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Rapid Sequence Intubation (RSI) Calculator

Rapid Sequence Intubation (RSI) Calculator


Rapid Sequence Intubation (RSI) Calculator

Overview

Rapid Sequence Intubation (RSI) is a critical procedure used to secure a patient's airway promptly and safely and create optimal intubating conditions. It is frequently performed in emergency medicine, anesthesia, and critical care settings for emergency airway management for intubations not anticipated to be difficult. RSI is indicated when a patient is unable to maintain their own airway or is at risk of losing it.  

Quick summary points:

  • The goal of preparation is to maximize the chances for successful intubation on the first attempt without adverse events.
  • Prior to drug administration - essential components:
    • Adequate preoxygenation - critical component to maximize the time for intubation and prevent desaturation during intubation.
    • Hemodynamic optimization - as indicated the patient may require vasopressors, blood products, crystalloids, etc., prior to administering RSI agents.
  • Choice of induction agent should take into account any existing condition(s) that could be exacerbated by using a suboptimal agent. Goal: minimize potential side effects.
  • The clinician should have a backup plan in place in the event intubation was not successful.
  • Look for any relative contraindications to RSI including significant anatomic or physiologic anomalies.
  • Evaluate the need for an "awake" intubation which must be considered in the presence of predictors of difficult airway management.
  • The seven P's mnemonic of RSI that summarizes the key steps:
    • Preparation
    • Preoxygenation
    • Physiologic optimization
    • Paralysis with induction
    • Positioning
    • Placement with proof
    • Postintubation management
  • Pretreatment agents that facilitate intubation prior to RSI should be viewed as supplementary and only administered if time permits.


Purpose of this program

Provide guidance on the best choice for induction and neuromuscular blocking agent based on the latest evidence

Background and dosing information are provided for the following agents:
  • Pretreatments: Lidocaine and Fentanyl
  • Induction agents: Etomidate, ketamine, propofol, midazolam
  • Paralytic dosing: Succinylcholine, rocuronium, vecuronium

Enter the patient's weight:

Weight:

Note: dosing is for adult patients only. A pediatric version will be available soon.
 


Sample step-by-step guide to performing Rapid Sequence Intubation:

  1. Preparation:

    • Ensure proper monitoring equipment is available, including cardiac and oxygen saturation monitors.
    • Gather necessary equipment, including laryngoscope, endotracheal tubes of appropriate sizes, stylet, suction device, and bag-valve-mask (BVM) apparatus.
    • Verify availability of medications such as induction agents and neuromuscular blocking agents.
    • Confirm intravenous access and prepare for possible difficult airway scenarios with backup devices like supraglottic airways or a surgical airway kit.

  2. Preoxygenation:

    • Administer high-flow oxygen to the patient via a non-rebreather mask, using a reservoir bag if available.
    • This step helps maximize oxygen reserves in the lungs to delay desaturation during the intubation process.

  3. Positioning and Monitoring:

    • Position the patient appropriately, ensuring alignment of the oral, pharyngeal, and tracheal axes.
    • Apply continuous cardiac and oxygen saturation monitoring to track the patient's vital signs and oxygenation status throughout the procedure.

  4. Administration of Induction Agents:

    • Administer a sedative and/or hypnotic medication to induce rapid unconsciousness and amnesia.
    • Commonly used agents include intravenous propofol, etomidate, or ketamine.
    • Choose the most suitable agent based on the patient's condition, contraindications, and potential side effects.

  5. Administration of Neuromuscular Blocking Agents:

    • Administer a neuromuscular blocking agent to induce muscle paralysis, facilitating smooth intubation.
    • Succinylcholine is often the drug of choice due to its rapid onset and short duration of action.
    • Alternative agents like rocuronium can be used when succinylcholine is contraindicated or unavailable.

  6. Laryngoscopy and Intubation:

    • Perform laryngoscopy with a curved or straight blade to visualize the vocal cords.
    • Insert the appropriately sized endotracheal tube through the vocal cords and into the trachea.
    • Confirm correct placement using multiple methods, including direct visualization, chest auscultation, and capnography.

