Rapid Sequence Intubation For Adults Outside The Operating Room

Rapid sequence intubation for adults outside the operating room
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Official reprint from UpToDate

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Author
Aaron E Bair, MD, MSc, FAAEM,
FACEP
Section Editor
Ron M Walls, MD, FRCPC, FAAEM
Deputy Editor
Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2016. | This topic last updated: Jun 28, 2016.
INTRODUCTION The first task of any clinician managing an acutely unstable patient is to secure the airway. In
most circumstances, emergency clinicians use rapid sequence intubation (RSI) to accomplish this task. RSI
incorporates a rapidly acting sedative (ie, induction) agent and a neuromuscular blocking (ie, paralytic) agent to
create optimal intubating conditions and enable rapid control of the airway. RSI presupposes the patient is at risk for
aspiration of stomach contents and incorporates medications and techniques to minimize this risk. Use of RSI also
helps to mitigate the potential adverse effects of airway manipulation.
This topic reviews the central concepts and techniques needed to perform rapid sequence intubation in adults in the
emergency setting outside the operating room. RSI for anesthesia, RSI in children, the medications used for
emergency RSI, and other subjects related to emergency airway management are reviewed separately. (See "Rapid
sequence intubation (RSI) in children" and "Induction agents for rapid sequence intubation in adults" and
"Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults" and "Pretreatment agents for rapid
sequence intubation in adults" and "Basic airway management in adults" and "Rapid sequence induction and
intubation (RSII) for anesthesia".)
DEFINITION Rapid sequence intubation (RSI) is the virtually simultaneous administration of a sedative and a
neuromuscular blocking (paralytic) agent to render a patient rapidly unconscious and flaccid in order to facilitate
emergent endotracheal intubation and to minimize the risk of aspiration. Preoxygenation is required to permit a
longer period of apnea without clinically significant oxygen desaturation. Bag-mask ventilation is avoided during the
interval between drug administration and endotracheal tube placement, thereby minimizing gastric insufflation and
reducing the risk of aspiration.
Indications RSI is the standard of care in emergency airway management for intubations not anticipated to be
difficult [1-7]. Multiple large prospective observational studies confirm that the implementation of RSI has led to
improved success and decreased complication rates for emergency intubations [1-6].
Contraindications Contraindications to RSI are relative. Circumstances exist where neuromuscular blockade is
undesirable due to the high likelihood of intubation or mechanical ventilation failure. Depending on clinical
circumstances, particular sedative or neuromuscular blocking agents may be relatively contraindicated, due to the
risk of potential side effects. (See 'Induction agents' below and 'Neuromuscular blocking agents' below and "The
difficult airway in adults".)
DESCRIPTION OF THE TECHNIQUE Rapid sequence intubation (RSI) depends on preparation and detailed
considerations at multiple steps. The "Seven P's of RSI" is a mnemonic that outlines these key steps (table 1) [8,9]:
Preparation
Preoxygenation
Pretreatment
Paralysis with induction
Protection and positioning
Placement with proof
Postintubation management
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Each step is discussed below.

Preparation Preparation includes assessing the patient's airway, developing an airway management plan, and
assembling necessary equipment and medications (table 2).
Once the need for intubation is determined, the clinician assesses the patient for anatomic features or clinical
findings that indicate the patient may be difficult to intubate or to ventilate using a bag-mask. Although the presence
of markers for difficult intubation or difficult bag-mask ventilation is not an absolute contraindication to RSI, if such
features are identified, alternatives to rapid sequence intubation (RSI) may be needed. Alternatives include an
"awake technique" in which the patient is lightly to moderately sedated and intubated using topical anesthesia, but is
not induced and paralyzed. (See "The decision to intubate" and "The difficult airway in adults".)
Prior to proceeding with RSI, at least one, but preferably two, functioning intravenous line should be in place, and
cardiac, pulse oximetry, and blood pressure monitors should be in place. The patient should be in an appropriate
area within the emergency department where necessary airway and resuscitation equipment are available. The
airway manager should have easy access to the head of the bed, and should adjust the height of the bed and
position of the patient to facilitate intubation.
The airway manager verifies that endotracheal tubes of appropriate sizes are available and their cuffs are free of
leaks. A stylette is placed in the tube. If a conventional laryngoscope is to be used, its light must be working and both
curved and straight blades of different sizes (generally Macintosh and Miller sizes 2, 3, and 4) should be available.
