The 7 P’s of Rapid Sequence Intubation (RSI)

Rapid Sequence Intubation (RSI) is a critical procedure for securing the airway in patients who are at high risk of aspiration or respiratory compromise. The “”7 Ps”” provide a structured approach to RSI, ensuring a higher success rate and minimizing complications.

• 1. Preparation:
  • This is a crucial step that involves gathering all necessary equipment, medications, and personnel.
  • Ensure that all equipment is functioning correctly (e.g., check laryngoscope light, inflate ETT cuff).
  • Have a backup plan in place in case of a failed intubation attempt.
  • Assign roles to team members (e.g., airway management, medication administration, monitoring).
• 2. Pre-oxygenation:
  • Maximize the patient’s oxygen stores before intubation to prevent hypoxia during the procedure.
  • Administer 100% oxygen via a non-rebreather mask or bag-valve-mask (BVM) for several minutes.
  • Consider using adjuncts like nasal cannula to provide apneic oxygenation.
• 3. Pretreatment:
  • Administer medications to mitigate the adverse physiological responses to intubation. Common medications include:
  • • Lidocaine: To attenuate the increase in intracranial pressure (ICP) in patients with head injuries.
    • Fentanyl: To blunt the hemodynamic response (hypertension, tachycardia) to intubation.
    • Atropine: To prevent bradycardia, especially in children.
• 4. Paralysis with Induction:
  • Administer medications to induce unconsciousness (induction agent) and muscle relaxation (paralytic agent).
  • Induction agents:
    • Etomidate
    • Ketamine
    • Propofol
  • Paralytic agents:
    • Succinylcholine (depolarizing)
    • Rocuronium, vecuronium (non-depolarizing)
  • Administer the induction agent followed immediately by the paralytic agent.
• 5. Protection and Positioning:
  • Position the patient to optimize visualization of the vocal cords.
  • The “”sniffing position”” (flexion of the neck and extension of the atlanto-occipital joint) is generally preferred.
  • Apply cricoid pressure (Sellick maneuver) to help prevent passive regurgitation and aspiration – its efficacy is debated.
• 6. Placement of the ETT with Proof:
  • Perform laryngoscopy and insert the endotracheal tube (ETT) into the trachea.
  • Confirm ETT placement using multiple methods, with capnography being the most reliable.
  • Secure the ETT to prevent dislodgement.
• 7. Post-intubation Management:
  • Provide mechanical ventilation and adjust ventilator settings as needed.
  • Administer appropriate sedation and analgesia.
  • Continue to monitor the patient closely for complications.