  7. Confirmation of Tube Placement:

    • Assess tube placement by observing chest rise and auscultating breath sounds over the chest bilaterally.
    • Use capnography to confirm the presence of exhaled carbon dioxide within the endotracheal tube.
    • Obtain a chest X-ray as soon as possible to confirm final tube position.

  8. Tube Securing and Post-intubation Care:

    • Secure the endotracheal tube in place using appropriate techniques (e.g., tube ties, adhesive tape).
    • Initiate mechanical ventilation with the appropriate settings based on the patient's condition.
    • Administer sedation, analgesia, and muscle relaxation as needed to optimize patient comfort and prevent complications.
    • Continuously monitor the patient's vital signs, oxygenation, and ventilation throughout the post-intubation period.



References Rapid Sequence Intubation

 

  1. Collins J, O'Sullivan EP. Rapid sequence induction and intubation. BJA Educ. 2022 Dec;22(12):484-490

  2. Hampton JP, Hommer K, Musselman M, Bilhimer M. Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update. Am J Health Syst Pharm. 2023 Feb 15;80(4):182-195.

  3. Engstrom K, Brown CS, Mattson AE, Lyons N, Rech MA. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med. 2023 May 10;70:19-29.

  4. Brull SJ, Fülesdi B. Rapid sequence induction and intubation without the use of neuromuscular blockers: Why noninferiority trials are clinically relevant. Anaesth Crit Care Pain Med. 2023 Jun;42(3):101208

  5. Arteaga Velásquez J, Rodríguez JJ, Higuita-Gutiérrez LF, Montoya Vergara ME. A systematic review and meta-analysis of the hemodynamic effects of etomidate versus other sedatives in patients undergoing rapid sequence intubation. Rev Esp Anestesiol Reanim (Engl Ed). 2022 Dec;69(10):663-673.

  6. Butler K, Winters M. The Physiologically Difficult Intubation. Emerg Med Clin North Am. 2022 Aug;40(3):615-627.

  7. Sivajohan A, Krause SC, Hegazy A, Slessarev M. Protocol for a systematic review on effective patient positioning for rapid sequence intubation. BMJ Open. 2022 Nov 4;12(11):e062988.

  8. Ali H, Abdelhamid BM, Hasanin AM, Amer AA, Rady A. Ketamine-based Versus Fentanyl-based Regimen for Rapid-sequence Endotracheal Intubation in Patients with Septic Shock: A Randomised Controlled Trial. Rom J Anaesth Intensive Care. 2022 Dec 29;28(2):98-104.

  9. Wang J, Han X, Cang J, Miao C, Liang C. Rapid sequence induction with a "modified timing principle" of rocuronium provides excellent intubating conditions: A randomised trial. Anaesth Crit Care Pain Med. 2022 Aug;41(4):101108.

  10. Jishnu M, Bhoi S, Sahu AK, Suresh S, Aggarwal P. Airway management practices among emergency physicians: An observational study. Turk J Emerg Med. 2022 Sep 30;22(4):186-191.

  11. Foster M, Self M, Gelber A, Kennis B, Lasoff DR, Hayden SR, Wardi G. Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation. Am J Emerg Med. 2022 Nov;61:131-136.

  12. Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76.
  13. Kornas RL, Owyang CG, Sakles JC, et al. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management.Anesth Analg 2021; 132:395.
  14. Okubo M, Gibo K, Hagiwara Y, et al. The effectiveness of rapid sequence intubation (RSI)versus non-RSI in emergency department: an analysis of multicenter prospective observational study. Int J Emerg Med 2017; 10:1.
  15. Mosier JM, Joshi R, Hypes C, et al. The Physiologically Difficult Airway. West J Emerg Med 2015; 16:1109.
  16. Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awaketracheal intubation (ATI) in adults. Anaesthesia 2020; 75:509.
  17. Tonna JE, DeBlieux PM. Awake Laryngoscopy in the Emergency Department. J Emerg Med 2017; 52:324.
Rapid Sequence Intubation (RSI) Calculator