Preoxygenation' above.)
Preoxygenation enables patients to tolerate a longer period of apnea without

desaturation. The oxygen saturation (SpO2) of adults with severe illness or obesity, and
pregnant patients nearing the end of their third trimester, falls below 90 percent in less
than three minutes, even if ideal preoxygenation is achieved. Time to desaturation in
emergency practice is often more rapid than anticipated.
● Physiologic optimization – Unless the need for intubation is immediate, patients

undergoing emergency intubation should be physiologically optimized prior to the
procedure. This includes hemodynamic optimization with intravenous (IV) fluids, blood
products, vasopressors, and inotropes as necessary; relief of hemopneumothorax and
hemostasis for trauma patients; and maximal preoxygenation for all. (See 'Physiologic
optimization' above.)
• Hypotension following RSI and interventions to help prevent or manage it are

summarized in the following table ( table 4).
• Hypoxemia following RSI and interventions to help prevent or manage it are

summarized in the following table ( table 3).
● Paralysis with induction – RSI involves the virtually simultaneous IV administration of

a rapidly acting induction agent and NMBA to produce deep sedation and muscular
relaxation. The characteristics of the induction agents used for RSI are summarized in
the following table ( table 6). A table summarizing RSI drug selection based upon the
clinical scenario is also provided ( table 5). (See "Induction agents for rapid sequence
intubation in adults for emergency medicine and critical care" and "Neuromuscular
blocking agents (NMBAs) for rapid sequence intubation in adults for emergency
medicine and critical care".)
● Positioning – This step includes positioning to improve laryngoscopy. Bag-mask

ventilation is not required if the patient has been successfully preoxygenated and is at
low risk for oxygen desaturation but can be performed when the risk of hypoxia is
greater than the risk of aspiration. (See 'Positioning and protection' above.)
● Placement with proof – Once intubation is performed, confirmation of proper

endotracheal tube (ETT) placement is crucial. End-tidal carbon dioxide (EtCO2)
determination (preferably with waveform capnography) must be performed to
determine proper placement. (See "Direct laryngoscopy and endotracheal intubation in

adults", section on 'Confirming proper tracheal tube placement'.)
● Postintubation management – The ETT must be secured, a postintubation chest

radiograph checked for positioning and evidence of complications, and appropriate
ventilator management implemented. Drugs used for RSI are generally short acting,
and the clinician must provide adequate longer-term sedation, analgesia, and
sometimes paralysis. (See 'Postintubation management' above and "Mechanical
ventilation of adults in the emergency department".)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Aaron Bair, MD, MSc, FAAEM, FACEP (deceased),
who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Terms of Use.
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83. Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of
Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med
2018; 72:627.
84. Driver BE, Prekker ME, Wagner E, et al. Recall of Awareness During Paralysis Among ED
Patients Undergoing Tracheal Intubation. Chest 2023; 163:313.
85. Lembersky O, Golz D, Kramer C, et al. Factors associated with post-intubation sedation
after emergency department intubation: A Report from The National Emergency Airway
Registry. Am J Emerg Med 2020; 38:466.
Topic 270 Version 60.0
GRAPHICS
Summary: The Seven Ps of rapid sequence intubation
Action Time
Preparation 10 minutes before intubation
Preoxygenation 5 minutes before intubation
Physiologic optimization 3 minutes before intubation (may be longer depending on necessary

interventions and time available)
Paralysis with induction Induction
Positioning with 30 seconds after induction

