Rapid sequence induction Rapid Sequence Induction (RSI) is an advanced medical procedure, designed for the expeditious induction

of sedation and subsequent intubation of the trachea of a patient (endotracheal intubation). RSI is generally used for patients who have an increased risk of aspirating stomach contents into the lungs due to a current disease process. If not performed properly, or if the patient is unable to be intubated very rapidly (2 minutes or less), the patient could suffer extreme morbidity from hypoxia, hypercapnia or acidosis, or even death. Technique The technique, RSI, strictly refers to the sedation and paralysis prior to an intubation procedure. The technique is a quicker form of the process normally used to "induce" a state of general anesthesia. The difference between an RSI and standard anaesthetic intubation is that the practioner assists the anaesthetist and applys cricoid pressure to prevent regurgitation. Medications are utilized to allow rapid placement of an endotracheal tube between the vocal cords, while the cords are being visualized with the help of a laryngoscope. The neuromuscular blocking agents paralyse all of the patient's skeletal muscles, most notably and importantly in the oropharynx, larynx, and diaphragm. Once the endotracheal tube has been passed between the vocal cords, a cuff is inflated around the tube in the trachea and the patient can then be artificially ventilated. RSI involves pre-oxygenating the patient with a tightly-fitting oxygen mask, followed by the sequential administration of pre-determined doses of a hypnotic drug and a rapid-acting neuromuscular blocker. Hypnotics used include thiopental, propofol and etomidate. Neuromuscular-blocking drugs used include suxamethonium (sometimes with a defasciculating dose of vecuronium) and rocuronium.[1] Other drugs may be used in a "modified" RSI. When performing endotracheal intubation, there are several adjunct medications available. No adjunctive medications, when given for their respective indications, have been proven to improve outcomes.[2] Opioids such as alfentanil or fentanyl may be given to attenuate the responses to the intubation process (tachycardia and raised intracranial pressure). This is supposed to have advantages in patients with ischemic heart disease and those with brain injury (e.g. after traumatic head injury or stroke). Lidocaine is also theorized to blunt a rise in intracranial pressure during laryngoscopy, although this remains controversial and its use varies greatly. Atropine may be used to prevent a reflex bradycardia from vagal stimulation during laryngoscopy, especially in young children and infants. Requirements The clinician that performs RSI must be skilled in intubation and in alternative and less invasive airway management techniques. Failure to intubate means needing to ventilate by bag-valve-mask. The clinician that performs RSI must be knowledgeable about the drug administered. The clinician must understand the time to onset of action of a drug and the required dosage. Otherwise, the clinician risks paralyzing a fully conscious patient. The clinician must also be aware of possible side effects of the drugs such as malignant

hyperthermia. The clinician must use sound judgment in selecting which drug is to be used and the amount to be used. Meticulous preparation and planning is necessary. Back-up plans must be in place. Plans may include the option to move to a non-visualized airway such as the combitube, or laryngeal mask airway. A mandatory emergency back-up plan is an emergency cricothyrotomy This procedure is relatively dangerous. A clinician removes all ability of the patient to breathe or to maintain a patent airway. For this purpose, most prehospital paramedic ambulances are required to have two paramedics in the patient compartment when performing this procedure. Mnemonic A mnemonic for performing RSI is the seven Ps Preparation prepare all necessary equipment, drugs and back-up plans Preoxygenation with 100% oxygen Premedication depending on the patient, just the hypnotic agent Paralyze suxamethonium or rocuronium Pass the tube visualize the tube going through the vocal cords Proof of placement using a reliable confirmation method Post intubation care secure the tube, ventilate Conclusion This procedure is usually performed by an anesthesia provider (e.g., anesthesiologist, certified registered nurse anesthetist or anesthesiologist assistant (AA-C)) in surgery and by medical personnel in the emergency department. It may also be performed in the prehospital setting[1] by persons trained to the paramedic level, including flight medics and flight nurses