Airway & Rapid Sequence Intubation (RSI)
The definitive emergency department airway guide: pre-oxygenation strategies, hemodynamically neutral induction, paralytic selection, video laryngoscopy technique, and the can't-intubate-can't-oxygenate (CICO) surgical airway pathway.
Resuscitation Quick Ribbon (First 2 Minutes)
Bottom-Line Clinical Pearl
RSI in the emergency department is fundamentally a resuscitation procedure. Peri-intubation cardiac arrest is prevented by pre-emptively treating hypoxia (NO DESAT, CPAP/BiPAP flush) and hypotension (push-dose pressors, fluid loading) BEFORE pushing induction agents. Etomidate (0.3 mg/kg) or Ketamine (1.5–2 mg/kg) are the primary induction agents; Ketamine is preferred in severe shock or reactive airway disease. If two laryngoscopy attempts and a supraglottic airway fail in a hypoxemic patient, execute an immediate scalpel-finger-bougie surgical cricothyroidotomy.
1. The 7 P's of Emergency Rapid Sequence Intubation
Rapid Sequence Intubation (RSI) is the virtually simultaneous administration of a potent sedative-induction agent and a neuromuscular blocking agent to induce rapid unconsciousness and flaccid motor paralysis for endotracheal intubation.
| Step | Timeline | Clinical Actions & Checkpoints |
|---|---|---|
| 1. Preparation | Zero minus 10 min | SOAP ME checklist: Suction, Oxygen, Airway gear (VL + DL), Pharmacy, Monitors, End-tidal CO2 |
| 2. Pre-oxygenation | Zero minus 5 min | 8 vital capacity breaths or 3 min non-rebreather at 15 L/min + nasal cannula at 15 L/min (NO DESAT) |
| 3. Pre-treatment / Optimization | Zero minus 3 min | Resuscitate before intubating: push-dose pressor for SBP < 100, normalize intravascular volume |
| 4. Paralysis with Induction | Zero | Push induction agent immediately followed by high-dose paralytic (Etomidate/Ketamine + Roc/Succ) |
| 5. Protection & Positioning | Zero plus 30 sec | Ear-to-sternal notch alignment; passive apneic oxygenation via 15 L nasal cannula |
| 6. Placement with Proof | Zero plus 60 sec | Video laryngoscopy, pass tube through cords under direct vision, inflate cuff, continuous waveform capnography |
| 7. Post-intubation Management | Zero plus 2 min | Secure tube, check depth (typically 21–23 cm at teeth), initiate post-intubation sedation and lung-protective ventilation |
2. Induction & Neuromuscular Blockade Dosing Matrix
| Agent | Standard Dose | Onset / Duration | Clinical Indication | Contraindications & Warnings |
|---|---|---|---|---|
| Etomidate | 0.3 mg/kg IV | 15–30 sec / 5–10 min | Hemodynamically neutral; excellent default agent | Transient adrenal suppression (minimal clinical significance for single dose) |
| Ketamine | 1.5–2.0 mg/kg IV | 30–60 sec / 10–20 min | Bronchodilator (Asthma/COPD), maintains MAP in shock | Direct myocardial depressant if catecholamine-depleted (end-stage shock) |
| Propofol | 1.5–2.5 mg/kg IV | 15–30 sec / 5–10 min | Status epilepticus, severe hypertensive emergency | Profound myocardial depression and peripheral vasodilation; AVOID in shock |
| Rocuronium | 1.2 mg/kg IV | 45–60 sec / 45–70 min | Preferred paralytic in most ED cases; no hyperkalemia risk | Prolonged duration; ensure post-intubation sedation plan is active immediately |
| Succinylcholine | 1.5–2.0 mg/kg IV | 30–45 sec / 5–10 min | Rapid onset, short duration | Hyperkalemia, burns > 24h, crush injury, malignant hyperthermia history, denervation/paralysis |
3. The Difficult Airway Algorithm & Cricothyroidotomy
The Scalpel-Finger-Bougie Surgical Cricothyroidotomy: If you cannot intubate and cannot oxygenate (CICO) with SpO2 falling below 80% despite BVM and supraglottic airway: 1) Palpate cricothyroid membrane; 2) Make a 3 cm vertical skin incision; 3) Horizontal stab through the membrane; 4) Insert index finger to maintain tract; 5) Slide gum elastic bougie along finger into trachea; 6) Railroad a size 6.0 cuffed endotracheal tube over bougie.
Test Your Airway & Rapid Sequence Intubation (RSI) Knowledge
Directly launch a targeted 5-question practice block from our 8,400+ board question bank.