protection
Placement (intubation) 45 seconds after induction

with proof
Post-intubation 60 seconds after induction

management
Used with permission from Brown III CA, Sakles JC, Mick N. The Walls Manual of Emergency Airway Management, 5th edition. 2018. Wolters Kluwer.
Graphic 77060 Version 6.0
Mnemonic for tracheal intubation preparation
S: Suction
T: Tools for intubation (laryngoscope blades, handle, video laryngoscope and other preferred devices)
O: Oxygen source for preoxygenation and ongoing ventilation
P: Positioning
M: Monitors, including ECG, pulse oximetry, blood pressure, EtCO2, and esophageal detectors
A: Assistant; Ambu bag with face mask; Airway devices (ETTs, syringe, stylets, LMA); Airway assessment
I: Intravenous access
D: Drugs, including induction agent, neuromuscular blocking agent, and desired adjuncts (eg, IV fluids,
vasopressor, fentanyl)
ECG: electrocardiogram; EtCO2; end-tidal carbon dioxide; ETTs: endotracheal tubes; IV:
intravenous; LMA: laryngeal mask airway.
Peri-RSI hypoxemia: Common causes and interventions
Important clinical Prevention and

Common causes Interventions
findings preparation
ETT malposition Bilateral decreased Extubate and Waveform

(dislodged; esophageal breath sounds reintubate capnography
placement) Gastric breath
sounds (esophageal
intubation)
Low PIP
Mainstem intubation Asymmetric breath Withdraw ETT Insert ETT

sounds appropriate appropriate
High resistance to distance and distance
BMV recheck breath Keep ETT well
High PIP sounds secured
ETT cuff malfunction Ventilator leak or Exchange ETT Inflate and check
low ventilation cuff of primary and
volumes backup ETT prior to
Loss of pilot balloon intubation
pressure
Mucus plugging Increased ETT suctioning Suction frequently if

secretions heavy secretions
High resistance to
BMV
High PIP
Rapid desaturation Sudden drop in Rescue mask Maximize

(causes: obesity, late oxygen saturation ventilation with oral preoxygenation:
term pregnancy, very soon after and nasal airways Upright sitting
inadequate induction and Rescue extraglottic (if no concern
preoxygenation, neuromuscular device for c-spine
intrapulmonary shunt blockade injury) or
[eg, ARDS, pneumonia]) reverse
Trendelenburg
position
Flush-rate
oxygen
BiPAP and PEEP
Continuous
passive
oxygenation
Profound shock or Specific findings

anemia vary with cause;
refer to UpToDate
topics and graphics
on rapid sequence
intubation
Pneumothorax Asymmetric breath Needle 18 gauge needle or

sounds thoracostomy chest tube kit at the
Subcutaneous (temporizing) bedside for high-
emphysema Tube thoracostomy risk patients
High resistance to
BMV
High PIP
Oxygen apparatus Hypoxemia Confirm oxygen

malfunction unexplained by source functioning,
clinical findings connections secure,
and tubing intact
RSI: rapid sequence intubation; ETT: endotracheal tube; PIP: positive inspiratory pressure; BMV: bag-
mask ventilation; ARDS: acute respiratory distress syndrome; c-spine: cervical spine; BiPAP: bilevel
positive airway pressure; PEEP: positive end-expiratory pressure.
Time to oxygen desaturation
Preoxygenation prolongs the period between paralysis with succinlycholine and oxygen desaturation
in all patients, but to varying degrees depending on patient attributes. This diagram shows the time
to desaturation for several different clinical conditions.
Reproduced with permission from: Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return
to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997; 87:979. Copyright © 1997
Lippincott Williams & Wilkins.
Common high-flow nasal cannula oxygen delivery circuits [1-3]
FiO2: fraction of inspired oxygen.
References:
1. Therapy Overview: Nasal High Flow (NHF). Fisher & Paykel Healthcare. Available at:
https://www.fphcare.com/us/hospital/infant-respiratory/nasal-high-flow/overview/ (Accessed on April 17, 2020).
2. Nishimura M. High-Flow Nasal Cannula Oxygen Therapy Devices. Respir Care. 2019; 64:735.
3. Precision Flow Plus. Vapotherm. Available at: https://vapotherm.com/precision-flow/ (Accessed on April 17, 2020).
Reverse Trendelenburg position
Physiologic changes that occur with reverse Trendelenburg positioning include the following:
Decreased venous return can cause decreased cardiac preload, cardiac output, and mean
arterial pressure. Compensatory mechanisms include increased heart rate, sympathetic tone,
and peripheral vascular resistance.
Lung volumes and functional residual capacity increase, compared with supine.
Cerebral perfusion pressure decreases with the head above the heart. Measurement of blood
pressure at the level of the Circle of Willis gives a more accurate representation of cerebral
perfusion than measurement at the level of the upper arm. Arm cuff measurements should be
adjusted to account for the gradient in hydrostatic pressure.
For further information, refer to UpToDate content on patient positioning for surgery and anesthesia.
IV: intravenous.
Illustration by Kiran Guthikonda, MD, PhD, Dartmouth-Hitchcock Medical Center.
Ramp position illustration
In the ramp position, the patient's head and torso are elevated such that the external auditory
meatus and the sternal notch are horizontally aligned (black line). This position allows for a better
view of the glottis in patients with obesity and should be used unless there are contraindications (eg,
possible cervical spine injury).
Peri-RSI hypotension: Common causes and interventions
Important
Common causes Interventions Prevention/preparation
clinical findings
High intrathoracic Normal or Slow ventilation Avoid overly rapid or

