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.1–20 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.
The first endotracheal tubes were developed for the resuscitation of the newborns 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.
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.
The primary indication for RSI is to quickly protect and secure the patient's 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, 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 10-1.
Table 10-1 Indications for RSI in the Emergency Department |Favorite Table|Download (.pdf)
Table 10-1 Indications for RSI in the Emergency Department
Airway protection and risk for pulmonary aspiration (e.g., full stomach, pregnancy, and obesity)
Application of advanced cardiac life support and administration of drugs
Definitive maintenance of airway patency
Depressed level of consciousness and questionable ability to maintain a patent airway
Emergency surgery and requirement for general anesthesia
Head trauma with a decreased Glasgow Coma Scale score
Head trauma with the need for airway control
Head trauma with the need for ventilation
Potentially difficult intubation after airway evaluation
Respiratory failure, actual or impending
Uncontrolled seizure activity requiring airway control
Uncooperative or combative patient with compromised airway