II. Precautions

  1. High risk procedure
  2. Must be able to completely control airway and ventilation after use
  3. Use a checklist!

III. Indications

  1. Preparation for intubating a conscious patient

IV. Protocol

  1. Walls protocol describes all steps in Endotracheal Intubation
    1. This page focuses on pharmacologic strategies in RSI (steps 3, 4 and 7)
    2. Endotracheal Intubation Preparation describes a safety checklist for readying for intubation
    3. Endotracheal Intubation Preoxygenation - prevent Hypoxia during intubation (including Apneic Oxygenation)
    4. Endotracheal Intubation describes techniques for maximal laryngeal visualization and ET insertion, confirmation
  2. Mnemonic: 7Ps (Walls)
    1. Preparation - step 1
      1. See Endotracheal Intubation Preparation
      2. Includes SOAP-ME Mnemonic
      3. See Endotracheal Tube
        1. Includes size and length selection of Endotracheal Tubes
      4. See Direct Laryngoscope
        1. Includes sizes of Miller Blade and Macintosh Blade
      5. See Video Laryngoscope
        1. Includes Video Laryngoscopy devices such as Glidescope, C-MAC, MacGrath
    2. Preoxygenation - step 2
      1. See Endotracheal Intubation Preoxygenation (includes Apneic Oxygenation)
      2. Significantly extends duration of safe apnea during intubation
    3. Pretreatment -step 3
      1. Rarely indicated in 2013
      2. See below
    4. Paralysis with Induction - step 4
      1. See below
    5. Positioning - step 5
      1. See Endotracheal Intubation
    6. Placement with Proof - step 6
      1. See Endotracheal Intubation
    7. Postintubation Management - step 7
      1. See Endotracheal Intubation
      2. Also see post-intubation agents described below
  3. Alternatives
    1. See Extraglottic Device
      1. Includes Laryngeal Mask Airway or LMA
      2. Consider as emergency device in case of Endotracheal Intubation failure
    2. See Nasotracheal Intubation
      1. May be considered in anticipated difficult airway of a conscious patient