pressure elevated airway rate (≤8 bpm) forceful ventilation
Poor BMV pressures Reduce ventilation
ventilation Abnormal breath force (for BMV)
technique sounds (eg, Increase expiration
Improper wheezing, time
mechanical diminished) IV bolus isotonic
ventilation fluid
settings
Induction agent Occurs within IV bolus isotonic Prepare norepinephrine

effects minutes of drug fluid infusion prior to giving
administration Norepinephrine induction agent to
Transient effect infusion patient with hypotension
Resolves with IVF Exclude other or signs of hemodynamic
bolus and time serious causes instability
Monitor for Consider push-dose

resolution pressor*
Significant prior or Signs of shock IV bolus isotonic In hypotensive or high-

ongoing fluid loss SI >0.8 fluid; repeat as risk patients, give IVF
POCUS shows needed bolus prior to
decreased IVC administering RSI
diameter and medications
hyperdynamic
heart
Significant prior or Blood loss Blood transfusion In patients with

ongoing Signs of shock Hemorrhage hemorrhagic shock or at
hemorrhage Pallor control/surgical risk for hemodynamic
consultation instability, initiate blood
transfusion prior to
administering RSI
medications
Obstructive shock
Pulmonary Possible Norepinephrine Give norepinephrine early

embolism hypoxemia infusion as needed
Lower extremity iNO or Consider push-dose
swelling epoprostenol pressor*
Dilated RV on (reduce PVR) For shock caused by PE,
POCUS or bedside avoid intubation if
echo possible; use BPAP or iNO
Cardiac Distended neck IV bolus isotonic to improve

tamponade veins, if patient fluid oxygenation/ventilation
not volume Pericardiocentesis Ketamine is preferred
depleted induction agent for
POCUS shows patients in non-
pericardial cardiogenic shock; avoid
effusion and propofol
compression of Reduce dose of induction
RA and RV agent ¶
In hypotensive or high-
risk patients with
tamponade, give IVF
bolus prior to
administering RSI
medications
Cardiogenic shock Crackles, Minimize PEEP BPAP as indicated before

distended neck Vasopressor RSI
veins, cool (norepinephrine) Etomidate is preferred
extremities and inotrope induction agent for
ECG may show (dobutamine) patients in cardiogenic
ischemia infusions shock; avoid propofol
POCUS shows Interventional Prepare norepinephrine
poor contractility, cardiology consult infusion prior to giving
B lines (catheterization; induction agent
Chest radiograph IABP; LVAD) Consider push-dose
may show signs of pressor*
ADHF
Distributive shock
Sepsis Fever, IV bolus isotonic In hypotensive or high-

