Rapid Sequence Intubation

A Guide for Assistants

Working outwith the theatre setting
 Contents Course Aim Basic Airway Care Rapid Sequence Intubation
and Oxygenation
Course Aim..............................................1 By imparting and improving upon the pertinent
Definition
knowledge and practical skills required of an Basic airway care and oxygenation are essential
Course Objectives...................................1
assistant during the Rapid Sequence Intubation to resuscitation. RSI allows the provision of Rapid sequence intubation is the administration
Basic Airway Care and Oxygenation......2 (RSI) procedure this short course aims to a definitive airway but this is impossible to of a potent induction agent (anaesthetic)
increase the confidence and performance of the achieve safely without prior maintenance of followed by a rapidly acting neuromuscular
Rapid Sequence Intubation....................2 nurse assisting. This will ensure that competent the airway and oxygenation. Some patients blocking agent (usually suxamethonium) to
Definition................................................2 and safe care is wholly delivered and that a may maintain and protect their own airway but induce unconsciousness and motor paralysis
The Sequence..........................................2 cohesive multidisciplinary approach is achieved. others may need assistance if not full support for tracheal intubation. It is assumed that the
during RSI preparation. patient has a full stomach, and is therefore
Preparation. ............................................3
Basic airway care begins with assessment. at risk of aspiration of gastric contents. The
Environment............................................3 Course Objectives Airway obstruction is best recognised by a look, aim is to render the patient unconscious and
Equipment...............................................3 paralysed so that they can be intubated.
listen and feel approach. Patients often have
The key learning points which will be achieved obstructed airways secondary to a decreased
Preoxygenation.......................................3 Maintenance of oxygenation throughout the
through pre-course reading material, lectures, conscious level. Reduced muscle tone allows the process is mandatory.
Pre-treatment. ........................................4 demonstrations and scenarios are as follows: tongue and surrounding soft tissues to occlude
Gaining a comprehensive understanding the airway. This may be partial with snoring
Paralysis with Induction.........................4 The Sequence
of the RSI procedure and of the assistants noises or complete with see-saw breathing.
Induction agents....................................4
role. First of all the decision to intubate should be
Sodium Thiopentone.................................4 This obstruction is relieved with simple
based on three fundamental assessments:
Recognising situations where RSI becomes positioning of the airway, using head tilt and
Etomidate...............................................4
appropriate. chin lift, or if neck movement is contraindicated,
Propofol..................................................4 1. Is there a failure of airway maintenance or
jaw thrust. Foreign body obstructions to the
Muscle relaxants...................................4 Utilising knowledge of the RSI procedure so protection?
airway may be removed if visible with forceps
that it can be applied efficiently in clinical or suction. Airway adjuncts such as an 2. Is there a failure of ventilation or
Protection and Positioning.....................5 practice. oropharyngeal airway (OPA) or a nasopharyngeal oxygenation?
Cricoid Pressure.......................................5 Developing an understanding of the airway (NPA) are often used to good effect to
3. What is the anticipated clinical course?
In-line Stabilisation...................................5 pharmacological agents involved, maintain a patent conduit for the passage of
their actions, preparation and their gas between the face and the pharynx.
Placement and Proof..............................6 Having decided to intubate the patient, the
administration.
Supplemental oxygen is provided to all person performing the procedure will assess
Difficult and Failed Airway......................6
Acquiring, developing and demonstrating critically ill patients for a number of reasons. the patient to anticipate a potentially difficult
Post-Intubation Management................7 the motor skills involved in assisting RSI. In the preparation for RSI this is to improve intubation. Whilst this is happening, preparation
oxygenation of the patient and provide a for the procedure should begin. Staff should
Maintenance Sedation and NMB............8 Acquiring knowledge and skills that consider
reservoir of oxygen to limit desaturation during work as a team to allow the procedure to
Benzodiazepines......................................8 strategies for post-intubation care and/or
drug-induced apnoea for intubation. progress smoothly. During RSI the team has a
Propofol..................................................8 failed and difficult intubations.
number of roles, these include:
It is always necessary to pre-oxygenate a
Vecuronium and Atracurium......................8
patient for an RSI and a bag-valve-mask (BVM) Airway assistant
Ventilator Settings....................................8 The development of this course has been
or anaesthetic C-circuit should be used for this
Considerations before Transfer...................8 supported by an educational grant from NHS Drug preparation
purpose. If used correctly, these provide high
Education Scotland.
Relatives.................................................8 concentrations of oxygen for the patient to Circulation and monitoring assistant
breathe. These pieces of equipment are also Drug administration: anaesthetic and
Appendix - Securing an ET tube.............9 used to ventilate the apnoeic patient.
emergency drugs
References and Bibliography.............. 10 Knowledge and skills of basic airway care, airway
2005 Rapid Sequence Intubation for Assistants Group
Cricoid pressure
Designed and produced for RSIA Group by Medical Illustration,
adjuncts and manual ventilation techniques are
Intubator
Learning Technology Section, The University of Edinburgh core to any airway intervention and are the fall
back position in failed intubation. In-line immobilisation where necessary