Suction devices are checked and ready for immediate use. A bag-mask and both oral and nasal pharyngeal airways
should be at the bedside. (See "Basic airway management in adults".)
The clinician selects the induction and paralytic agents (and pretreatment medications, if desired) to be used and
determines the doses. Allergies and potential contraindications should be considered carefully. The medications to
be used are drawn up into labeled syringes.
An important goal of preparation is to maximize the chances for successful intubation on the first attempt. Studies
suggest that the risk of an adverse event during tracheal intubation (eg, aspiration, hypotension, esophageal
intubation) increases substantially with the number of attempts. As an example, one retrospective emergency
department (ED) study of 1828 intubations reported that 14 percent of patients intubated on the first pass
experienced an adverse event compared to 47 percent of those intubated on the second attempt [10].
A critical and often overlooked part of this initial phase of RSI is preparation for unanticipated difficulty. An
assessment of airway difficulty should be performed before the decision is made to proceed with RSI. Even if there
are no indicators of difficult intubation identified and the intubation appears likely to be routine, the airway manager
must have a backup plan to manage unanticipated problems with intubation or bag-mask ventilation. Backup plans
will vary with the clinical situation, the availability of devices, and the training of the provider. Equipment necessary to
implement the backup plan should be at the bedside. (See "The difficult airway in adults".)
Preoxygenation Any patient who may require urgent tracheal intubation should immediately be given high flow
oxygen at the highest possible concentration [11]. This is often done using a facemask with an oxygen reservoir
(often referred to as a nonrebreather facemask); however, this method does not provide oxygen concentrations as
high as a true nonrebreather mask, such as a bag-mask resuscitator device with a one-way exhalation valve [12].
Alternatively, eight vital capacity breaths may be used in cooperative patients and will provide equivalent
pre-oxygenation in less than one minute.
Additional strategies to prevent oxygen desaturation during emergency airway management include the following
[11]:
For patients not immobilized for possible spinal injury, oxygenation is improved by placing them in a 20 degree
head-up position [13-15]. Alternatively, 30 degree reverse Trendelenburg positioning (bed kept straight but
angled with patients head up) may be used for immobilized patients. The benefits of the head-up position for
obese patients are discussed separately. (See "Emergency airway management in the morbidly obese patient",
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section on 'Preoxygenation'.)
During the apneic period of RSI, provide oxygen via nasal cannula at a flow rate of 5 L/minute. This technique
extends the period of adequate oxygen saturation during apnea, according to several randomized trials, and
may improve outcomes [16-19].
If necessary, patency of the upper airway can be maintained with adjuncts (nasal or oropharyngeal airways)
and positioning maneuvers (chin lift and/or jaw thrust). The chin lift is not used when spinal precautions are
being observed. (See "Basic airway management in adults", section on 'Airway maneuvers'.)
For patients who are unable to achieve oxygen saturation above 93 percent despite high flow oxygen, and who
are judged able to tolerate positive pressure support, pre-oxygenation delivered via a positive pressure device
(eg, CPAP) may enhance apnea time [20-22]. Disposable positive end-expiratory pressure (PEEP) valves that
can be attached to a standard bag-valve mask are available, in addition to standard positive pressure devices.
The benefits of positive pressure ventilation to improve preoxygenation in obese patients are reviewed
separately. (See "Emergency airway management in the morbidly obese patient", section on 'Preoxygenation'.)
Clinicians may need to adjust the method for providing preoxygenation according to clinical circumstances. However,
a period of preoxygenation longer than three to five minutes in critically ill patients is unlikely to provide significant
benefit [23]. In cooperative patients capable of taking deep breaths, nitrogen washout can be achieved by having the
patient take eight vital capacity (ie, maximal) breaths [24,25].
Manual ventilation prior to intubation should be reserved for patients who are hypoxic (saturation <91 percent) and if
used the provider should be particularly mindful of maintaining a slow rate (approximately eight breaths per minute),
giving a low volume (approximately 8 mL/kg), and avoiding excessive force when ventilating (deliver breath over a
full one to two seconds) to prevent overinflation of the lungs and distension of the stomach. (See "Basic airway
management in adults", section on 'Ventilation volumes, rates, and cadence'.)