hypotension, fluid; repeat as risk patients, give IVF
tachycardia, focal needed bolus prior to
signs of infection Norepinephrine administering RSI
infusion for sepsis medications
Ketamine is preferred
induction agent for
patients in non-
Anaphylaxis Skin and mucosal IV bolus isotonic cardiogenic shock; avoid
signs (hives, fluid; repeat as propofol
flushing, edema) needed
Give norepinephrine for
Respiratory signs Epinephrine for sepsis early as needed
(wheeze, cough, anaphylaxis Reduce dose of induction
congestion) agent ¶
Consider push-dose
pressor*
Older adult patient Frail appearing IV bolus isotonic Prepare norepinephrine

with poor CV reserve
ECG may show fluid infusion prior to giving

ischemia Norepinehrine induction agent
History of CAD or infusion Reduce dose of induction
reduced EF agent ¶
Consider push-dose
pressor*
RSI: rapid sequence intubation; BMV: bag-mask ventilation; bpm: beats per minute; IV: intravenous;
IVF: intravenous fluid; SI: shock index; POCUS: point-of-care ultrasound; IVC: inferior vena cava; RV:
right ventricle; iNO: inhaled nitric oxide; PVR: pulmonary vascular resistance; PE: pulmonary
embolism; BPAP: bilevel positive airway pressure; RA: right atrium; ECG: electrocardiogram; ADHF:
acute decompensated heart failure; PEEP: peak end-expiratory pressure; IABP: intra-aortic balloon
pump; LVAD: left-ventricular assist device; CV: cardiovascular; CAD: coronary artery disease; EF:
ejection fraction; SBP: systolic blood pressure.
* The use of a push-dose pressor is based on clinical judgement. It is most appropriate for patients
with overt shock (eg, SBP <90 mmHg, SI >1) but may be useful in any hemodynamically unstable
patient being intubated. Options include phenylephrine 100 microgram (50 to 200 microgram) IV or
epinephrine 10 microgram (5 to 20 microgram) IV, depending upon whether vasoconstriction alone or
vasoconstriction and inotropic support is desired. Appropriate measures to improve hemodynamics
as much as possible should be taken prior to intubation and push-dose pressor use.
¶ Reductions in the dose of the induction agent depend upon clinical circumstance. In general, the
authors reduce the ketamine dose by 50% when a reduction is needed. Reductions in the etomidate
dose are generally not necessary.
Medication selection for RSI in adults by clinical setting
Neuromuscular Physiologic optimization

Induction
Clinical scenario blocking (including pre-induction
agent*
agent* ¶ medications) Δ
Elevated ICP (head Etomidate 0.3 Succinylcholine ¶ May give fentanyl 3 mcg/kg IV
injury, stroke) mg/kg IV or 1.5 mg/kg IV or over 30 to 60 seconds, if time
ketamine 1 to 2 rocuronium 1.5 permits and patient is not in
mg/kg IV (avoid mg/kg IV shock, for conditions exacerbated
ketamine if by rise in ICP (eg, acute brain
signs of cerebral injury, ischemic stroke,
herniation; intracranial hemorrhage,
ketamine meningitis, encephalitis, cerebral
preferred in edema)
patients with
severe
hypotension)
Cardiovascular Etomidate Succinylcholine or May give fentanyl 3 mcg/kg IV

emergency excluding rocuronium over 30 to 60 seconds, if time
cardiogenic shock (ACS, permits
aortic dissection)
Shock Ketamine or Succinylcholine 2 Pre-RSI management depends on

etomidate mg/kg IV or cause and may include:
(reduce dose by rocuronium Hypovolemic shock: Isotonic
half for IVF bolus
cardiogenic Hemorrhagic shock: Blood
shock; ketamine transfusion
preferred by
Septic shock: Isotonic IVF
some for septic
bolus; vasopressor
shock)
(norepinephrine)
Reactive airway disease
Stable blood pressure Ketamine or Succinylcholine or Pre-RSI management may include

propofol 1.5 to 2 rocuronium NPPV, heliox, high-flow oxygen (in
mg/kg IV addition to albuterol and other
standard medical therapy)
Hypotensive/unstable Ketamine or Succinylcholine or

