Rapid Sequence Intubation (RSI)

Use these numbers at the bedside. Each adult and pediatric value is per kilogram of the weight your protocol specifies; drug choice and doses vary by protocol and must follow local protocols and medical direction.

RSI pairs a fast-acting induction agent with a paralytic, and both go in together. That puts the patient under and relaxes the muscles for tracheal intubation. The goal is good intubating conditions in the shortest time, because the airway stays unprotected the entire time.

How It Works

• Induction agent: puts the patient under. Your choice depends on hemodynamics (see Medications & Settings).
• Paralytic: relaxes the muscles so the laryngoscopist can see the cords. It also stops spontaneous breathing.
• Oxygen throughout: preoxygenation, apneic oxygenation and gentle bag-mask ventilation (BVM) keep desaturation in check.
• Confirmation: sustained waveform capnography (EtCO₂) is how you prove tube position.
• Sedation and analgesia: must start at once. A paralyzed patient cannot show you they are aware.

Where It Fits

RSI lives inside the Difficult Airway Society (DAS) linear algorithm. Plan A is tracheal intubation. Plan B is a second-generation supraglottic airway (SGA). Plan C is facemask ventilation, and Plan D is an emergency front-of-neck airway. Non-drug options can be the better choice when the patient is safer without paralysis: noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), awake intubation, delayed sequence intubation (DSI) and rapid sequence airway (RSA).

Indications

• Failure to maintain or protect the airway: declining mental status, severe intoxication, head injury with loss of protective reflexes.
• Failure of oxygenation or ventilation despite NIV or HFNC.
• Anticipated deterioration: transport of a patient who will worsen, combative trauma, inhalation injury, or airway burns.

RSI drugs are not needed when the patient is deeply comatose, flaccid and apneic, or in cardiac arrest. That is a crash airway, and it gets no drugs. Depressed consciousness with tone or gag reflexes still present? That patient is a candidate for RSI.

Absolute Contraindications

None, when intubation is truly indicated. Drug-specific contraindications apply, too (see succinylcholine under Medications & Settings).

Relative Contraindications & Cautions

• Profound shock: SBP <90 mmHg or shock index >0.9. Start a vasopressor before induction and reduce induction doses.
• Severe acidosis (pH <7.2): the patient depends on high minute ventilation. Apnea worsens acidosis quickly.
• Severe hypoxemia (for example ARDS or pneumonia), right heart failure or massive pulmonary embolism.
• Predicted "can't intubate, can't oxygenate": consider awake intubation before paralysis.
• Succinylcholine-specific risks: malignant hyperthermia (MH) susceptibility, skeletal muscle myopathy, hyperkalemia, and burns, crush, denervation or upper motor neuron injury after the acute phase.

Consider an Alternative

Alternatives to RSI: NIV or HFNC for oxygenation. Awake intubation with topical anesthesia for a predicted difficult airway. DSI for an agitated hypoxemic patient who cannot be preoxygenated. An SGA when intubation is not needed to protect the airway.

Abort / Stop Criteria

Abort the attempt and ventilate with BVM. Do it if SpO₂ falls below 90% or the attempt runs past about 30 seconds.

Team Roles During the Procedure

• Operator: performs laryngoscopy and calls the plan.
• Airway/oxygen manager: preoxygenation, BVM and apneic oxygenation.
• Medication clinician: draws up and gives drugs, reads each label aloud.
• Monitor and recorder: watches SpO₂, ECG, BP and EtCO₂, and times the attempt.

Anatomic Difficulty

Predict rescue ventilation and supraglottic airway difficulty with MOANS and RODS. Predict cricothyrotomy difficulty with SMART. Do both before the first attempt.

Physiologic Risk

Physiology causes more peri-intubation deaths than anatomy does. Each trigger below is a reason to optimize first:

• SBP <90 mmHg or shock index >0.9.
• SpO₂ <93% on the best oxygen available.
• pH <7.2 or a high work of breathing.
• Right heart failure or massive pulmonary embolism; severe ARDS with high PEEP requirement.

Site / Device Check

Confirm suction is on and within reach, BVM with PEEP valve is connected, the second-generation SGA and surgical airway kit are present, waveform EtCO₂ is connected, and the push-dose vasopressor is labeled and ready.

Patient Positioning & Preparation

Ramp the patient so the ear aligns with the sternal notch. Preoxygenate in this position, and keep head and neck in line when cervical spine injury is possible.

These are typical adult and pediatric references. Before you use one, check it against local protocol and current drug labeling.

