Overview
Rapid sequence induction (RSI) is an emergency airway management technique designed to minimize the time between loss of consciousness and securing the airway, reducing the risk of aspiration in patients with full stomachs or other risk factors.
RSI is critical for emergency airway management in patients at risk of aspiration, including trauma patients, obstetric emergencies, and patients with delayed gastric emptying. It balances the need for rapid airway control with aspiration prevention.
Learn more in our comprehensive RxDx Anesthesia Course
Indications
Recent food intake within 6-8 hours
Emergency trauma requiring airway management
Emergency cesarean section or obstetric complications
Bowel obstruction or ileus
Increased aspiration risk due to pregnancy
Gastroparesis and delayed gastric emptying
Urgent procedures without fasting
Recent abdominal surgery or pathology
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (aspiration risk factors, airway evaluation), equipment check (laryngoscope, endotracheal tube, suction), preoxygenation, and understanding the RSI algorithm and backup plans.Step-by-Step Procedure
Step 1: Preoxygenation
Administer 100% oxygen via face mask for 3-5 minutes to achieve nitrogen washout and create oxygen reservoir.
⚠️ Common Mistakes to Avoid:
- Inadequate preoxygenation
- Poor mask seal
- Not using high flow oxygen
💡 Pro Tip:
Use high flow oxygen (15L/min) and ensure proper mask seal. Monitor SpO2.
Step 2: Patient Positioning
Position patient in sniffing position with head extended, neck flexed, and shoulders elevated.
⚠️ Common Mistakes to Avoid:
- Poor positioning
- Inadequate neck extension
- Not elevating shoulders
💡 Pro Tip:
Use a pillow under the head and ensure proper alignment.
Step 3: Induction
Administer induction agent (propofol, etomidate, or ketamine) followed immediately by muscle relaxant (succinylcholine or rocuronium).
⚠️ Common Mistakes to Avoid:
- Delayed muscle relaxant
- Wrong medication doses
- Poor timing
💡 Pro Tip:
Administer muscle relaxant immediately after induction agent. Use appropriate doses.
Step 4: Cricoid Pressure
Apply cricoid pressure (Sellick maneuver) to prevent regurgitation and aspiration.
⚠️ Common Mistakes to Avoid:
- Wrong pressure location
- Inadequate pressure
- Too much pressure
💡 Pro Tip:
Apply pressure at the cricoid cartilage with 10N of force. Release if vomiting occurs.
Step 5: No Bag-Mask Ventilation
Avoid positive pressure ventilation between induction and intubation to prevent gastric insufflation.
⚠️ Common Mistakes to Avoid:
- Bag-mask ventilation
- Gastric insufflation
- Increased aspiration risk
💡 Pro Tip:
Do not ventilate between induction and intubation unless absolutely necessary.
Step 6: Laryngoscopy
Perform laryngoscopy and intubate as quickly as possible after muscle relaxation.
⚠️ Common Mistakes to Avoid:
- Delayed intubation
- Poor technique
- Multiple attempts
💡 Pro Tip:
Intubate quickly and efficiently. Have backup plan ready.
Step 7: Position Confirmation
Confirm tube position using multiple methods: auscultation, EtCO2, chest rise.
⚠️ Common Mistakes to Avoid:
- Relying on single method
- Not checking bilateral breath sounds
- Ignoring EtCO2
💡 Pro Tip:
Always use multiple confirmation methods. EtCO2 is most reliable.
Master RSI with RxDx
Access 100+ procedure videos and expert guidance with the RxDx app
Post-procedure Care
Post-RSI care includes confirming tube position, monitoring for complications (aspiration, failed intubation), securing the airway, and documenting the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Aspiration | 1-5% | Hypoxemia, wheezing, decreased breath sounds, fever | Suction, oxygen therapy, antibiotics, chest physiotherapy | Proper technique, cricoid pressure, rapid intubation |
| Failed intubation | 2-8% | Cannot visualize vocal cords, multiple attempts, hypoxemia | Call for help, use backup plan, consider surgical airway | Proper preparation, backup equipment, skilled operator |
| Hypoxemia | 5-15% | Low SpO2, bradycardia, cyanosis, agitation | Stop procedure, bag-mask ventilation, reoxygenate | Adequate preoxygenation, rapid intubation, backup plan |
| Cardiovascular collapse | 1-3% | Hypotension, bradycardia, cardiac arrest | CPR, vasopressors, emergency drugs, ACLS | Appropriate medication doses, monitoring, preparation |
| Esophageal intubation | 2-5% | No breath sounds, gastric distension, no EtCO2 | Remove tube immediately, reoxygenate, reattempt | Confirm position with multiple methods, watch tube pass cords |
| Dental trauma | 1-3% | Tooth damage, bleeding, loose teeth | Document injury, consult dentist, provide referral | Gentle technique, avoid using teeth as fulcrum |
Clinical Pearls
Always have a backup plan for failed RSI - know your difficult airway algorithm.
Preoxygenation is crucial - aim for 100% SpO2 before induction.
Administer muscle relaxant immediately after induction agent - timing is critical.
Apply cricoid pressure correctly - 10N force at the cricoid cartilage.
Do not ventilate between induction and intubation - prevents gastric insufflation.
Have all equipment ready before starting - speed is essential in RSI.
Monitor for aspiration post-RSI - especially in the first 24 hours.
Practice RSI regularly - muscle memory saves lives in emergencies.
Use appropriate medication doses - avoid cardiovascular collapse.
RSI is a high-risk procedure - always have help available.