KEY POINTS■ Providers who are left alone when caring for critically ill patients should have the ability to control the airway, and intubation is the gold standard for defi nitive airway control.
■ Rapid sequence intubation consists of administration of a rapid-acting sedative, either with or without pretreatment, followed by a paralytic agent before attempting to pass the endotracheal tube.
■ Medications commonly used to attenuate either the underlying illness or the anticipated response to endotracheal intubation include opioids, lidocaine, beta-adrenergic antagonists, and nondepolarizing neuromuscular blocking agents (NMBAs).
■ Midazolam, etomidate, propofol, and ketamine are some of the agents commonly used to induce rapid sedation.
■ Immediately following sedation (or nearly simultaneously), paralysis is achieved with depolarizing or nondepolarizing NMBAs. Succinylcholine is a rapid-acting depolarizing NMBA, and rocuronium and vecuronium are nondepolarizing NMBAs.
Rapid sequence intubation (RSI), also referred to as rapid sequence induction for intubation, is the process of quickly inducing sedation and paralysis in order to perform tracheal intubation safely and more easily in emergent settings. RSI allows the clinician to secure the airway quickly, thereby minimizing the opportunity for regurgitation and aspiration of gastric contents. This overview highlights some of the recent literature on RSI. PAs should seek specific instruction, practical training, and credentialing for this technique before attempting the procedure.
INDICATIONS
Emergent tracheal intubation is commonly used in cases of chronic obstructive pulmonary disease, exacerbation of heart failure, trauma, head injury, and drug overdoses. Patients who can no longer control their own airway are frequently encountered in the emergency department (ED) or ICU as well as on the general medical floor. In one small prospective study, the most common reasons for intubation were patients' inability to protect their own airway (70%), presence of brain injury (54%), and poor oxygenation/ventilation (26%).1 These indications are not mutually exclusive.
For trauma and obtunded patients, the mantra "less than eight, intubate" has long been used to indicate that patients who have a Glasgow Coma Scale (GCS) score less than 8 are likely to need their airway secured.2 Recently, even more conservative guidelines have been suggested. National guidelines for field care of combat head trauma, for example, recommend securing the airway in patients with a GCS score less than 9.3 Persons with head injuries may be particularly prone to emesis and will benefit from rapid control of the airway.
WHO SHOULD PERFORM RSI?
Traditionally, anesthesiologists perform most intubations. Recently, however, this skill has become common for emergency physicians, internists, paramedics, and other health care providers. In the state of Washington, PAs can perform any procedure that their supervising physician can perform as long as the physician trains and allows the PA to perform it.4 Any provider who is left alone caring for critically ill patients should have the ability to control the airway, and intubation is the gold standard for definitive airway control.
Intubation, which has been performed by ED physicians in the United States for some time, has more recently become a common procedure for ED physicians in the United Kingdom. In a 2007 study conducted in Scotland, intubations performed by emergency physicians were compared with those performed by anesthesiologists. The study found that overall success rates were identical (97%) and the number of complications was similar for the two groups.5 These findings lend credibility to the concept that with proper training and experience, nonanesthesiologists can safely perform this procedure.
Internists who practice critical care medicine also benefit from these skills. In a review article directed at the critical care physician, Reynolds and Heffner similarly recommend the increased use of RSI in the ICU setting.6 The article identifies combativeness, comorbidities, baseline hypoxemia, acidosis, and hemodynamic instability as conditions in which the ICU patient would benefit from rapid induction and paralysis to facilitate airway control.6
THE PROCEDURE
RSI consists of administration of a rapid-acting sedative, with or without pretreatment, followed by a paralytic agent before attempting to pass the endotracheal tube. Walls, one of the pioneers of RSI in emergency medicine, describes the seven Ps classically used to guide clinicians in the procedure: Preparation, Preoxygenation, Pretreatment, Paralysis with induction, Protection and positioning, Placement with proof, and Postintubation management7 (Table 1). Detailed instruction in RSI is beyond the scope of this article. Instead, this discussion focuses on recent literature regarding pretreatment, paralysis with induction, protection and positioning, and postintubation management.