Post-Intubation Sedation & Analgesia

• Analgesia first: fentanyl infusion 0.7–10 mcg/kg/hr (ICU range; titrate to the protocol target).
• Propofol infusion: start 5 mcg/kg/min; usual 5–50 mcg/kg/min if BP allows. When you need deeper sedation, or faster titration, propofol is the house choice.
• Dexmedetomidine: 1 mcg/kg IV over 10 min, then 0.2–0.7 mcg/kg/hr (ICU range), for light sedation. (PADIS 2025 gives a conditional recommendation for dexmedetomidine over propofol for sedation of ventilated adults.) The label flags hypotension and bradycardia. The loading dose may not be required when you convert from other sedatives. If the patient is hemodynamically unstable, omit or reduce the loading dose. Do not use dexmedetomidine as first-line sedation right after RSI.
• Hypotension: cut back the sedative, treat the BP, and reassess. Pick a sedative the patient's hemodynamics can tolerate, per protocol.

Paralytic Dosing Notes

• Succinylcholine: label intubation dose is 0.6 mg/kg (range 0.3–1.1 mg/kg); RSI practice commonly uses 1–1.5 mg/kg. Confirm the local dose.
• Rocuronium: label gives 0.6–1.2 mg/kg for RSI; 1.2 mg/kg gave about 67 min of clinical relaxation (range 38–160 min), so plan sedation and the next airway step accordingly.

Phase 1: Prepare

1. Resuscitate and optimize: assess SBP, shock index, SpO₂ and pH. Correct real hypovolemia or bleeding with blood for hemorrhage. A routine prophylactic fluid bolus does not prevent peri-intubation collapse (PREPARE II). Start a vasopressor before induction if the patient is hypotensive.
2. Brief the team: name roles, the first attempt and Plans A to D, and the drug doses aloud.
3. Check equipment: suction on, BVM with PEEP valve, video laryngoscope, bougie, SGA, surgical airway kit and monitors. Label every syringe and the push-dose vasopressor.
4. Position: ramp the patient so the ear aligns with the sternal notch.
5. Preoxygenate: use NIV for hypoxemic patients (PREOXI). Use a non-rebreather with nasal cannula at 15 L/min when NIV is not available. Continue about 3–5 minutes, or until EtO₂ is maximized if monitored.

Phase 2: Perform

6. Give pretreatment if the protocol uses it: fentanyl 1 mcg/kg IV for a hypertensive or tachycardic patient. Timing per protocol.
7. Give the induction agent at the dose in the table, over 30–60 seconds.
8. Give the paralytic immediately after the induction agent (near-simultaneous), then flush.
9. Apply apneic oxygenation: nasal cannula at 15 L/min or HFNC through every attempt.
10. Ventilate if the patient desaturates: gentle BVM with PEEP valve between induction and laryngoscopy reduced severe hypoxemia (PREVENT) without increasing aspiration.
11. Wait for relaxation, about 1 minute for rocuronium and succinylcholine in label data. Do not laryngoscope before the jaw is relaxed.
12. Laryngoscopy: video laryngoscope first-line. Limit the attempt to about 30 seconds and use the bougie early if the view is poor.

Phase 3: Confirm & Secure

13. Pass the tube and inflate the cuff at the depth that the protocol uses. Stop the attempt if SpO₂ falls below 90%.
14. Confirm placement: sustained waveform EtCO₂ over at least 5–6 breaths (see Confirmation & Monitoring).
15. Secure the tube with a commercial holder or well-applied tape and document depth.
16. Start ventilation with lung-protective settings (see the intubation page).
17. Start sedation and analgesia immediately, analgesia first, while the paralytic is still active.
18. Reassess hemodynamics every 3–5 minutes; positive pressure ventilation and induction drugs can drop BP. Use push-dose vasopressor or infusion as needed.

Alternative Technique: Delayed Sequence Intubation (DSI)

Think of DSI for the combative, hypoxemic patient who cannot be preoxygenated. Give a dissociative dose of ketamine per protocol while the patient keeps breathing. Then preoxygenate with a high-flow nonrebreather or NIV. Move on to standard RSI once oxygenation is adequate. The dissociative dose is set by protocol. It goes in slowly, with extra aliquots to effect.

Alternative Technique: Rapid Sequence Airway (RSA)

Place a supraglottic airway after induction and paralysis. It bridges the patient to oxygenation and ventilation. Then reattempt intubation once the patient is optimized. Use it when laryngoscopy is failing, or when no intubation attempt is safe.

Primary Confirmation

A sustained waveform EtCO₂ across at least 5–6 breaths is your proof of tracheal placement. Without one, treat the tube as esophageal until shown otherwise. Pull it, re-oxygenate, then either re-attempt or place an SGA.

