Rapid Sequence Induction and Intubation

Question 1

Indications for RSI

Answer 1

Fasting unreliable
- Over 20/40 pregnant
- Obesity
- Hiatus hernia/ GORD
- History of oesophageal or bariatric surgery
- Gastroparesis due to diabetes, CKD, neuromuscular conditions

Not fasted
- Unknown history or unconcious
- Bowel obstruction
- Acute pain or trauma resulting in gastric stasis

Question 2

Risks of RSI

Answer 2

• Hypoxia
• Hypotension
• Difficult airway and failed intubation
• Pulmonary aspiration

Question 3

Preparation of patient for RSI

Answer 3

• Assess the airway
• Reliable IV access
• Sat up, ramped positioning
• Pre-oxygenation aiming for an FeO2 >0.9
• Consider an NG tube or if already in place then aspirate
• Optimise haemodynamic state- fluids, vasopressors, inotropes

Question 4

Preparation of equipment for RSI

Answer 4

• SpO2, ECG, BP and waveform capnography are essential
• Arterial line and CVC should be considered if haemodynamically unstable
• Suction (x2 if significant airway contamination is likely)
• VL
• Bougie/ stylet
• Range of tube sizes
• Drugs
• Induction: propofol 1-3mg/kg, thiopentone 3-5mg/kg, ketamine 1-2mg/kg
• NMBD: suxamethonium 1-2mg/kg, rocuronium 1.2mg/kg
• Optional adjuncts: fentanyl 1-3mcg/kg, alfentanil 10-50mcg/kg, lidocaine 1-1.5mg/kg

Question 5

Preparation of team for RSI

Answer 5

In theatres, this may just be an anaesthetist and ODP

Outside theatres there should be:
- Intubator
- Airway assistant (also applying cricoid)
- Team leader, medications, monitor, 2nd intubator
- Runner

Cricoid- vertical downward pressure on the cricoid cartilage using the thumb and first finger. 10N when the patient is awake and 30N when the patient is unresponsive.

Question 6

Preparation for difficulty for RSI

Answer 6

• Communicate an airway plan before RSI
• In the event of failed intubation the priority should be oxygenation
• Follow DAS algorithm in general