Rapid sequence intubation is the cornerstone technique for securing the airway in patients at risk for aspiration of gastric contents. While the classic RSI technique remains widely taught, modifications including gentle bag-mask ventilation and rocuronium-based approaches have gained evidence-based support. The availability of sugammadex has shifted the risk-benefit calculation for neuromuscular blocking agent selection.
Goal: secure airway with minimal time between loss of consciousness and tracheal intubation to prevent aspiration
Classic RSI: preoxygenation, induction agent + succinylcholine 1–1.5 mg/kg, cricoid pressure, no bag-mask ventilation
Modified RSI with rocuronium 1.2 mg/kg is increasingly accepted, especially with sugammadex availability as rescue
Preoxygenation for 3–5 minutes of tidal breathing or 8 vital capacity breaths extends safe apnea time
Cricoid pressure (Sellick maneuver) is controversial; evidence for aspiration prevention is limited
Apneic oxygenation via high-flow nasal cannula (15 L/min) during laryngoscopy extends safe apnea time significantly. Apply it before induction and leave it running throughout the intubation attempt.
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