RSI Procedure Summary

Pre-oxygenation

  • 100% oxygen for 3 minutes
  • 20° head-up tilt if possible
  • Maximizes oxygen reserve
  • Delays desaturation during apnea

RSI Sequence (PEACH)

  1. Pre-oxygenation
  2. Induction drug injection
  3. Neuromuscular blocking drug
  4. Apneic oxygenation
  5. Cricoid pressure at LOC
  6. Laryngoscopy & intubation
  7. Tube placement confirmation
  8. Cricoid pressure removal
  9. Ventilation established
  10. Post-intubation review

Apneic Oxygenation

  • Nasal cannulae at 15 L/min
  • Extends safe apnea time
  • Useful adjunct to pre-oxygenation
  • Abandon if prevents mask seal

Cricoid Pressure

  • 30-40 Newtons force
  • Applied at loss of consciousness
  • Do not use during active vomiting
  • Remove after tube confirmation

Tube Confirmation

  • Waveform capnography (gold standard)
  • Chest wall symmetry
  • Auscultate both axillae
  • Auscultate epigastrium

Rapid Sequence Induction: Procedure

Comprehensive guide to the RSI procedure for emergency airway management

Introduction

Rapid sequence induction of anaesthesia (RSI) involves injecting an anesthetic induction drug to achieve hypnosis, immediately followed by a neuromuscular blocking drug to produce complete paralysis. The lungs are not ventilated between induction and intubation to prevent gastric inflation.

Time Sensitivity

The time from loss of consciousness to securing the airway is minimised because the patient's stomach is assumed to be full.

RSI Sequence (PEACH)

Step-by-Step Procedure

  1. Pre-oxygenation
  2. Injection of precalculated dose of induction drug
  3. Injection of precalculated dose of neuromuscular blocking drug
  4. Commence apnoeic oxygenation
  5. Cricoid pressure applied at loss of consciousness
  6. Laryngoscopy and intubation
  7. Confirmation of tracheal tube placement
  8. Cricoid pressure removed
  9. Ventilation established and tube secured
  10. Post-intubation review

Pre-oxygenation

Effective pre-oxygenation greatly increases the oxygen reserve within the lungs. This maximises the time before desaturation of arterial blood occurs during apnoea, and decreases the risk of severe hypoxaemia and its associated morbidity and mortality.

Standard Technique

Special Considerations

Difficult Pre-oxygenation

Some ill patients are not adequately pre-oxygenated with standard technique. A good airway management technique with a well-fitting mask and high-flow oxygen is essential.

PEEP Application

Gentle application (maximum 10 cmH2O) of PEEP may augment pre-oxygenation in patients failing to achieve an arterial blood oxygen saturation above 95%; avoid inflating the stomach, which increases risk of regurgitation and aspiration.

Low Respiratory Rate

A patient with a low respiratory rate may not achieve sufficient alveolar ventilation and will require assisted ventilation to achieve adequate pre-oxygenation.

Apnoeic Oxygenation

Apnoeic oxygenation continues delivery of oxygen in the absence of ventilation, provided the airway is patent. It increases significantly the time before desaturation of arterial blood occurs during anaesthesia.

Technique

Important Caveat

If the nasal cannulae tubing prevents an adequate seal being formed, this may be counterproductive since it will diminish the benefit of pre-oxygenation and should be abandoned.

Cricoid Pressure

Applied in an attempt to reduce passive reflux of gastric contents into the pharynx and subsequent aspiration into the lungs.

Contraindication

Should not be used in presence of active vomiting because it may cause oesophageal rupture.

Application Technique

  1. Cricoid ring is identified (below the thyroid cartilage and cricothyroid membrane)
  2. Trained assistant stabilizes between thumb and middle finger before induction
  3. As consciousness is lost, firm pressure applied to center of cricoid cartilage
  4. Index finger presses directly backwards to compress upper esophagus
  5. Optimal force is 30-40 newtons
    • Inadequate pressure will not occlude the esophagus
    • Excessive force or incorrect placement will deform larynx

Removal Criteria

Cricoid pressure should only be removed once correct tube placement has been confirmed (or if it is thought to be distorting the anatomy of the laryngeal inlet and contributing to intubation failure).

Laryngoscopy and Intubation

Laryngoscopy Technique

  1. Laryngoscope held in the left hand
  2. Tip of blade inserted into right side of patient's mouth
  3. Blade advanced further into oropharynx, gradually toward midline
  4. Maintain tongue displacement anteriorly and to the left
  5. When epiglottis seen, blade tip placed in vallecula
  6. Epiglottis lifted by elevation of laryngoscope in line of handle
  7. Laryngeal inlet seen anterior to arytenoid cartilages
  8. Vocal cords identified
  9. Use suction to clear secretions, blood or vomiting

Intubation Technique

Bougie Use

Routine use of a size 4 laryngoscope blade (for adults) and an intubating bougie is recommended during RSI; the bougie is passed behind the epiglottis and into the trachea; detection of clicks as the bougie slides over the tracheal rings helps to confirm correct placement.

  1. Tracheal tube railroaded over bougie into trachea
  2. Assistant threads tracheal tube over bougie until grasping end
  3. While bougie held still, practitioner advances tracheal tube under direct vision
  4. Cuff should lie just beyond vocal cords
  5. Rotation of tracheal tube 90° counterclockwise may ease passage
  6. Assistant removes bougie while practitioner grasps tube firmly
  7. Cuff inflated slowly until air leak during lung inflation
  8. Ideally use pressure gauge to ensure correct cuff pressure

Confirmation of Tracheal Tube Placement

Expected Tube Depth

As a general rule, when the tracheal tube is at the correct depth, the patient's teeth will lie between 20-21 cm in an adult female and 22-23 cm in an adult male.

Confirmation Methods

Waveform Capnography

Gold standard for confirming tracheal placement. Continuous monitoring is essential.

Clinical Assessment

  • Inspect chest wall for symmetry of movement with ventilation
  • Auscultate both axillae for air entry
  • Auscultate epigastrium to confirm absence of air insufflating stomach

Once tracheal intubation is confirmed, release the cricoid pressure and secure the tube.

Post-intubation Review

Initial Assessment

  • Reassess patient using ABCDE approach
  • Inject long-acting neuromuscular blocking drug if indicated
  • Use suction catheter to clear material from proximal airways

Monitoring

  • Check HR, SpO2, BP, end tidal CO2 and peak inspiratory pressure
  • Request chest x-ray to examine tube position
  • Withdraw or advance tube as required based on assessment

RSI Complications and Troubleshooting

Failed Intubation

  • Have failed intubation drill ready
  • Maintain oxygenation with bag-mask ventilation
  • Call for senior help early
  • Consider supraglottic airway device

Desaturation

  • Ensure adequate pre-oxygenation
  • Use apneic oxygenation
  • Limit intubation attempts to 30 seconds
  • Ventilate between attempts if needed

Hemodynamic Instability

  • Choose induction agents carefully in shock
  • Have vasopressors prepared
  • Monitor blood pressure closely
  • Be prepared to fluid resuscitate