etomidate rocuronium
Prolonged seizure Propofol or Succinylcholine

activity etomidate preferred
(rocuronium may
be used if EEG
monitoring
immediately
available)
Geriatric patient Etomidate Succinylcholine or Physiologic optimization may

preferred rocuronium include isotonic IVF bolus, blood
(reduce dose by transfusion, and/or vasopressor
half if frail, (norepinephrine) infusion for
hypotensive, or hypotensive patients or those at
significant risk of hypotension with RSI
comorbidity)
RSI: rapid sequence intubation; ICP: intracranial pressure; IV: intravenous; ACS: acute coronary
syndrome; IVF: intravenous fluids; EEG: electroencephalogram; NPPV: noninvasive positive pressure
ventilation; ECG: electrocardiogram.
* Standard dose is provided once in the table but is the same for all conditions unless otherwise
specified.
¶ Succinylcholine is contraindicated with:

Malignant hyperthermia (patient or family history)
Neuromuscular disease with denervation
Muscular dystrophy
Stroke over 72 hours old
Rhabdomyolysis
Significant burn over 72 hours old
Hyperkalemia with ECG changes
Δ For more details about physiologic optimization, please refer to the UpToDate topics on RSI.
Rapid sequence intubation induction agents for adults
Drug
Class Benefits Contraindications Notes Dos
name
Etomidate Imidazole Excellent sedation Known to suppress Use cautiously 0.3

derivative with little adrenal cortisol if patient has mg/k
hypotension production sepsis; initial
dose of
glucocorticoid
may be needed
Ketamine Phencyclidine Stimulates Use in patients with May be an 1 to 2

derivative, catecholamine elevated ICP or excellent mg/k
dissociative release elevated blood induction
anesthetic pressure is agent for
Bronchodilation
controversial patients with
bronchospasm,
septic shock,
AND
hemodynamic
compromise
Midazolam Benzodiazepines Potent dose- Dose-related Frequently 0.2 to

related amnesic myocardial underdosed 0.3
properties depression can result mg/k
in hypotension
Propofol Alkylphenol Bronchodilation No absolute 1.5 to

derivative contraindications 3
mg/k
Dose-related
hypotension
Thiopental Ultrashort- Cerebroprotective Potent venodilator May not be 3 to 5

sodium acting and anti- and myocardial commercially mg/k
barbiturate convulsive depressant; can available.
properties cause hypotension Rarely used.
Relatively
contraindicated in
reactive airway
disease due to
histamine release
Acute intermittent
and variegate
porphyrias
Richmond Agitation-Sedation Scale (RASS)
Score Term Description
+4 Combative Overtly combative or violent, immediate danger to staff
+3 Very agitated Pulls on or removes tubes or catheters, aggressive behavior toward

staff
+2 Agitated Frequent nonpurposeful movement or patient-ventilator dyssynchrony
+1 Restless Anxious or apprehensive but movements not aggressive or vigorous
0 Alert and calm
-1 Drowsy Not fully alert, sustained (>10 seconds) awakening, eye contact to voice
-2 Light sedation Briefly (<10 seconds) awakens with eye contact to voice
-3 Moderate Any movement (but no eye contact) to voice

sedation
-4 Deep sedation No response to voice, any movement to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Procedure
1. Observe patient. Is patient alert and calm (score 0)?
2. Does patient have behavior that is consistent with restlessness or agitation?
Assign score +1 to +4 using the criteria listed above.
3. 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).
4. 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).
Reproduced with permission from: Sessler C, Gosnell M, Grap MJ, et al. The Richmond agitation-sedation scale. Validity and
reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166:1338. Copyright © 2002 American Thoracic
Society.
Contributor Disclosures
Calvin A Brown, III, MD Equity Ownership/Stock Options: Airway Management and Education Center
[Airway education]. All of the relevant financial relationships listed have been mitigated. John C Sakles,
MD No relevant financial relationship(s) with ineligible companies to disclose. Ron M Walls, MD,
FRCPC, FAAEM Other Financial Interest: Airway Management Education Center [Health care provider
education and resources]; First Airway [Health care provider education and resources]. All of the
relevant financial relationships listed have been mitigated. Jonathan Grayzel, MD, FAAEM No relevant
financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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23/02/2024 18:49 Rapid sequence intubation in adults for emergency medicine and critical care - UpToDate

Official reprint from UpToDate®

Rapid sequence intubation in adults for emergency

Literature review current through: Jan 2024.