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 Appendix Securing an ET tube

There are a set series of steps forming the basis Stylet and Bougie as adjuncts to help However, the time taken to desaturate from Sodium thiopentone
of RSI, these are the seven Ps. placement of tube 90% to zero is very short. In the healthy adult
Suction with Yankauer suction device This is an ultra-short acting barbiturate that
it is 120 seconds, and in a child it is only 45
1. Preparation acts on the GABA receptor complex in the
seconds. Desaturation is much more rapid
brain. It decreases cerebral metabolic oxygen
2. Preoxygenation if the lungs are abnormal, (eg pulmonary
consumption and reduces cerebral blood
oedema) or if oxygen consumption is increased
3. Pre-treatment flow and intra-cranial hypertension whilst
(eg trauma, burns etc)
maintaining cerebral perfusion pressure
4. Paralysis and induction
(usually). The recommended dose in an adult is
5. Protection and positioning usually 35 mg/kg and in a child is 5-8 mg/kg.
Pre-treatment These doses are halved where hypovolaemia
6. Placement with proof
is suspected. The chief side effects are
7. Post-intubation management Some medical staff may wish to administer
venodilation and myocardial depression which
drugs such as lignocaine, opiates or atropine to
can lead to significant hypotension.
Of these seven steps, nursing staff are mitigate the effects of the procedure. However
particularly involved in preparation, this is a decision for the individual clinician.
protection/positioning and post-intubation A rapid fluid bolus may be appropriate to limit Etomidate
management. It is these that we will the hypotensive effect of anaesthesia and This is the most haemodynamically stable
concentrate on in the following text. positive pressure ventilation. induction agent and hence has gained in
popularity. The relative cardiovascular stability
of etomidate makes it useful in hypovolaemic
Preparation Paralysis with Induction shock, anaphylaxis and asthma where a
further drop in blood pressure might prove
This essentially means preparing equipment The patient must receive high concentration
Here, a rapidly acting anaesthetic induction catastrophic. It has similar cerebral effects to
for the expected intubation and also for the oxygen throughout this time.
agent is given in a dose adequate to produce thiopentone and so is useful in cases where
potential complication of a difficult or failed prompt loss of consciousness. This is followed intra-cranial hypertension is suspected. Its dose
intubation. The following should be considered:
Preoxygenation by the neuromuscular blocking agent such as is 0.2-0.3 mg/kg.
suxamethonium.
Environment
This is the provision of high concentration
Propofol
Clinical area e.g. resuscitation room oxygen to the patient for ideally 5 minutes prior
to the procedure. This builds up a reservoir of This is an agent which may also be used as an
Monitoring ECG monitor, BP, SpO2,
oxygen in the lungs to allow a period of apnoea induction agent in emergency RSI. It produces
capnography
during RSI. If it is not possible to give 5 minutes significant venodilation, myocardial depression
Intravenous access preferably two iv lines of preoxygenation then 8 vital capacity breaths and can reduce cerebral perfusion pressure. If it
Position on trolley should optimise access (the largest breaths a patient is able to take) is used, dose reduction similar to Thiopentone
for intubation should be taken. is required. It is commonly used as an infusion
for maintenance sedation after intubation.
Drugs drawn up in labelled syringes + This allows the patient with normal lungs to
checked by medical staff maintain oxygen saturations over 90% for
several minutes as shown in the table below: Muscle relaxants
Equipment Type of patient Amount of time a patient Induction agents
can maintain Sa 02 > 90%
Suxamethonium is the most commonly used
Two functioning laryngoscopes fitted with The most commonly used induction agents are neuromuscular blocking agent (NMB) for
Healthy 70 kg adult 8 minutes
appropriate blade. summarised below. There is no single ideal emergency rapid sequence intubation, having
Moderately ill adult 5 minutes agent and the choice will vary in accordance a rapid onset and short half-life. The dose in
Endo tracheal tube - test cuff inflation and
10 kg child 4 minutes with the clinical situation and the familiarity RSI is 1.5 mg/kg. It acts by non-competitively
have smaller sizes ready:
Obese adult 3 minutes of the doctor with the drug that he/she blocking the neuromuscular junction, inducing
- Male, size 8 to 9 mm
Very ill patient <2 minutes administers. fasciculation followed by paralysis. It takes
- Female, size 7 to 8 mm