Giving oxygen in anticipation of RSI has several important effects. In addition to improving the patient's
oxyhemoglobin saturation, high flow oxygen displaces nitrogen in the patient's lungs. "Washing out" the nitrogen and
replacing it with oxygen converts the lung's functional residual capacity into an oxygen reservoir. Preoxygenation
also increases oxygen stores in the blood and tissues. The combined effect is to enable patients to tolerate a longer
period of apnea without oxygen desaturation. Preoxygenation is essential if clinicians are to avoid the need for
assisted ventilations interposed between paralysis and placement of the endotracheal tube.
Researchers have characterized the expected time to desaturation after apnea is induced in properly preoxygenated
patients of various ages and comorbid conditions (figure 1) [26]. A healthy 70 kg adult can maintain oxygen
saturation above 90 percent for approximately eight minutes. Young children typically fall below the 90 percent
threshold in less than four minutes. The oxygen saturation of adults with severe illness or obesity, and pregnant
women nearing the end of their third trimester, falls below 90 percent in less than three minutes despite optimal
preoxygenation.
The important concept is that preoxygenation provides a longer period before clinically significant desaturation,
regardless of the patient's condition. The duration of this period varies greatly, depending upon patient attributes,
and continuous monitoring of oxyhemoglobin saturation by pulse oximetry is essential. When assessing oxygen
saturation, remember that pulse oximetry readings obtained with a finger probe may lag behind the central arterial
circulation, particularly in critically ill patients [11,27].
Pretreatment Pretreatment is the administration of medications prior to the induction phase of RSI for the
purpose of mitigating adverse effects associated with endotracheal intubation. The drugs used for pretreatment vary
with clinical circumstances. Pretreatment agents for RSI are discussed in detail separately. (See "Pretreatment
agents for rapid sequence intubation in adults".)
Paralysis with induction The concept of RSI is based on the virtually simultaneous intravenous administration of
a rapidly acting induction agent and a neuromuscular blocking agent (paralytic). Agent selection and dosing are
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aimed at producing a state of deep sedation and muscular relaxation quickly. RSI does NOT involve titration of either
agent to reach this state. The dose of each agent is precalculated to achieve the desired effect. Onset of action after
administration is variable depending on the agent chosen, but the goal is to achieve intubation level paralysis and
sedation 45 to 60 seconds after the drugs are given by IV push.
Induction agents The ideal RSI induction agent acts quickly to provide a deep state of unconsciousness, as
well as analgesia, with limited side effects. No available agent meets this ideal standard. Drugs that have been used
as induction agents include etomidate, ketamine, midazolam, propofol, and short-acting barbiturates (eg, thiopental).
The induction agents used for RSI are discussed in detail separately. (See "Induction agents for rapid sequence
intubation in adults".) A summary table of induction agents is provided (table 3).
Neuromuscular blocking agents The use of a neuromuscular blocking agent (NMBA) to produce rapid
paralysis comprises the cornerstone of RSI. Neuromuscular blocking agents do NOT provide analgesia or sedation.
In the context of RSI, they are used immediately following an induction agent. The NMBAs used for RSI are
discussed in detail separately. (See "Neuromuscular blocking agents (NMBA) for rapid sequence intubation in
adults".)
Protection (cricoid pressure) and positioning This phase of RSI refers to protecting the airway against
aspiration prior to placement of the endotracheal tube by avoiding bag-mask ventilation and applying cricoid
pressure (Sellick's maneuver). Bag-mask ventilation is unnecessary if the patient has been successfully
preoxygenated. (See 'Preoxygenation' above.)
Furthermore, ventilation interposed between paralysis and intubation creates a potential hazard if stomach
insufflation results in regurgitation and aspiration. Provided oxygen saturation remains above 90 percent, bag-mask
ventilation is unnecessary, even between laryngoscopy attempts. If the patient's saturation percentage falls below
90, or is unknown, clinicians provide ventilatory support using a bag-mask, while maintaining cricoid pressure.
Sellick originally described the concept of cricoid pressure as a method to prevent passive regurgitation. A
systematic review questions the technique's effectiveness and we consider it optional during RSI [28]. Sellick's
maneuver is performed using the thumb and index or middle finger to apply firm downward pressure on the cricoid
cartilage thereby compressing the esophagus between the cricoid cartilage and the anterior surface of the vertebral
body (figure 2). A common error is to apply pressure to the thyroid cartilage (Adam's apple).
