Rapid Sequence Intubation Medical Slides

Present the goal: maximize oxygen reservoir to extend safe apnea time. Techniques: (1) 3 minutes of tidal volume breathing on 100% FiO2 via tight-fitting NRB mask (achieves FeO2 >85%), (2) 8 vital capacity breaths if time-limited, (3) high-flow nasal cannula at 15 L/min during mask preoxygenation (apneic oxygenation — NODESAT trial showed improved first-pass SpO2). Position: 25-degree head-up (ramped position) improves FRC and extends safe apnea time, especially in obese patients (from 2-3 min to 5-6 min). Target: SpO2 >95% before paralysis; EtO2 >85% if available. In critically ill patients, nasal cannula should continue during intubation attempt (FELLOW trial).

Present the hemodynamic-based selection: Ketamine (1.5-2 mg/kg IV) — sympathomimetic, maintains BP, bronchodilator — preferred in hypotension, sepsis, asthma, status epilepticus. Etomidate (0.3 mg/kg IV) — hemodynamically neutral — preferred in cardiac patients, polytrauma; concern for adrenal suppression (single dose likely clinically insignificant per meta-analyses). Propofol (1.5-2 mg/kg IV) — potent vasodilator — use only in hemodynamically stable patients, excellent for status epilepticus. Midazolam (0.1-0.3 mg/kg) — slow onset, unpredictable — generally avoided for RSI. Key point: dose-reduce ALL agents in shock (e.g., ketamine 0.5-1 mg/kg, etomidate 0.15 mg/kg).

Present the structured approach: After failed first attempt → optimize (reposition, suction, change blade/operator, use bougie). After 3 failed attempts or cannot-intubate-cannot-oxygenate → declare failed airway. Rescue sequence: (1) supraglottic airway device (LMA/iGel — success rate >95% as rescue), (2) if SGA fails → front-of-neck access (FONA). FONA options: surgical cricothyrotomy (scalpel-bougie-tube technique per DAS 2015 guidelines is fastest and most reliable), needle cricothyrotomy (temporary bridge, especially in children <10). Emphasize: the decision to move to FONA should not be delayed — cognitive fixation on repeated laryngoscopy attempts is the primary cause of cannot-intubate-cannot-oxygenate deaths.