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45-60 secs to induce paralysis and takes 8-10 to be opened giving better access. The head and How do we predict which patients are
mins to recover life-sustaining breaths. It can neck are maintained in the neutral position. If likely to be difficult?
produce a rise in serum potassium levels and is trauma is not suspected, a small pillow can be
contra-indicated in the following circumstances: placed under the head flexing the lower cervical The factors listed below may all contribute to
spine and extending the head on the neck; the difficult BVM, laryngoscopy, intubation and
ECG or biochemical evidence of surgical airway management. Identification of
so-called sniffing position.
hyperkalaemia these factors may make the intubator decide
Patient 24 hours post burn that RSI should not be attempted and that
other methods of securing the airway should
Patient 7 days post crush injury or Placement and Proof be used. The team should always discuss and
denervation understand the plan for a difficult intubation
Intubation should be performed carefully
Guillain-Barre syndrome and other neurological and have appropriate equipment prepared.
and gently. The larynx is visualised and the
conditions associated with denervation (e.g. The correct pressure applied to the cricoid endotracheal tube placed. The stylet, if used, is
critical illness polyneuropathy in intensive care cartilage would be approximately that which Look externally
then removed and the cuff inflated.
patients) is uncomfortable when pressing on the
Tube position is confirmed by a combination of: These factors may make BVM or intubation
It is also contra-indicated in patients with bridge of the nose. difficult and include the following:
a personal or family history of malignant visualising the passage of the ET tube
hyperthermia. between the cords Body habitus, head and neck anatomy
Cricoid pressure is applied from the moment (short neck), mouth (small opening, loose
Rocuronium is the main alternative if listening to both sides of the chest and over teeth or prominent teeth, macroglossia),
the patient loses consciousness and maintained
suxamethonium is contraindicated and in the stomach jaw abnormalities (micrognathia, significant
throughout the entire intubation sequence
certain cases may be the drug of choice. The until the endotracheal tube has been correctly end-tidal CO2 measurement which is the malocclusion), beards.
dose is 1 mg/kg. It has a comparable time to placed, position verified and the cuff inflated. most reliable method
paralysis but a longer recovery time of 20-25 Only when instructed by the intubator should Obstruction
minutes. It will not produce the fasciculations Cricoid pressure can be discontinued on
cricoid pressure be released. instruction from the intubator. If intubation
seen with suxamethonium. Upper airway obstruction should always make
B.U.R.P The intubator may ask you to perform cannot be achieved, oxygenation will be you aware that airway management is likely to
Backwards, Upwards, Rightwards Pressure on maintained with basic airway manoeuvres be difficult. This may present as stridor, inability
and bag mask ventilation. Further attempts at
Protection and Positioning the larynx to improve their view of the cords. to swallow secretions or alteration in voice
intubation can then be made safely. quality. Causes of upper airway obstruction
Cricoid Pressure In-line Stabilisation include epiglottitis, abscess, foreign body,
In failed intubation a return to basic airway
thermal injury, tumour, and trauma.
management with bag-mask-valve ventilation
Shortly after the administration of the induction
using 100% oxygen will gain time until a
agent, the patient will stop breathing and lose Neck mobility
definitive airway can be secured.
the reflexes that ordinarily protect the airway.
During this phase it is vitally important to help The ability to position the head and neck is vital
prevent regurgitation of gastric contents with to give an optimum view of the larynx. Neck
the application of cricoid pressure. Here, firm Difficult and failed airway mobility can be significantly reduced in patients
pressure (about 10 pounds) is applied to the with trauma (cervical collar) or in the elderly and
cricoid cartilage. Difficult airway in those with arthritis.

