Mastering RSI in the ED: Sedate, Paralyze, TubeĀ 

-Case-
Youā€™re managing a 56-year-old man in respiratory distress from severe pneumonia. Heā€™s working hard to breathe, oxygen sats are falling despite noninvasive support, and heā€™s becoming confused. Itā€™s time to intubate. Your nurse looks at you: “What meds do you want for RSI?” Itā€™s your time to shineā€¦

-Overview-
RSI is the cornerstone of emergency airway management. It involves simultaneous administration of a sedative (induction agent) and a neuromuscular blocker to achieve rapid unconsciousness and paralysis for safe intubation.

RSI Prep:

  1. Prepare: equipment (ET tube, blade, etc.), suction, monitoring, backup airway plan
  2. Preoxygenate: 100% FiOā‚‚ via non-rebreather or BVM with PEEP
  3. Paralyze and Induce: administer sedative and paralytic
  4. Pass the Tube: intubate!
  5. Post-Intubation Care: confirm placement, secure tube, initiate sedation

-Induction Agents-

-Paralytics-

-Fast Facts-

  • In hypotensive or shocked patients, ketamine is preferred
  • Suspected elevated ICP or head injury? Etomidate or ketamine are your friends!
  • Contraindications to succinylcholine? Use rocuronium!
  • Anticipated difficult airway? Consider delayed sequence intubation or awake approach

RSI is a critical skill for emergency providers, and getting the meds right can be the difference between a smooth airway and disaster. Whether itā€™s etomidate for the crashing trauma patient or ketamine for the hypotensive asthmatic, the choice must be quick and precise. Know your drugs, anticipate complications, and prepare for what comes next – because in airway management, thereā€™s no time for guesswork!

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

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Tamir Zitelny, MD

-References-

  1. Walls RM, Murphy MF. Manual of Emergency Airway Management. 5th ed. Wolters Kluwer; 2018.
  2. Reiter PD, Strother CG. Rapid sequence intubation. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK470403/
  3. Reichman EF, Simon RR. Emergency Medicine Procedures. 2nd ed. McGraw Hill; 2013.
  4. Cash RE, Crowe RP, Panchal AR, et al. Duration of paralysis after rapid sequence intubation with succinylcholine versus rocuronium in the emergency department. Acad Emerg Med. 2021;28(4):407-414. doi:10.1111/acem.14197
  5. Green SM, Roback MG, Krauss B, et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57(5):449-461. doi:10.1016/j.annemergmed.2010.11.030
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