Rapid Sequence Intubation (RSI) Calculator
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
- 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
- The seven P's mnemonic of RSI that summarizes the key steps:
- Physiologic optimization
- Paralysis with induction
- Placement with proof
- Postintubation management
Pretreatment agents that facilitate intubation prior to RSI
should be viewed as supplementary and only administered if time
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,
Enter the patient's weight:
Note: dosing is for adult patients only. A pediatric version will be
Sample step-by-step guide to performing Rapid Sequence Intubation:
- 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.
- 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.
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.
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.
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.
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.
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.
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.
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