This is when preintubation examination has

Failed airway
identified factors that are more likely to
make Bag-Valve-Mask ventilation (BVM), A failed airway is distinct from a difficult
laryngoscopy, intubation or surgical airway airway and is defined as:
The best position for intubation may not be management difficult. The incidence of difficult
airway in the Emergency Department setting is 1. Failure of an intubation attempt in a patient
possible if cervical spine injury is suspected. Here
estimated to be 20% in some centres. where oxygenation cannot be maintained
an assistant may be called upon to maintain in-
(Cant intubate, Cant oxygenate)
line stabilisation. This allows the cervical collar

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2. Three unsuccessful intubation attempts by an expert may wish to try a further intubation
Maintenance sedation Ventilator Settings
an experienced operator attempt. The items of equipment and technique
should be carefully considered, e.g. using a and NMB Check for adequate chest movement and that
This situation is uncommon in emergency inflation pressures are not too high (>25-30cm
different laryngoscope blade, stylet or bougie,
department RSI. The incidence of intubation Benzodiazepines H2O). Standard initial setting would be 10
different size of ETT, rescue medication,
failure is approximately 0.5 2.5% (Walls et al ml/Kg tidal volume at 10-12 breaths per min.
altering amount of cricoid pressure, altering
NEAR data). Midazolam has the quickest onset and offset However, this may vary with clinical situation
patients head position, considering the BURP
times of all the benzodiazepines. They promote and is a decision for the team leader.
In a failed airway situation the immediate (Backwards, Upwards, Rightwards Pressure on
amnesia and sedation but have a longer time
priority is to OXYGENATE the patient sufficiently the larynx) manouevre etc.
to onset than induction agents. They are
to prevent hypoxic brain injury. commonly used to maintain sedation in a Considerations before transfer
If the oxygen saturation still remains less
than 90% despite optimum basic airway patient who has been intubated and may be
The following points should be checked:
Priorities in the failed airway situation management it is likely that a surgical airway delivered as an infusion in this context.
will be performed. This can be a needle Destination agreed
1. Call for the most senior assistance available
(Consultant in A&E, ICU, Anaesthetics, ENT or surgical cricothyroidotomy. It is vital to Propofol Ensure adequate oxygen, fluids and
+/- difficult airway trolley) familiarise yourself with the equipment for this, emergency drugs
This is an agent which may also be used
where it is kept and how to be a good assistant
2. Assess whether oxygenation is adequate: as an induction agent in emergency RSI. It Documentation complete and copied
when a surgical airway is performed.
produces significant venodilation, myocardial
Results and X-rays to accompany patient
If able to oxygenate and maintain REMEMBER: Patients do not die from a failure depression and can reduce cerebral perfusion
saturation >90% with BVM then may to intubate. They die from HYPOXIA due to pressure. It is commonly used as an infusion for Inform receiving area
be able to buy sufficient time to use failure to stop trying to intubate. maintenance sedation after intubation.
alternative techniques e.g. fibreoptic scope
Relatives
If unable to maintain saturation >90% Vecuronium and Atracurium
then go back to GOOD basics while Post-Intubation Management It is important that a member of the team keeps
These are longer acting NMBs used to maintain
more help arrives/preparation for a relatives as fully informed of events as possible.
After tube placement is confirmed, the ET tube paralysis in the intubated patient. The
surgical airway is occurring bolus doses are 0.1mg/kg and 0.5-1 mg/kg
can be tied or taped in place. Blood pressure
- High flow oxygen via anaesthetic respectively.
should be measured and reported to the team
circuit or BVM
leader. Mechanical ventilation can now be Finally a nasogastric or orogastric tube should
- Suction initiated. A chest X-ray should be obtained to be inserted to prevent any gastric distension.
- OPA and NPA confirm ET tube position and assess the lungs.
- Head positioning +/- pillow
- 2 person ventilation technique
- Consider the use of an LMA Standard Post Intubation Care:

