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RSI Intubation for Nurses: Rapid Sequence Intubation

Critical care Emergency (ER) ICU Procedures & Skills Pulmonary
Reading time icon Reading time 25 minutes

RSI, or Rapid sequence intubation, is the process of intubating people in the hospital, pre-hospital, and emergency department settings when the patient is awake.

It involves multiple different steps that need to occur to quick succession, to provide first sedation, then paralysis, then insertion of the endotracheal tube into the trachea. 

Learn all about RSI intubation, and specifically what the nurse’s role during an intubation is, and which compications and montioring parameters to watch out for!

Indications for RSI Intubation

So when does a person need intubed? Well, this really depends, but emergent intubations often involve severe respiratory distress

Patients in acute respiratory failure will typically present with:


  • TACHYPNEA: Increased respiratory rate > 20 rpm

  • HYPOXIA: SPO2 < 90%

  • INCREASED WOB: Increased work of breathing characterized by use of accessory muscles

  • ADVENTITIOUS BREATH SOUNDS: Presence of abnormal breath sounds including wheezing, crackles, rhonchi, or diminishment

  • OTHER ABNORMAL VITAL SIGNS: May be present including tachycardia, hypertension, hypotension, fever, or altered mental status

Tripod Position

Tripod position is when a patient is sitting over the bed leaning forward, supporting their upper body with their hands on the knees or another surface. This helps accessory muscles breath more easily, but can be an ominous sign to someone who is in respiratory distress. Think COPD!

Indications for Rapid Sequence intubation (RSI intubation) includes:

  • Acute Respiratory Failure (from pneumonia, COPD, CHF, Covid, etc)
  • Anaphylactic reaction or Angioedema
  • When the patient cannot protect their airway (severe alcohol intoxication, drugs, etc.)
  • For surgery

The Nurse’s Role during RSI

So what is YOUR responsibility as the nurse?  Well don’t worry, you shouldn’t actually be the one to intubate the patient (although there are some exceptions such as NICU nurses and Flight nurses). 

The person who placed the Endotracheal (ET) tube is usually a paramedic, physician, and sometimes an advanced practice provider (PA, NP, or CRNA). This is usually:

  • EM Physician but sometimes APP
  • IM Physician
  • Anesthesia

The nurse’s role is not to physically intubate, but nurses are essential in making sure the intubation goes safely and smoothly. They are also on the front lines to notice and intervene when things go wrong!

The nurse’s role is to prepare the patient and equipment,  administer the medications, help manage the airway (although this is usually the job of respiratory therapists), and monitor the patient.

Afterwards, they are required to keep the patient sedated with titratable sedatives.

It is still important for nurses to understand how the RSI intubation process goes, even if they are not the ones placing the ET tube. It takes a team of nurses, respiratory therapists, physicians, and more to have a successful intubation without any complications.

Alternatives to RSI Intubation

Are there any alternatives to intubation? Yes and no.

There are certainly treatments we can try before jumping to intubation. These include nebulizers, certain IM/SQ meds, a non-rebreather, High-flow nasal cannula, and CPAP or BIPAP.

However, usually when intubation is decided on, it is when the patient is in impending respiratory arrest, or when the other treatments already aren’t enough.

RSI intubation is kind of our last saving measure that we can do to save their life and stabilize their respiratory system.

RSI MEDICATIONS

Before diving into the steps of RSI, we need to review the important medications that are given during RSI.

It is the nurses responsibility to draw these up, reconstitute them, and give them. Any medication that a nurse gives, they should know how the medication works, any side effects, and what to monitor for.

Sedatives

First we’re going to talk about sedatives. A sedative is a medication that acts as a CNS depressant – essentially putting the patient to sleep. Different sedatives work in different ways. Sometimes, it takes multiple different sedatives at the same time to effectively sedate a patient.

Sedatives are also called induction agents – inducing sedation in the patient. They also decrease the sympathetic response, making the body better tolerate the overall intubation experience.

In regards to RSI Intubation, SEDATIVES ARE ALWAYS GIVEN FIRST

This is because you need to knock the patient out before you paralyze them, as this is a very frightening experience if not. It can also cause tachycardia, hypertension, and increased ICP if you don’t!

Etomidate

Etomidate is the most common sedative that will be ordered for RSI intubation. 

Etomidate does not offer any analgesia, so sometimes fentanyl is added to minimize the SNS stimulation for patients with significant cardiovascular disease or increased ICP patients.

Etomidate does not really affect blood pressure, but it can cause some mild increase in airway resistance.

SIDE EFFECTS & MONITORING

  • MYOCLONUS: Etomidate can cause myoclonus to occur, which is brief and harmless, but can be mistaken for a seizure.

  • ADRENAL SUPPRESSION: Etomidate can cause adrenal suppression for 12-24 hours after the injection. This could potentially impact hemodynamic stability (blood pressure), mainly in patients who are at risk such as those with pre-existing adrenal insufficiency or severe sepsis.

