Who needs one
Anyone with a full stomach or impaired gastric emptying: emergency surgery, bowel obstruction, trauma, pregnancy beyond the first trimester, significant reflux, and diabetic gastroparesis. Fasting time is a guide, not a guarantee, and pain and opioids both stop a stomach emptying.
Preparation is most of it
Two working suckers within reach, a tipping trolley, the tube and a bougie ready, a plan B stated out loud, and the whole team briefed on who does what. Pre-oxygenate to an end-tidal oxygen above 0.85 and consider high-flow nasal oxygen through the apnoeic period.
Drugs together, no hand ventilation
The induction agent and relaxant go in immediately after one another and the patient is not ventilated by hand, so the stomach is not inflated and the time to a protected airway is as short as possible. Classically thiopental with suxamethonium; commonly now propofol with rocuronium at 1.2 mg/kg, which is as fast and reversible with sugammadex.
Cricoid pressure, and the argument about it
Thirty newtons of backward pressure on the cricoid cartilage, applied by a trained assistant. The evidence for benefit is weak and it can worsen the laryngoscopic view; the modern position is to apply it, and to release it immediately if it is making intubation harder.
Confirm, then relax
Sustained capnography is the only acceptable confirmation of tracheal placement. Auscultation, misting and chest rise all lie. Only once you have a trace do you release cricoid pressure and move on.
Watch it done
Rapid sequence induction training
A hospital's training film of the RSI: preoxygenation, the drugs in sequence, cricoid, the tube.
Source: Homerton University Hospital · Watch on YouTubeWatch for
- Preoxygenation to an end-tidal target
- Induction agent then relaxant with no gap
- Who releases cricoid pressure and when