RSI is indicated in patients who require incubation and have recently ingested
food or have an uncertain history.
This technique couples sedation to induce unconsciousness (induction) with muscular
paralysis.
Common circumstances include head trauma, intoxication, cardiac emergency, multiple
trauma, seizures and respiratory failure.
Procedure
Preoxygenate the patient for 5 minutes with 100% oxygen by facemask or 4
tidal volume breaths of 100% oxygen if patient is conscious.
Prepare equipment for intubation.
Pretreatment
Lidocaine (1.0-1.5 mg/kg IV) to possibly reduce rise in intracranial
pressure in head trauma patients may be considered.
Defasciculate with a nondepolarizing agent if succinylcholine is used
as paralytic.
Vecuronium (0.02 mg/kg IV) OR
Succinylcholine (0.1 mg/kg IV)
Atropine (0.01-0.02 mg/kg IV) for pediatric or bradycardic patients.
*If possible, wait, 2 minutes for pretreatment to take effect
Induction.
Thiopental (3-5 mg/kg IV) reduces intracranial pressure in head injury.
Dose is 0.5-1.0 mg/kg in a hypotensive patient. Contraindicated in asthmatics.
For patients needing analgesia in addition to induction consider opiates
(fentanyl 2-10 micrograms/kg IV) OR
Etomidate (0.2-0.3 mg/kg IV) OR
Ketamine (1 -2 mg/kg IV) increases cardiac output, vasoconstriction
in hypotensive patient; bronchodilates in asthmatic patient.
Apply cricoid pressure (Sellick maneuver)
Important in preventing aspiration.
Paralysis
Succinylcholine (1.0-1.5 mg/kg IV) contraindicated in bum patients or
patients with preexisting paralysis because of resultant hyperkalemia.
OR
Vecuronium (0.2 mg/kg) for patients with increased intracranial pressure
or those in status asthmaticus
Intubate (see endotracheal intubation)
Release cricoid pressure once ETT placement is confirmed via auscultation
or end tidal CO2
Complications
Complications secondary to intubation or inability to secure an airway.
Succinylcholine may cause fasciculations and increased intracranial pressure,
both of which may be prevented by defasiculation. It may also cause malignant
hyperthermia, hyperkalemia, and dysrrythmias.
Ketamine is associated with emergence phenomenon hallucinations and dysphoria
upon emergence from sedation. Treat with benzodiazipines.
Thiopental may cause hypotension, laryngospasm, or bronchospasm (contraindicated
in reactive airway disease).