  • HEART FAILURE EXACERBATION: Etomidate doesn’t cause HF, but patients with pre-existing HF may have exacerbated underlying myocardial dysfunction after administration.

  • TACHYPNEA: Increased respiratory rate > 20 rpm

Versed

Versed, also called Midazolam, is the most commonly used Benzodiazepine used for sedation for RSI intubation.

Versed also does not cause analgesia, but is a good choice for patients in status epilepticus because it offers anticonvulsant properties.

However, it can decrease the blood pressure, so this should be avoided in patients who are hemodynamically unstable.

SIDE EFFECTS & MONITORING

  • HYPOTENSION: Versed can cause a decrease in Mean Arterial Pressure (MAP) by 10-25%. This means Versed should generally be avoided in hypotensive patients or those at risk for hypotension (severe sepsis, trauma, etc).

Ketamine

Ketamine is a newer sedative used for RSI intubation. It’s structurally similar to PCP, and can cause some interesting side effects. However, it can be a great sedative and analgesic to help with rapid sequence intubation.

The good thing about Ketamine is it preserves the respiratory drive. This makes it excellent choice for minor procedural sedation where intubation is not needed.

However, the increased catecholamine stimulation can cause tachycardia, hypertension, and possibly increased ICP, making it a poor choice for head traumas and hypertensive crises, and also those with cardiac ischemia or aortic dissections.

However, this can be helpful in patients who are hypotensive to increase BP or in severe asthmatics to cause bronchodilation (in theory).

SIDE EFFECTS & MONITORING

  • LARYNGOSPASM: Ketamine increases the risk of laryngospasm, especially in those with a history of upper respiratory disease or asthma. This is because ketamine does not suppress pharyngeal and laryngeal reflexes. In this case, it can be helpful to use fentanyl with it.

  • KETOFOL: Ketofol is the combination of ketamine and fentanyl. This can cause analgesia, sedation, and amnesia and can be a good choice for patients with severe bronchospasm.

  • INCREASED CARDIAC ACTIVITY: Ketamine causes increased stimulation of the sympathetic nervous system, releasing catecholamines leading to tachycardia, hypertension, increased myocardial demand, and even possible cardiac arrhythmias. This can be beneficial in patients who are hypotensive but dangerous for those with active cardiac disease or aortic dissection.

  • EMERGENCE REACTIONS: Ketamine can cause an “emergence phenomenon” primarily when used for procedural sedation. This is when the patient may experience vivid and/or disturbing dreams as they wake up. Hallucinations and frank delirium may occur postoperatively up to 24 hours. This usually does not happen with patients who are intubated and sedated for over 24 hours.

Propofol

Propofol is a common sedative, and a frequent agent of choice for maintaining sedation with a slow titratable drip. It has a characteristic appearance of milk.

Propofol is the drug that Michael Jackson was found to have overdosed on. It causes deep sedation and does diminish the patients respiratory drive.

Propofol has the following actions on the body:

  • Decreases airway resistance: Good for bronchospasm
  • Neuro-Inhibition: Good for intracranial pathology
  • Suppresses SNS: Good for hypertension, bad for hypotension & conditions which decrease cerebral perfusion

Propofol IV push?

Make sure your specific state and facility allow RNs to give IV boluses of propofol, and if so, make sure the provider is always at the bedside. Since propofol causes deep sedation, it may not be within your scope as a nurse to push it. Seems silly, but always protect your license!

SIDE EFFECTS & MONITORING

  • HYPOTENSION: Propofol has a blood pressure-lowering effect, which can decrease the MAP by 10%, but sometimes even ≥ 30%. Use caution if the patient has borderline low pressure or a baseline MAP of 60-70 mmHg. Patients at risk for hypotension include severe sepsis, trauma, severe aortic stenosis, etc.

  • BRADYARRHYTHMIAS: Propofol can cause bradyarrhythmias to occur. This is more common with high doses, prolonged duration, and concurrent medications like beta-blockers, paralytics, and opioids. Patients with a history of cardiac disease are at increased risk.

  • QT PROLONGATION: QT prolongation can predispose your patient to dangerous ventricular arrhythmias like Torsades de Pointes and VFIB. This is more common with:
    • High propofol doses
    • Elderly patients
    • Structural heart disease
    • Congenital Long QT
    • QT prolonging medications
    • Electrolyte Disturbances

  • ANAPHYLAXIS: Anaphylaxis is rare with Propofol but can occur, usually within 5-10 minutes after infusion. Those with a history of soybean or egg allergy are probably fine to take it.

  • SOYBEAN ALLERGY: Allergy to soybeans or egg used to be a contraindication for receiving propofol, but newer formulations of the drug rarely produce a reaction and are likely safe.