Secondary Confirmation

• Bilateral chest rise with each BVM breath.
• Equal breath sounds in both axillae (listen high to avoid transmitted sounds).
• No epigastric sounds during ventilation.
• SpO₂ rises after intubation rather than falling.
• Ultrasound or chest radiograph to check depth when the tube position is uncertain.

Ongoing Monitoring

• Continuous waveform EtCO₂ for the whole procedure and transport.
• SpO₂ and BP every 3–5 minutes after induction.
• Recheck tube depth and capnography after every move and handoff.
• Check the train-of-four or clinical twitch before any repeat paralytic dose.

Pediatrics

• Desaturation: Children desaturate faster. Preoxygenate longer if the child can tolerate it, and use apneic oxygenation.
• Tube size: Use length-based tape or the Broselow tape per local protocol. Check cuff pressure.
• Succinylcholine: The boxed warning covers hyperkalemic rhabdomyolysis and cardiac arrest. It applies to apparently healthy children with undiagnosed myopathy (for example Duchenne).

Older Adults

• Some older patients are more sensitive to rocuronium (label). Use lower doses of propofol, and titrate.
• Older patients have less oxygen reserve. Preoxygenate fully, and do not rush the attempt.

Pregnancy

• Pregnant patients desaturate fast. Start nasal oxygenation and mask ventilation right after induction. Keep them going through the attempt.
• Use lateral uterine displacement as indicated. Consider a 20–30° head-up position before the first attempt (OAA/DAS 2015).
• Limit intubation attempts to two. Then move early to a second-generation supraglottic airway, per the OAA/DAS obstetric guideline.
• If intubation is difficult, consider releasing cricoid pressure early.
• If the patient can be neither intubated nor oxygenated, follow the CICO pathway. Timely perimortem cesarean delivery is part of the obstetric algorithm.

Obesity

• Obese patients desaturate faster. Preoxygenate fully, ramp the patient, and use apneic oxygenation.
• Dose the paralytic on the weight basis the protocol specifies. Succinylcholine goes on actual body weight (see Dosing basis).

Traumatic Brain Injury

• Hypotension and hypoxia make secondary brain injury worse. Avoid both before, during and after RSI. Treat hypotension early, against the local TBI blood-pressure target.
• When a cervical spine injury is possible, keep in-line stabilization (see Positioning).

Renal Failure or Dialysis

• Sugammadex is not recommended if creatinine clearance is under 30 mL/min or on dialysis (label). Use the alternative reversal per protocol.

Physiologically Difficult Airway

Pre-Procedure Assessment and Indications already cover shock, severe hypoxemia, acidosis and right heart failure. Use the physiologic plan before any paralytic.

Immediate Aftercare

• Recheck tube depth, EtCO₂ and breath sounds after every move.
• Start sedation and analgesia immediately, analgesia first.
• Set the ventilator; titrate SpO₂ to the target in the intubation page.

Ongoing Maintenance

Check cuff pressure within the range the protocol sets (commonly 20–30 cm H₂O). Keep the tube secure and document the depth at the lip or teeth.

Transport Considerations

• Secure the tube and reconfirm EtCO₂ after every move, loading or handoff.
• Expect cuff pressure changes with altitude; check during flights.
• Vibration and noise make auscultation unreliable; rely on EtCO₂ and waveform monitoring.
• Paralysis from rocuronium can last an hour or more; keep sedation running during transport.

Pearls

• Resuscitate before you intubate: Optimize BP, oxygenation and acid-base status before you push any drugs.
• Oxygen all the way: NIV for hypoxemic patients. Apneic oxygenation runs through every attempt.
• Bag between induction and laryngoscopy when the patient is desaturating.
• Plan the rescue first: Have the SGA and surgical airway ready before the paralytic goes in.
• Video laryngoscope first-line where available. Switch devices instead of repeating a failed attempt.

Common Pitfalls

• Propofol in shock: Use a hemodynamically stable agent at a reduced dose. Resuscitate first.
• Routine fluid bolus as prophylaxis: It does not prevent collapse. Treat real hypovolemia.
• Forgetting post-intubation sedation: The paralyzed patient cannot show you they are aware.
• Repeating the same failed attempt: The fix is a change of device, position or plan.
• No waveform, assumed placement: Remove the tube and re-attempt. Keep going until EtCO₂ confirms it.

Skill Maintenance

• Run RSI simulation at least every few months with the full team, including the medication clinician.
• Practice the push-dose vasopressor preparation and label check until it is routine.
• Rehearse the failed-airway pathway, including the CICO trigger and the scalpel-bougie-tube sequence.
• Debrief every intubation: first-pass success, peak desaturation and time to confirmation.