What are the contraindications for rapid sequence intubation (RSI)?

Updated: Oct 11, 2018
  • Author: Keith A Lafferty, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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Answer

Absolute contraindications include the following:

  • Total upper airway obstruction, which requires a surgical airway
  • Total loss of facial/oropharyngeal landmarks, which requires a surgical airway

Relative contraindications include the following:

  • Anticipated "difficult" airway, in which endotracheal intubation may be unsuccessful, resulting in reliance on successful bag-valve-mask (BVM) ventilation to keep an unconscious patient alive: In this scenario, techniques for awake intubation and difficult airway adjuncts can be used. Multiple methods can be used to evaluate the airway and the risk of difficult intubation (eg, LEMON rule, 3-3-2, Mallampati class, McCormack and Lehane grade). Please refer to the Difficult Airway Assessment section below for details.
  • The "crash" airway, in which the patient is in an arrest situation, unconscious and apneic: In this scenario, the patient is already unconscious and may be flaccid; further, no time is available for preoxygenation, pretreatment, or induction and paralysis. BVM ventilation, intubation, or both should be performed immediately without medications.

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