V. Protocol: Pretreatment - step 3 (not indicated in most cases)

  1. ABC Mnemonic (not indicated in most cases)
  2. Pretreatment (Fentanyl, Lidocaine, Atropine) is now rarely indicated (in 2013)
    1. Indications are listed below for completeness, but are not generally recommended
    2. No evidence of benefit for any of these agents
  3. Asthma or COPD
    1. Lidocaine 1.5 mg/kg (120 mg for 80 kg adult)
  4. Brain (prevention of Intracranial Pressure increase with intubation)
    1. Fentanyl 4-5 mcg/kg (320 mcg for 80 kg adult) given slowly over 1-2 minutes
      1. More than twice the Analgesic dose
    2. Lidocaine 1.5 mg/kg (no longer recommended)
      1. Multiple studies show no benefit for neurologic outcome
      2. Lin (2012) Am J Emerg Med 30(9): 1782-7 +PMID:22633717 [PubMed]
      3. Robinson (2001) Emerg Med J 18(6): 453-7 +PMID:11696494 [PubMed]
  5. Cardiovascular disease (Ischemic Heart Disease, aortic aneurysm, Aortic Dissection)
    1. Fentanyl 3 mcg/kg
  6. Children under age 12 months (optional for ages 1 to 5 years)
    1. Greatest predictive factor for Bradycardia on intubation is Hypoxia
      1. Apneic Oxygenation (Nasal Cannula delivered High Flow Oxygen throughout intubation)
      2. Prolongs safe intubation time (see above)
    2. Atropine 0.02 mg/kg
      1. Atropine has historically been used to prevent Bradycardia when intubating children
      2. Not routinely recommended for any age
        1. Fleming (2005) CJEM 7(2): 114-7 +PMID:17355661 [PubMed]
      3. Consider Atropine ready at the time of intubation in case of Symptomatic Bradycardia
      4. If Atropine used in cases of suspected Non-accidental Trauma
        1. Consider performing Retinal Exam immediately after RSI with Atropine
      5. Avoid Atropine to dry secretions with Ketamine (results in thicker secretions)
  7. Hypotension
    1. Avoid intubating a severely hypotensive patient (outside of crash airway without RSI)
      1. RSI, NIPPV and Endotracheal Intubation may all significantly lower Blood Pressure further
      2. Transition from negative pressure ventilation (diaphragm) to intubation decreases Preload
      3. Peri-Intubation Hypotension is ominous, and may herald imminent Cardiac Arrest
    2. Risk factors for Peri-Intubation Hypotension
      1. Advanced age
      2. Neuromuscular Blockers
      3. COPD
      4. Sepsis
      5. Hypoxemia
      6. Morbidly obese or cacchexia
      7. Pre-intubation Blood Pressure <140 mmHg
    3. Temporize airway and breathing management (Nasal Airway, bipap) during stabilization
    4. Consider awake intubation
    5. Consider Arterial Line for Blood Pressure Monitoring
      1. Place before radial pulses are lost
      2. Arterial Lines remain reliable even in Hypotension and Tachycardia (contrast with Blood Pressure cuffs)
    6. Consider Inferior Vena Cava Ultrasound for Volume Status
      1. Fluid responsiveness may be assessed with Passive Leg Raise Maneuver combined with IVC Ultrasound
      2. IVC <1.5 cm on Ultrasound immediately after intubation, is associated with Hypovolemia
    7. Optimize systolic Blood Pressure prior to RSI
      1. Use agents less likely to lower Blood Pressure
        1. Avoid Propofol as Sedative (induction agent) for emergency intubation
        2. Ketamine in 0.25 to 0.5 mg/kg boluses until dissociation
        3. Etomidate 0.3 mg/kg IV
        4. No RSI agents are needed in Cardiac Arrest (crash airway)
      2. Fluid Resuscitation
        1. Standard bolus of crystalloid in a peri-intubation hemodynamically Unstable Patient is 20 cc/kg IV
        2. Even in CHF, 250 to 500 ml crystalloid bolus is tolerated to stabilize BP for intubation
      3. Vasopressors
        1. Phenylephrine
        2. Norepinephrine
          1. Peri-intubation Norepinephrine is associated with increased mortality in-hospital and 90 day
          2. Smischney (2015) BMC Res Notes 8:445 [PubMed]