  • ELEVATED TRIGLYCERIDES & LIPASE: Propofol is a lipophilic fatty solution that contains triglycerides. Infusion can lead to elevations in triglycerides and lipase, which usually occurs 2-4 days after initiation. This can lead to pancreatitis, especially in those who are already at risk.

  • PRIS: PRIS stands for Propofol Infusion Syndrome. PRIS is rare but deadly. When it occurs, the patient suffers from acute refractory bradycardia which may lead to asystole and also may have:
    • Severe metabolic acidosis
    • Cardiovascular collapse
    • Rhabdomyolysis
    • Hyperlipidemia
    • Renal failure
    • Hepatomegaly

    This is more common with high doses (>4mg/kg/hr) and long duration of use (>48 hours).

Choosing the Right Sedative

There are some specific scenarios where one sedative may be more appropriate than others. Regardless, it is always the Providers preference and what they’re familiar with. 


  • HEAD INJURY OR STROKE: Etomidate

  • STATUS EPILEPTICUS: Propofol or Etomidate

  • SEVERE BRONCHOSPASM: Propofol or Ketamine (+/- fentanyl)

  • CARDIOVASCULAR DISEASE: Etomidate +/- Fentanyl

  • SHOCK: Etomidate 0.15mg/kg or ketamine 1mg/kg

Paralytics

Paralytics, also called neuromuscular blocking agents (NMBAs), are given immediately after the sedative kicks in, which produces a paralyzing effect on the body. This relaxes the patients muscles and makes the intubation easier for the Physician or APP, and minimizes complications.

Succinylcholine

Succinylcholine or Sux for short, is the classic paralyzing agent for RSI. It is termed a “depolarizing neuromuscular blocker” because they cause the muscle cells to “fire” or depolarize, but then don’t let the muscles repolarize, leading to paralysis.

While used in most scenarios, this is contraindicated in conditions which may cause hyperkalemia or may lead to an exaggerated response. This is because even in normal patients, Sux can increase potassium levels by 0.5-1.0 mEq/L.

These conditions include:

  • Malignant hyperthermia (personal or family history)
  • Neuromuscular disease with denervation (i.e. MS)
  • Muscular dystrophy
  • Stroke > 72h old (especially with significant motor denervation)
  • Rhabdho
  • Significant burn(s) over 72h old
  • Significant Hyperkalemia
SIDE EFFECTS & MONITORING

  • FASCICULATIONS: Sux commonly causes fasciculations of the muscles prior to causing full paralysis. This may increase ICP and stimulate emesis leading to aspiration.

  • BRADYCARDIA: A metabolite of Sux can stimulate muscarinic receptors to release acetylcholine, producing bradycardia of the sinus node. This can be treated with atropine.

Myesthenia Gravis

Patients with MG are resistant to Sux, so should be given 2mg/kg

Rocuronium

Rocuronium or “ROC” for short is a “non-depolarizing” NMBA used for sedation for RSI intubation. This is because it is an acetylcholine antagonist, blocking its effects and leading to paralysis.

ROC is used when Sux is contraindicated as above.

Some conditions which may decrease the efficacy of the paralysis include:

  • Respiratory alkalosis
  • Hypercalcemia
  • Demyelinating lesions (MS)
  • Peripheral neuropathies
  • Muscle trauma

  • HYPERTENSION: ROC can increase peripheral vascular resistance and cause a temporary increase in BP. It can also cause transient hypotension in some people.

  • TACHYCARDIA: ROC can cause temporary tachycardia for about 5 minutes.

  • RIGHT-SIDED HF: ROC may worsen pulmonary HTN, leading to right-sided heart failure in those who are predisposed.

Other Paralytics

Other non-depolarizing paralytics include Vecuronium and Pancuronium, but these are not used as often.

Vecuronium, shortened to “VEC”, is not used as frequently, as it has a longer onset of action – around 3 minutes. This can be reduced with a smaller “priming” dose.

RSI INTUBATION PROCEDURE

  • Sniffing Position Icon 

    1. PREPARE THE PATIENT

    To prepare the patient for RSI intubation, make sure they are positioned in the “sniffing” position, supine with their neck flexed. Placing a towel between their head and neck can help.

    Make sure the patient is getting hyper-oxygenated at the same time, usually with a Non-rebreather or a Bag-valve mask at 100%.

    Respiratory therapists are often in charge of airway along with the Provider.

    Place the patient on the monitor including telemetry, continuous pulse ox, and end-tidal CO2 if possible.

    Explain the procedure to the patient and ensure informed consent is obtained, either written or verbal. Written is often not able to be obtained due to the emergent nature of many intubations.

    If the patient is altered, ensure there is no DNR or DNI order form or POLST.

