Technique
Rapid sequence intubation refers to the pharmacologically induced sedation and neuromuscular paralysis prior to intubation of the trachea. The technique is a quicker form of the process normally used to induce general anesthesia. With standard intravenous induction of general anesthesia, the patient typically receives an opioid, such as fentanyl, and then a drug to induce unconsciousness (commonly propofol). Generally a person undergoing will be manually ventilated for a short period of time before a neuromuscular blocking agent (for example succinylcholine or rocuronium) is administered and the patient is intubated. During rapid sequence induction, the person still receives an IV opioid. However, the difference lies in the fact that the induction drug and blocking agent are administered in rapid succession with no time allowed for manual ventilation. In either case, the endotracheal tube is placed shortly after onset of action of the blocking agent. Medications are utilized to allow rapid placement of an endotracheal tube between the vocal cords, while the cords are being visualized with the aid of a laryngoscope. 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.
This procedure involves preoxygenating the lungs with a tightly-fitting oxygen mask, followed by the sequential intravenous administration of predetermined doses of a sleep-inducing drug and a rapid-acting neuromuscular blocking agent. Commonly used hypnotics include thiopental, propofol and etomidate. Commonly used neuromuscular blocking agents used include succinylcholine and rocuronium. The neuromuscular blocking agents paralyze all of the skeletal muscles, most notably and importantly in the oropharynx, larynx, and diaphragm. Opioids such as fentanyl may be given to attenuate the responses to the intubation process (accelerated heart rate and increased intracranial pressure). This is supposed to have advantages in patients with ischemic heart disease and those with brain injury (e.g. after traumatic brain 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. Despite their common use, such adjunctive medications have not been demonstrated to improve outcomes.
One important difference between RSI and routine tracheal intubation is that the practitioner does not typically manually assist the ventilation of the lungs after the onset of general anesthesia and cessation of breathing, until the trachea has been intubated and the cuff has been inflated.
Read more about this topic: Rapid Sequence Induction
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