Rapid Sequence Intubation (RSI): Background of RSI

Brief History

• Mendelson first described the deleterious effects of aspiration in 1946.

• Succinylcholine was introduced in 1951.

• Cricoid pressure first described by Sellick in 1961.

• These were collated by Stept and Safar in 1970 to describe a technique they called Rapid Sequence Induction and Intubation.
  • It consisted of preoxygenation, induction with a predetermined dose of thiopental followed by succinylcholine, application of cricoid pressure at loss of consciousness, avoidance of positive pressure ventilation, and finally tracheal intubation with a cuffed tube before removal of the cricoid pressure.
• Airway management is the cornerstone of resuscitation and is a defining skill for the specialty of emergency medicine

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Definition:

• Rapid sequence intubation (RSI) is the virtually simultaneous administration of a sedative and a neuromuscular blocking (paralytic) agent to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation and to minimize the risk of aspiration

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Indications for Intubation

Failure to oxygenate or ventilate

• Ventilatory failure is a primary indication for intubation if it can not be reversed by clinical means and persistent hypoxemia persists despite maximal oxygen supplementation.
  • This assessment checks the patient’s respiratory status, blood oxygen levels and includes a physical examination of their breathing.
  • Healthcare professionals can use capnography for continuous monitoring on exhaled CO2 levels which are related with ventilation pattern & ABGs measure pH values along with pCO2 (partial pressure carbon dioxide) level that can be done by accessing arterial line insertion site through an incision made near elbow or wrist-armpit area.
  • Patients who need assisted ventilation due to poor lung function may need intubation.

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Failure to Maintain or Protect the Airway

• If a patient is unable to maintain an open airway, the clinician should use various maneuvers that will aid in establishing one.
• When a patient requires airway protection, intubation is usually necessary unless they are experiencing temporary or reversible conditions. For example, if someone needs to be put on an oxygen tank while recovering from opioid overdose then other methods of protecting their airways should suffice until the condition passes.

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Anticipated Clinical Course

• The presence of certain conditions are indicators that an intubation is necessary for a patient even if there isn’t immediate threat to airway patency or adequate ventilation.
  • These signs indicate with moderate likelihood that the condition will require intubation in order to evaluate and treat them.
  • Examples include drug overdoses, multiple trauma patient with hypotension, and pentrating neck trauma.

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