Performing rapid sequence intubation (RSI): the 7 Ps of intubation

Rapid sequence intubation (RSI) is used across emergency care to quickly induce unconsciousness and paralysis before intubating patients who aren't fasted or otherwise prepared. The creators of the Difficult Airway Course codified the critical steps into the 7 Ps of RSI, which serve as a structured, repeatable framework for every stage of the procedure. Skipping or rushing any of these steps raises risk, so mastering the full sequence—not just the induction step—is what protects your patient and your first-pass success.

In this lesson from our Advanced Airway Management course, you'll learn how to:

• Recognize anatomic and physiologic predictors of a difficult airway using the LEMON, ROMAN, RODS, SMART, and CRASH mnemonics
• Identify when RSI is contraindicated
• Optimize preoxygenation and physiologic status 
• Choose an induction agent and neuromuscular blocking agent based on the patient's clinical profile
• Position the patient to align the airway axes and improve first-pass success
• Confirm tracheal tube placement with continuous quantitative capnography
• Set up post-intubation sedation, analgesia, and ventilator management

What is rapid sequence intubation?

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Rapid sequence intubation (or RSI) is a technique designed to quickly induce unconsciousness and muscle paralysis before tracheal intubation. It's particularly advantageous in emergency settings where patients are not fasted or otherwise prepared for intubation. Using both an induction and a neuromuscular blocking agent, RSI improves first-pass success and reduces the risk of aspiration, making it standard in emergency departments. 

Comparing RSI across emergency and critical care settings

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However, the use of RSI in intensive care units, prehospital environments, or operating rooms can vary based on patient characteristics, available equipment, training, and institutional culture, despite the fact that studies have shown the technique provides better intubation conditions and higher first-pass success rates compared to using induction agents alone. So, the goal with RSI is induction, or the initiation of general anesthesia, paralysis, and endotracheal tube placement in short order.

The 7 Ps of RSI: preparation

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The critical steps to performing RSI have been codified into seven Ps by the creators of the Difficult Airway Course. First is preparation. Begin by assessing the patient for any anatomic or physiologic predictors of a difficult airway using the LEMON, ROMAN, RODS, SMART, and CRASH mnemonics. 

Recognizing contraindications to RSI

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Also, assess for any potential contraindications to RSI, then tailor your equipment and plan based on these assessments. RSI is contraindicated when the patient must maintain airway patency or when paralysis risks a can't intubate, can't ventilate situation. In such cases, use a different airway management technique without paralysis.

Preoxygenation before intubation

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The next P stands for preoxygenation. This involves not only bringing the oxygen saturation to 100%, or as close as possible, but also providing 100% oxygen to wash out the nitrogen within the airways to serve as a reservoir, which increases apneic oxygenation times. Optimal preoxygenation maximizes the safe time available to perform the procedure and may provide as much as six to eight minutes of adequate oxygenation in a healthy patient.

Optimizing physiology before RSI

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The third P stands for physiologic optimization. This step involves recognizing and addressing hypotension, acidosis, volume depletion, or other factors which increase risk of complications during or after the procedure. Most commonly, this will mean fluids and/or vasopressors, but tailor the resuscitation to each individual patient.

Paralysis with induction: choosing RSI medications

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Next is paralysis with induction. Although this step is the defining step of RSI, the preceding steps should never be skipped or rushed. The induction and paralysis step involves bolus administration of an induction agent followed immediately by a neuromuscular blocking agent. The rapid bolus is critical and can achieve the desired effect in as little as 45 seconds with optimal dosing.

Selecting induction and neuromuscular blocking agents

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Commonly used induction agents include ketamine and etomidate, although propofol or a benzodiazepine could be considered in certain clinical scenarios. Succinylcholine and rocuronium are the options for neuromuscular blocking agents. Succinylcholine has a shorter half-life and, therefore duration of action, than rocuronium, but it is contraindicated in patients at risk for malignant hyperthermia and in patients at risk of dangerous hyperkalemia, such as those with renal failure, inherited myopathies, burns, crush injuries, and denervation from stroke or trauma.

Positioning and placement with proof: confirming tube placement

[3:36]
The fifth P stands for positioning, where we aim to align the oral, pharyngeal, and laryngeal axes. You will also want to elevate the torso in cases where abdominal pressure would create restriction to ventilation, such as pregnancy or obesity. Most of this preparation, including ensuring the bed can tilt as needed and that there are towels available, should be set up before the patient is unconscious and apneic.

Post-intubation management: sedation, analgesia, and the ventilator

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Our next P stands for placement with proof. Generally, patients will be flaccid and apneic within 30 to 60 seconds of induction and neuromuscular blockade. At this point, attempt to place the endotracheal tube using your preferred method. If at any point the patient desaturates below 90% prior to the endotracheal tube being placed, bag the patient back up to their highest possible saturation before another attempt.
Once the tube is placed, confirm tracheal placement using continuous quantitative capnography. If that is not available, a colorimetric end-tidal CO2 detector could be used. At this point, a post-intubation chest x-ray should be ordered as well.

Beginning post-intubation management

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This brings us to our last P, post-intubation management. There's an old saying in medicine: the dumbest kidney is smarter than the smartest doctor. The same concept can be applied to the lungs. Once you have paralyzed and intubated the patient, you have taken over control of their airway protection, ventilation, and oxygenation. That's a big responsibility, so make sure you do it well.
First, make sure to reassess all vital signs. Has there been any hemodynamic change that needs to be addressed? How is the oxygenation and ventilation? Next, make sure that sedation and analgesia are set up. Medications such as propofol, midazolam, or fentanyl are often used. But almost all patients need at least some form of sedation and analgesia after intubation. Do not mistake paralysis for comfort.

Setting the ventilator after rapid sequence intubation

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Finally, the ventilator should be set up according to the patient's needs, whether that is to maximize oxygenation with ARDS, maintain ventilation in a metabolic acidosis, or some other clinical scenario. The details of ventilator management are beyond the scope of this course.