As an assistant it is important to predict what ECG

sequence of events will occur in the failed SpO2
airway situation and what items of equipment
NIBP / A-Line
may be required.
Capnograph
Providing high concentration oxygen and
Naso / Oro Gastric tube
going back to GOOD basic airway opening
manoeuvres with the use of assistance Urinary Catheter
and adjuncts will frequently allow some CXR
improvement in the patients condition.
Arterial Blood Gas
If good basic care improves matters and the
Maintenance sedation and NMB
oxygen saturation is greater than 90% then

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 References and Bibliography

Manual of Emergency Airway Management. Ron M Walls. Lippincott Williams & Wilkins 2000. ISBN 0-
7817-2616-6.
The effects of single-handed and bimanual cricoid pressure on the view at laryngoscopy. Yentis S.M.
Anaesthesia, April 1997, vol. 52, no. 4, pp. 332-335(4)
Rapid sequence intubation in the emergency department. Dufour D.G.; Larose D.L.; Clement S.C.
Journal of Emergency Medicine, September 1995, vol. 13, no. 5, pp. 705-710(6)
Assessing the Force Generated With Application of Cricoid Pressure (1). AORN Journal; December 1,
2000; Koziol, Carol A. Cuddeford, James D. Moos, Dan D.

List of main contributors to development of the RSI course

Dr Angus Cooper Co-ordinator
Consultant in Emergency Medicine Dr Graham R Nimmo
Accident and Emergency Department Consultant Physician in Medicine and Intensive Care
Aberdeen Royal Infirmary Western General Hospital
Foresterhill Edinburgh EH4 2XU
Aberdeen AB25 2ZN &
Educational Co-Director
Mr Mark Dunn,
Scottish Clinical Simulation Centre
Specialist Registrar in Emergency Medicine
Stirling Royal Infirmary
Royal Infirmary of Edinburgh
Livilands Gate FK8 2AU
Little France
Edinburgh EH16 4SA Dr Angela Oglesby
Consultant in Emergency Medicine
Dr Stephen Hearns
Royal Infirmary of Edinburgh
Consultant in Emergency Medicine
Little France
Accident and Emergency Department
Edinburgh EH16 4SA
Royal Alexandra Hospital
Corsebar Road Ms Ruth Paterson
Paisley PA2 9PN Practice Development
Acute Medicine
Mr Mike Johnston
Western General Hospital
Consultant in Emergency Medicine
Edinburgh EH4 2XU
Accident and Emergency Department
Ninewells Hospital and Medical School Dr Dave Pedley
Dundee DD1 9SY Specialist Registrar in Emergency Medicine
Accident and Emergency Department,
Ms Lindy Manson
Ninewells Hospital and Medical School,
Educational Co-ordinator
Dundee DD1 9SY
Ward 20 ICU
Western General Hospital Ms Karen Scrimgeour
Edinburgh EH4 2XU Accident and Emergency Department,
Ninewells Hospital and Medical School,
Dr Dermot McKeown
Dundee DD1 9SY
Consultant in Anaesthesia and Intensive Care
Room S8503 Dr Shobhan Thakore
Anaesthesia, Critical Care and Pain Medicine Consultant in Emergency Medicine,
Make a loop, place both ends of tape through, Royal Infirmary of Edinburgh Accident and Emergency Department,
Little France Ninewells Hospital and Medical School,
pull ends in opposite directions and tie round
Edinburgh EH16 4SA Dundee DD1 9SY
patients head.
Thanks also to Ian Ballard and Alison Neilands,
Scottish Clinical Simulation Centre
Stirling Royal Infirmary
Livilands Gate FK8 2AU
and to Dorothy Armstrong, Professional Officer, NES
and to all the participants in the discussions about, and dry runs of, the course.

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