Rapid Sequence Induction/Intubation
Summary
This is a brief summary on Rapid Sequence Induction/Intubation.
Introduction
With this technique, we give the agents (induction + muscle relaxant at predetermined dosages) quickly one after the other. We want to achieve a definitive airway in less than 1 minute. The technique is used in patients that are at aspiration risk.
Steps
- Ensure that the patient has a well-running IV line. Try to insert a large bore IV cannula. Preferably 18G or larger. Place any available monitors – standard monitors include Sats Probe, ECG, and NIBP.
- Prepare and position the patient.
- Pre-oxygenate the patient.
- Give the IV Induction followed by the muscle relaxant.
- Remember, the dosages are calculated.
- Examples:
- Induction Agent: Propofol @ 1-2.5mg/kg IV stat, Etomidate 0.2 – 0.5mg/kg IV stat, Ketamine 1-2mg/kg IV stat, Thiopentone 3-6mg/kg IV stat or Midazolam 01. – 0.4mg/kg IV stat. Remember that each has its own side effects/benefits. In summary, Propofol causes hypotension, Etomidate maintains hemodynamic stability, Ketamine rises the pressures (blood pressure, ICP, intra-ocular pressures), and is also a bronchodilator.
- Muscle Relaxant: Suxamethonium @ 1mg/kg or high dose Rocuronium @ 1.2mg/kg IV stat. Suxamethonium has contraindications/side effects!
- Examples:
- Remember, the dosages are calculated.
- Once the fasciculation from suxamethonium has disappeared or 45 seconds have elapsed, then intubate the patient.
- An assistant holds down the cricoid (cricoid pressure) to prevent reflux and aspiration
- Inflate the ET cuff
- Check the position of the tube
- You saw the tube passing the vocal cords
- There is mist on the ET tube
- Capnography is working
- There is adequate chest movement
- Auscultate for equal breath sounds, and around the epigastrium
- Connect the ET tube to the ventilator or to the bag valve mask (BVM)
- Secure the tube
- The assistant then removes the cricoid pressure
Remember
- If you use a high dose of Rocuronium then it is called a modified Rapid Sequence Induction/Intubation.
- Suxamethonium is a depolarizing muscle relaxant that lasts around 5mins. Rocuronium is a Non-Depolarizing muscle relaxant and may last around >30mins.
References and Further Reading
1. Hayward, C., Jackson, C., Thoresson, M. and Ellis, J., n.d. EAST LONDON HOSPITAL COMPLEX: ANAESTHETICS HANDBOOK. 2nd ed. pp.18 – 20.
2. Anesthesia Key. 2022. 12: Intravenous Anesthetics and Benzodiazepines. [online] Available at: https://aneskey.com/12-intravenous-anesthetics-and-benzodiazepines [Accessed 14 May 2022].
2. Anesthesia Key. 2022. 12: Intravenous Anesthetics and Benzodiazepines. [online] Available at: https://aneskey.com/12-intravenous-anesthetics-and-benzodiazepines [Accessed 14 May 2022].
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