While in practice cricoid pressure is maintained by an assistant, the airway manager directs the application and
duration of force being applied. When used, cricoid pressure is applied immediately following induction and
maintained until adequate tube placement has been confirmed. Sometimes Sellick's maneuver may obscure the
glottic view, impede passage of the endotracheal tube, or prevent adequate ventilation (when ventilation is
necessary). If so, the intubator should have the assistant reduce or remove cricoid pressure.
Although Sellick's maneuver may reduce gastric insufflation during bag-mask ventilation, evidence that cricoid
pressure reduces the incidence of aspiration of gastric contents is scant and consists primarily of observational
clinical studies and experimental data [28,29]. Several studies suggest it may contribute to airway obstruction and
difficulty intubating in some cases, even when a video laryngoscope is used [28,30-33]. However, one observational
study performed in elective surgery patients suggests that cricoid pressure is effective at occluding the upper
esophagus (as determined by the inability to pass gastric tubes of two different sizes) [34]. While the topic remains
controversial, until more definitive literature is published, we suggest that the use of Sellick's maneuver during RSI
and bag-mask ventilation be considered optional.
A systematic review of cricoid pressure studies noted the following [28]:
Case series and retrospective reviews describe both the success and failure of cricoid pressure to prevent
aspiration.
Cricoid pressure is often used inconsistently and applied improperly in all airway management settings.
Cricoid pressure may impair the function of the lower esophageal sphincter.
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Possible risks from cricoid pressure include movement of unstable cervical spine fractures and esophageal
injury.
Placement with proof After flaccidity is achieved, assessed by masseter muscle tone (ie, laxity of the jaw with no
resistance to mouth opening), laryngoscopy can be performed. The time to muscular relaxation will vary depending
on the neuromuscular blocking agent used. When used with an appropriate induction agent, succinylcholine
generally produces excellent intubating conditions within 45 seconds, compared with rocuronium, which requires 60
seconds. The goal of laryngoscopy is direct visualization of the glottic aperture. Once the glottis is visualized, the
clinician places the endotracheal tube (ETT) between the vocal cords, inflates the cuff, withdraws the stylette, and
confirms placement.
Confirmation of proper ETT placement is crucial; unrecognized esophageal intubation leads to devastating
complications. End-tidal CO2 (EtCO2) determination (either colorimetric or quantitative) is the most accurate means
of confirming ETT placement in most circumstances, and we recommend it be used with every intubation. Clinical
indicators alone, such as visualization of the ETT through the cords, misting of the tube with ventilation, and
auscultation of breath sounds over the lung fields, cannot be relied upon to confirm proper ETT placement. In
cardiac arrest patients not producing CO2, alternative means of confirmation may be needed if CO2 is not detected.
A single-view chest radiograph is only useful to determine depth of placement (eg, tracheal versus right mainstem).
It is not useful for distinguishing endotracheal from esophageal intubation. The methods for proving proper ETT
placement are discussed in greater detail separately. (See "Direct laryngoscopy and tracheal intubation in adults",
section on 'Confirming proper tracheal tube placement'.)
Postintubation management RSI remains incomplete until the properly placed endotracheal tube is secured.
Several techniques are commonly used to secure the tube, including taping, tying, and using proprietary
tube-holders. There is some evidence to suggest that a tube stabilizing device may be better tolerated than taping
for long-term management [35-37]. The technique employed for ED airway management should be readily available,
easy to apply, and secure.
A post-procedural chest radiograph is obtained to confirm depth of tube placement and to evaluate for evidence of
barotrauma as a consequence of positive pressure ventilation.
Hypotension can occur soon after emergent intubation [38], often as a result of reduced venous return, because of
increased intrathoracic pressure from mechanical ventilation. Lingering effects of the induction agent may contribute.
While diminished venous return and sedation are common causes, clinicians should not assume they alone account
for patient hypotension and should consider other potentially dangerous causes, including pneumothorax and
cardiac ischemia. Initial management of hypotensive episodes consists of boluses of IV crystalloid and careful
monitoring of airway pressures. Critically ill patients may be depleted of endogenous catecholamines, causing
hypotension, and may require treatment with exogenous catecholamines. (See "Treatment of severe hypovolemia or
hypovolemic shock in adults" and "Mechanical ventilation of adults in the emergency department", section on
'Approach to ventilated patient in distress' and "Use of vasopressors and inotropes".)
Mechanical ventilation is initiated. Ventilator settings may need modification according to clinical circumstance. (See
"Mechanical ventilation of adults in the emergency department", section on 'Disease-specific ventilatory
management'.)