VI. Protocol: Paralysis with induction - step 4

  1. Sedation with paralysis (standard, recommended protocol)
    1. Can never over-dose paralytics
      1. Best to over-estimate than under-estimate dose (e.g. 2 mg/kg of Succinylcholine or Rocuronium)
      2. Low Cardiac Output may reduce effect and delay onset of action (overcome by higher dose)
      3. Re-dose fully in reliable IV if suspected infiltration of first dose via a poorly placed IV
    2. Consider half dose or lower of induction agents in Hypotension
      1. Indicated in Hypotension
      2. Midazolam, Propofol and Barbiturates doses should be lowered
        1. Decrease induction dose to 10 to 20% standard dose (avoid >50% of standard dose)
      3. Alternatively, use Etomidate or Ketamine for induction
        1. Etomidate or Ketamine do not lower Blood Pressure and may be given at full dose
      4. References
        1. Driver (2023) Ann Emerg Med 82(4):417-24 +PMID: 37389494 [PubMed]
  2. Sedation without paralysis (facilitated intubation, use only with caution in difficult airway)
    1. See Difficult Airway for other ways to approach a patient with risk of failed airway
    2. Precaution: May significantly Handicap intubation technique
      1. RSI with sedation only (without paralytic) is not recommended
        1. Risk for adverse outcome (multiple intubation attempts, airway injury, aspiration, death)
        2. Bozeman (2006) Prehosp Emerg Care 10(1): 8-13 [PubMed]
      2. Sedation without paralysis may lead to inadequate Muscle relaxation for intubation
        1. Etomidate is short acting
          1. May not allow for adequate intubation attempt without paralysis
        2. Propofol is longer acting, but risks Hypotension
      3. Risk of Emesis and aspiration
        1. Consider pretreatment with Ondansetron to suppress Gag Reflex
      4. Full dose paralytics are recommended for even the lowest GCS scores (outside of crash airway)
        1. Avoid half-dose paralytics or defasciculating dose
    3. Indications
      1. Patients who are not resisting stabilization measures AND
      2. Difficult Airway (with risk of a unsupportable patient if intubation unsuccessful)
        1. Otherwise complete paralysis for 8 minutes (Succinylcholine) to 45 minutes (Rocuronium)
        2. A patient aware, "locked-in", paralyzed without sedation or Analgesic is torture
          1. Avoid, unless the only alternative is death
    4. Alternatives
      1. Dissociative Awake Intubation
      2. Awake Nasotracheal Intubation
    5. Technique
      1. Prepare Paralytic Agent for injection (even if not immediately injected)
      2. Consider pretreatment with Ondansetron to suppress Gag Reflex
      3. Administer sedation (e.g. Etomidate) at standard dosing
        1. Dissociative Awake Intubation with Ketamine 1-2 mg/kg
        2. Consider adding Etomidate 0.1 mg/kg to suppress Gag Reflex
    6. References
      1. Braude in Herbert (2013) EM:Rap 13(11): 14
      2. Weingart in Majoewsky (2012) EM:Rap 12(2): 8
  3. Sedation agents
    1. Etomidate 0.2 to 0.3 mg/kg (24 mg for an 80 kg adult) or
      1. Agent of choice in most cases (most hemodynamically stable agent)
      2. Preferred in Hemorrhagic CVA with increased Blood Pressure
      3. Possible increased mortality in Rapid Sequence Intubation (RSI)
        1. Meta-analysis number needed to harm (NNH): 31
        2. Kotani (2023) J Crit Care 77:154317 +PMID: 37127020 [PubMed]
      4. May cause adrenal suppression (which may impact survival in Sepsis)
        1. Consider Ketamine as an alternative induction agent in Sepsis
        2. Not Clinically Significant if used in single dose as induction agent for intubation
          1. McPhee (2013) Crit Care Med 41(3): 774-83 [PubMed]
        3. Avoid in Sepsis for any longer use than brief
          1. Cuthbertson (2009) Intensive Care Med 35(11): 1868-76 [PubMed]
          2. Jabre (2009) Lancet 374(9686): 293-300 [PubMed]
    2. Ketamine 1.5 mg/kg (120 mg for an 80 kg adult)
      1. Do not exceed 1.5 mg/kg in shock cases
      2. Preferred agent in copd, Asthma, Angioedema (and possibly Sepsis)
        1. Ketamine is not associated with apnea, regardless of dose
        2. Ketamine also has Bronchodilator properties (ideal for COPD, Asthma)
      3. Not contraindicated in Closed Head Injury (previously thought to increase Intracranial Pressure)
        1. Appears to be neuroprotective by increasing Cerebral Perfusion Pressure
        2. Does not lower Seizure threshold
      4. Consider administration with Zofran (due to associated Vomiting)
      5. Not contraindicated in Coronary Artery Disease, Congestive Heart Failure or Hypertension
      6. Avoid concurrent Atropine to dry secretions (worsens increased airway secretions by thickening them)
    3. Propofol (Diprivan)
      1. Consider for Status Epilepticus
      2. Contraindicated in hypotensive patients
    4. Thiopental (Pentothal)
      1. Older agent, rarely used in U.S. in 2013
      2. Consider for Status Epilepticus (Fast-acting anti-epileptic)
      3. Consider Increased Intracranial Pressure (Fastest lowering of ICP of any induction agent)
      4. Contraindicated in hypotensive patients or porphyria
      5. Risk of skin necrosis if infiltrates (highly alkalotic agent with pH 10)
    5. Midazolam (Versed)
      1. Considered a poor agent for RSI
      2. Rarely given at adequate doses (a typical adult dose for RSI is an astounding 8-10 mg)
      3. Could be considered in Status Epilepticus
      4. Risk of Hypotension
      5. Risk of Agitation in the elderly and those with liver disease
  4. Paralysis agents
    1. Succinylcholine 1.5 mg/kg (120 mg for an 80 kg adult) or
      1. Contraindicated if Hyperkalemia risk (see Succinylcholine)
        1. Do not re-dose Succinylcholine (Hyperkalemia risk increases)
        2. If longer paralysis is needed, switch to Rocuronium
      2. Wait at least one minute for defasciculation prior to intubating (risk of Emesis)
      3. Oxygen Saturation drops more quickly with Succinylcholine due to oxygen utilization for paralysis
        1. Use Apneic Oxygenation
      4. Duration or paralysis: 8 minutes (far shorter than Rocuronium)
        1. Optimal duration to reduce the risk of patient awareness without adequate sedation
        2. Allows for earlier resumption of Neurologic Exam (e.g. Status Epilepticus, head or neck Trauma)
        3. Some prefer in anticipated difficult airway
          1. However, return of spontaneous breathing in 8 minutes is a poor back-up strategy
          2. An Advanced Airway is needed regardless of failed intubation (see Difficult Airway Assessment)
    2. Rocuronium 1 to 1.2 mg/kg (80-96 mg for 80 kg adult)
      1. Agent of choice in children (and in adults if Succinylcholine contraindicated)
      2. Many recommend Rocuronium for all intubations as the safest option in undifferentiated ED presentations
      3. Inadequate sedation and analgesia is common following Rocuronium (due to long duration)
        1. Err on the side of more aggressive sedation and analgesia while patient is paralyzed
        2. Awareness of intubation (paralysis persists longer than sedation) should NEVER be allowed to occur
        3. Initiate bolus and infusion of Sedative (e.g. Propofol) immediately after intubation (prepare before)
        4. Korinek (2014) Eur J Emerg Med 21(3): 206-11 +PMID:23510899 [PubMed]
      4. Duration of paralysis: 45 minutes
        1. Sugammadex tightly binds Rocuronium and Vecuronium to reverse paralysis
      5. Some prefer in difficult airway due to longer duration of action
        1. Positive Pressure Ventilation may be easier with paralysis
        2. Longer duration allows for repeat attempt without re-dosing in case of failed intubation