  • Bag-Valve-Mask Icon 

    2. USING A BVM

    If using a BVM hooked up to 100% oxygen, make sure you are squeezing the BVM with each spontaneous breath to ensure the valve opens and the oxygen is given to the patient!

  • Endotracheal Tube Icon 

    3. PREPARE THE EQUIPMENT

    Bring the code cart at the bedside. You don’t necessarily need to hook up the defibrillation pads, but always follow facility protocol.

    Most of the equipment needed will be found in the Airway drawer, usually one of the last drawers.

    The equipment needed for the actual intubation will be:

    • Laryngoscope
    • ET tube
    • Stylet
    • 10cc syringe
    • Suction Tubing & Yankauer
    • ETCO2 or CO2 detector
    • Stethoscope
    • Bag-valve mask

    Ask the Provider which size ET tube they’ll want, which is often 7.0 for females and 8.0 for males.

    The stylet will need to be placed inside the ET tube, which is usually cuffed. This will be removed once the Provider gets the tube in the right spot.

  • Injection Icon 

    4. ADMINISTER MEDICATIONS

    The Provider will give you a verbal order for which sedative(s) and paralytic they want.

    Verbally clarify the name and dose, and begin to draw up the medications. You may need to grab these medications from an “RSI kit” in the Accudose, or they may be located in your code cart.

    Usually, one of the nurses will assume the “medicine” responsibility while the others are preparing the patient and equipment.

    Some medications will require reconstitution. This means you may need to mix saline with powdered medication to make a solution. Verify the final doses/amounts with another nurse.

    Make sure to accurately label each, so you don’t mix up the sedative and the paralytic!

    Once everyone is ready for the intubation, wait for the Provider’s verbal “ok” to give the medications, and administer the medications as above. Most are given quickly over 5-10 seconds.

    First the sedative, then once the patient has decreased LOC and you get the next verbal OK from the Provider, administer the paralytic.

    RT should be bagging the patient at this time until the Provider is ready for the intubation. This is usually within 30-60 seconds after administering the paralytic.

  • Intubation Icon 

    5. THE INTUBATION

    Your main job is now done, and now you just watch the intubation procedure and monitor the patient, following any verbal orders that are given.

    The Provider will place the ET tube between the vocal cords, typically 21cm deep in women and 23cm in men. This is measured at the teeth.

  • CXR Icon 

    6. VERIFY PLACEMENT

    Immediately after intubation, the tube needs to be verified. This is verified in multiple ways.

    First, a CO2 detector may be attached to the ET tube. Observing color change from purple to yellow indicates CO2.

    If the patient is hooked up to an ETCO2, with each BVM breath, you should see normal CO2 levels near 35-45 mmHg.

    Additionally, someone should listen to all breath sounds listening for equal breath sounds.

    Lastly, the patient should have a portable CXR ordered to verify the placement. The radiologist may recommend pulling out or pushing deeper x amount of cm.

  • Vented Patient Icon 

    7. MAINTAIN VENT + SEDATION

    Now the patient is successfully intubated. Your main job now is keeping the patient sedated so that the Ventilator can do its job and breath for the patient.

    This usually involves a continuous titratable drip, often propofol. The patient may also require additional sedatives, analgesics, and sometimes further paralytics.

    Of course, make sure to chart everything and continue to monitor the patient’s vital signs.

    If in the ER or Med-Surg, your goal should be to get that patient admitted/transferred ASAP.

RSI INTUBATION COMPLICATIONS

Unfortunately, not all RSI intubations go smoothly. These are usually emergent procedures and are not done in a controlled environment. 

As the nurse, you are the first one who is going to notice any complications while monitoring your patient.  It’s important to know what to look out for and how these complications are managed.


  • ESOPHAGEAL INTUBATION: This is when the ET tube is in the esophagus instead of the trachea. This becomes obvious when verifying placement. When it occurs, the ET tube will be completely removed, and the Provider will re-insert the tube with another attempt.

  • GASTRIC TUBE: An OG or NG to suction should be placed in all patients after intubation to decompress the stomach to prevent emesis and to decrease intrathoracic pressure. A foley should also be placed.

  • RIGHT MAINSTEM INTUBATION: If the ET tube is placed slightly too deep, it will often go into the Right Mainstem Bronchus of the right lung. This is because it is more vertical than the left. If left, the patient may have signs of hypoxemia and worsening respiratory status, and if not fixed can cause barotrauma, pneumothorax, and hemothorax. Breath sounds should be equal throughout the lobes, but a CXR will need to be done to verify this isn’t the case. Treatment involves pulling out the ET tube per radiologists recommendations, which the Provider should do.

  • PERFORATION: A traumatic insertion can cause perforation of the esophagus or trachea. This is very rare, but severe. Signs include the presence of subcutaneous emphysema in the mediastinum and worsening respiratory status. A CXR may show pneumomediastinum, subcutaneous emphysema, and possible pneumothorax.

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