Why is rapid sequence intubation (RSI) the preferred method of endotracheal tube intubation (ETTI) in the emergency department (ED)?

Updated: Apr 07, 2020
  • Author: Keith A Lafferty, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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Answer

RSI is the preferred method of endotracheal tube intubation (ETTI) in the emergency department (ED). This is because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). This is important in patients who have not fasted and because of this are at much greater risk for vomiting and aspiration. To this end, the goal of RSI is to intubate the trachea without having to use bag-valve-mask (BVM) ventilation, which is often necessary when attempting to achieve intubating conditions with sedative agents alone (eg, ketamine, etomidate, propofol).

Instead of titrating to effect, RSI involves administration of weight-based doses of an induction agent (eg, ketamine, etomidate) immediately followed by a paralytic agent (eg, rocuronium, succinylcholine) to render the patient unconscious and paralyzed within 1 minute. These medications share commonality in short onset/offset times and potent efficacies. This method has been proven safe and effective in EDs over the past 4 decades, and it is considered the standard of care. When administered by experienced, well-trained emergency physicians, use of neuromuscular blocking agents in patients undergoing emergent tracheal intubation is associated with a significant decrease in procedure-related complications. [4]


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