Rapid Sequence Intubation in the Prehospital Setting

Securing and maintaining a patent airway are the highest priorities when caring for critically ill patients. When airway intervention is required, it should be performed in an expedient and organized fashion by an experienced individual, with the goal of providing a definitive airway safely, minimizing any possible complications. Rapid sequence induction, or RSI, has this goal in mind. Performing RSI successfully requires experience; a thorough understanding of its indications, contraindications and limitations; and a working knowledge of the pharmacology of agents used to assist in intubation. This article reviews how to recognize airway or ventilatory compromise, manage the problem, and emphasize the proper use of RSI with a focus on clinical skills, and discusses the pharmacology and indications of the various agents employed with this technique.

Brief History

Since its introduction in the late 1970s, there has been a great deal of controversy over RSI within the medical community. This controversy stems partly from individuals who are not familiar with their EMS systems’ competence and feel that this task cannot be safely performed by a nonphysician.

Numerous studies, however, have proven that, in experienced hands, RSI can be safely performed in the prehospital setting. Some studies have tried to demonstrate that nasal intubation is superior to pharmacology-assisted oral intubation. Although nasal intubation may be quicker in some providers’ hands, RSI has a consistently higher initial success rate.

Of utmost importance, there must be a highly organized and structured physician-based quality assurance program behind every EMS system that uses RSI in its airway management protocols. If RSI is to be adopted by an EMS agency, cooperation is necessary from everyone in that system.

For instance, local emergency department directors should be consulted and their concerns and comments addressed regarding medical command and control concerning RSI use by EMS providers. Motivated and cooperative operating room personnel and anesthesiologists are invaluable, for that is where various skills and experience with pharmacologic agents can be obtained during the training process. The OR is also useful for performing monthly and yearly quality skills assessments for every participant practicing this technique.

Airway Anatomy

The airway is divided into upper, middle and lower regions. Each region is comprised of separate structures.

Upper Airway

The upper airway begins with the face and facial skeleton, which includes the mandible and maxilla. This means that facial fractures are airway injuries as well. Also within this region are the nasopharynx and oropharynx, which conduct air to the lower airways, humidify gases and clear debris.

Middle Airway

The middle airway is principally composed of the larynx, located midline in the neck and fairly vulnerable to injury. However, it is relatively well-protected from its two muscular lateral sides and the vertebral column posteriorly. The mandible adds some anterior protection as well. The larynx is comprised of cartilage, of which the thyroid and cricoid are major components. The vocal cords are situated within the larynx. This region is narrow, and edema, secretions or foreign bodies can quickly compromise airway patency.

Lower Airway

The trachea delineates the middle and lower airways as it exits the neck and enters the chest. It is made up of incomplete cartilage rings anteriorly that are open posteriorly and held together by elastic muscle tissue posteriorly. It travels into the chest and ends as the airway divides into the right and left mainstem bronchi. The trachea is relatively well-protected; however, injury can occur from blunt trauma to the chest, primarily decelerating injuries, as well as from penetrating injuries.

Prehospital RSI Airway