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Rapid sequence induction (RSI) of anesthesia, sometimes referred to as “crash” induction, has become a safe and effective method of establishing emergent airway control in patients with suspected life-threatening emergencies. It ensures optimal patient compliance in a well-controlled environment. RSI involves the near simultaneous administration of a potent sedative-hypnotic agent and a neuromuscular blocking agent.1 Various pretreatment drug regimens have been advocated to prevent potentially deleterious side effects, such as aspiration of gastric contents, cardiovascular excitation or depression, and intracranial pressure elevation.

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The first endotracheal tubes were developed for the resuscitation of the newborn and victims of drowning in the nineteenth century but were not used in anesthesia until 1878.13 Muscle relaxants were not prepared until some 60 years later. Succinylcholine was prepared by the Nobel Laureate Daniel Bovet in 1949, after which it gained the widespread usage it still enjoys today. The RSI technique did not come into modern day practice until the end of World War II.

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Patients can be hypoxic, confused, uncooperative, unstable, and unknowing of their medications or medical conditions and can require airway control within minutes of arrival at the Emergency Department. RSI is the preferred method for securing the airway in the Emergency Department, as these patients are at risk for aspiration. These risks include vomiting from gastrointestinal obstruction, opioids, or hypotension; regurgitation from diabetic gastroparesis, gastroesophageal reflux, increased gastric pressure, or decreased lower esophageal sphincter tone; impaired laryngeal protective reflexes; and difficult airway management.7 Conditions such as recent meal ingestion, pain, obesity, and pregnancy place patients at higher risk as well.

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The primary indication for RSI is to quickly protect and secure the airway. The rationale behind RSI is to create an environment in which the trachea can be intubated as quickly and with as little difficulty as possible. The clinical conditions occurring at the time of attempted intubation are therefore of great importance. During RSI of anesthesia, the drugs used to produce hypnosis and muscle relaxation interact together to produce the intubating conditions. A complete list of the indications for RSI appears in Table 4-1.

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Table 4-1. Indications for Rapid Sequence Intubation (RSI) in the Emergency Department
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