DEFINITION AND KEY CONCEPTS

RSI is the virtually simultaneous administration of an induction agent and a neuromuscular

CONTRAINDICATIONS AND PRECAUTIONS

Contraindications to RSI are relative. The most important contraindication to RSI is

anesthesia and light sedation) is preferred to minimize the likelihood of precipitous

Basic preparation steps — Preparation for RSI includes:

In addition, an assessment must be performed for the presence of any physiologic

Choosing between RSI and awake intubation — If an anatomically difficult airway is

● Healthy 70-kg male: 6 to 8 minutes

● Inadequate spontaneous ventilation ‒ In the patient with inadequate spontaneous

● Adequate spontaneous ventilation and cooperative ‒ In cooperative patients with

● Adequate spontaneous ventilation but uncooperative ‒ In patients who are

In a small observational study in intensive care unit and emergency department

Right-to-left intrapulmonary shunting — When airspace disease (eg, pneumonia, acute

Adjunct strategies to maximize preoxygenation — Additional strategies to prevent or

Use of passive oxygenation in this setting is also supported by observational studies

● Techniques to increase airway patency ‒ If necessary, patency of the upper airway

● Common conditions that cause or exacerbate hypotension following RSI and

● Common conditions that cause or exacerbate hypoxemia following RSI and

Hemodynamic compromise should be managed aggressively to optimize conditions prior to

Neuromuscular blocking agents — Use of an NMBA to produce rapid paralysis is the

A systematic review of cricoid pressure studies noted the following [73]:

Placement with proof — After complete neuromuscular blockade is achieved, as assessed

Confirmation of proper ETT placement is crucial; unrecognized esophageal intubation leads

"Mechanical ventilation of adults in the emergency department", section on 'Approach to

If longer-term neuromuscular blockade is needed, the timing of subsequent doses of both

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Preoxygenation – Preoxygenation performed with the patient sitting upright or in

Preoxygenation enables patients to tolerate a longer period of apnea without

● Physiologic optimization – Unless the need for intubation is immediate, patients

• Hypotension following RSI and interventions to help prevent or manage it are

• Hypoxemia following RSI and interventions to help prevent or manage it are

● Paralysis with induction – RSI involves the virtually simultaneous IV administration of

● Positioning – This step includes positioning to improve laryngoscopy. Bag-mask

● Placement with proof – Once intubation is performed, confirmation of proper

determine proper placement. (See "Direct laryngoscopy and endotracheal intubation in

● Postintubation management – The ETT must be secured, a postintubation chest

Use of UpToDate is subject to the Terms of Use.

15. Jaber S, Jung B, Corne P, et al. An intervention to decrease complications related to

21. Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation

Australas 2017; 29:372.

50. Lane S, Saunders D, Schofield A, et al. A prospective, randomised controlled trial

54. Caputo N, Azan B, Domingues R, et al. Emergency Department use of Apneic

57. Oliveira J E Silva L, Cabrera D, Barrionuevo P, et al. Effectiveness of Apneic Oxygenation

77. Vasudevan A, Srinivasan S, Vinayagam S, et al. Assessment of effectiveness of cricoid

80. McNelis U, Syndercombe A, Harper I, Duggan J. The effect of cricoid pressure on

Summary: The Seven Ps of rapid sequence intubation

Preparation 10 minutes before intubation

Preoxygenation 5 minutes before intubation

Physiologic optimization 3 minutes before intubation (may be longer depending on necessary

Paralysis with induction Induction

Positioning with 30 seconds after induction

Placement (intubation) 45 seconds after induction

Post-intubation 60 seconds after induction