VII. Protocol: Post-intubation Management - step 7

VIII. Management: Special Circumstances

  1. Status Asthmaticus
    1. Sedation: Ketamine
  2. Congestive Heart Failure
    1. Sedation: Etomidate
  3. Status Epilepticus
    1. Sedation: Thiopental, Midazolam, Propofol
  4. Multiple Trauma or Hemorrhagic Shock
    1. Sedation: Etomidate
  5. Shock
    1. Use lower induction agent doses (e.g. half dose)
    2. Use increased paralytic doses
      1. Rocuronium 2 mg/kg
      2. Succinylcholine 3-4 mg/kg
    3. References
      1. Orman and Hayes in Herbert (2017) EM:Rap 17(1): 10
      2. Heier (2000) Anesth Analg 90(1): 175-9 +PMID:10625000 [PubMed]

IX. Resources

  1. FPnotebook: Virtually Resuscitated RSI
    1. http://www.fpnotebook.com/vr/rsi
  2. Rapid Sequence with Rocuronium and Ketamine Video (Sacchetti)
    1. http://www.youtube.com/watch?v=kTd7km_jnKw
  3. RSI Calculator (slide-rule bedside calculator for RSI drugs)
    1. http://www.RSIcalculator.com

X. References

  1. Herbert (2012) EM: RAP-C3 2(5): 3-4
  2. Swaminathan and Weingart in Herbert (2019) EM:Rap 19(5): 11-12
  3. Levitan (2013) Practical Airway Management Course, Baltimore
  4. McClain, Lawner and Butler (2019) Crit Dec Emerg Med 33(12): 19-27
  5. McCollum (2024) EM:Rap, published 3/25/2024
  6. Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 24-35
  7. Walker L. A. (1993) Emerg Med Rep, 14(15):127-32 [PubMed]

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