The LSUHSC New Orleans
Emergency Medicine Interest Group
The Student Procedure Manual
Rapid Sequence Induction
by Kevin Martinez
with Patrick Hymel
- 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
- Common circumstances include head trauma, intoxication, cardiac emergency, multiple
trauma, seizures and respiratory failure.
- 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.
- 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
- 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
- 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.
- Succinylcholine (1.0-1.5 mg/kg IV) contraindicated in bum patients or
patients with preexisting paralysis because of resultant hyperkalemia.
- 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 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).
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