If long-term paralysis is needed, the timing of subsequent doses of both paralytic and sedative agents should be
anticipated. Providing both long-term analgesia and sedation is important given the relatively short duration of action
of some of the agents frequently used for RSI and the ability of paralysis to obscure the patient's capacity to
communicate pain or distress. Appropriate sedation, guided by a sedation scale, often obviates the need for
neuromuscular paralysis to permit mechanical ventilation. (See "Sedative-analgesic medications in critically ill adults:
Selection, initiation, maintenance, and withdrawal".)
VARIATIONS OF TECHNIQUE The general approach described above is a commonly accepted way of
performing rapid sequence intubation (RSI). There are, however, a number of variations, depending on clinical
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circumstance.
Accelerated sequence The accelerated approach is useful for a critically unstable patient when there is not
sufficient time for the full period of preoxygenation. In this case, the time line can be abbreviated by providing eight
vital capacity breaths, rather than three to five minutes of tidal volume breathing [25,39,40]. The pretreatment phase
can also be accelerated to begin just prior to induction. If the patient is in extremis, the pretreatment phase can be
eliminated altogether. (See "Pretreatment agents for rapid sequence intubation in adults" and "Rapid sequence
intubation (RSI) in children", section on 'Pretreatment'.)
Timing principle This concept has been described in the anesthesia literature and involves the administration of
a relatively slower-onset paralytic agent prior to induction [41-43]. The clinician waits for the early signs of the onset
of paralysis before giving the induction agent. The purpose is to coordinate the onset of the paralytic and induction
agents. It is possible the patient will experience a period of muscular weakness or paralysis while still awake if this
approach is used. For this reason, the technique is not recommended or used in emergency medicine practice.
The timing principle should not be confused with the practice of administering a long-acting agent with a slower
onset (eg, rocuronium) immediately prior to the induction agent, when both are given in rapid succession. This is
done to coordinate the onset of action. The intention is to capitalize on the more rapid onset of the induction agent
by giving it after the neuromuscular blocking agent (NMBA), affording the latter a bit more time to take effect.
Typically, when performing RSI using succinylcholine, the induction agent is given before the NMBA. The
fundamental distinction between the timing principle and this approach is that the clinician does not wait for the onset
of paralysis before giving the induction agent, but is merely reversing the order of the induction and paralytic agents
to allow for their different times to effect.
SUMMARY AND RECOMMENDATIONS Rapid sequence intubation (RSI) has become the mainstay of
emergency airway management. RSI uses a rapidly acting sedative (ie, induction) and a neuromuscular blocking (ie,
paralytic) agent to create optimal intubating conditions and enable rapid control of the airway. RSI presupposes the
patient is at risk for aspiration of stomach contents and incorporates medications and techniques to minimize this
risk. Use of RSI helps to mitigate the potential adverse effects of airway manipulation. The basic approach to RSI
consists of the "Seven P's":
Preparation Assess the patient for anatomic features or clinical findings that indicate the patient may be
difficult to intubate or to ventilate using a bag-mask. Make an airway management plan, including a backup
approach, based on the clinical scenario. Gather equipment and medications. Necessary equipment is
described in the text. (See 'Preparation' above.)
Preoxygenation We recommend that any patient who may require endotracheal intubation be given high flow
oxygen immediately (Grade 1B). Preoxygenation creates an oxygen reservoir in the lungs, blood, and tissues
that enables patients to tolerate a longer period of apnea without oxygen desaturation. The oxygen saturation
of adults with severe illness or obesity, and pregnant women nearing the end of their third trimester, falls below
90 percent in less than three minutes, even if ideal preoxygenation is achieved. Time to desaturation in
emergency practice is often more rapid than anticipated. Strategies to maximize preoxygenation are provided
in the text. (See 'Preoxygenation' above.)
Pretreatment Depending upon clinical circumstance and if time allows, specific medications may be given
prior to the induction phase of RSI for the purpose of mitigating adverse effects associated with intubation. (See
"Pretreatment agents for rapid sequence intubation in adults".)
Paralysis with induction RSI involves the virtually simultaneous intravenous administration of a rapidly acting
induction agent and a neuromuscular blocking agent (paralytic) aimed at producing a state of deep sedation
and muscular relaxation quickly. Different induction agents are used depending on clinical circumstances (table
3). (See "Induction agents for rapid sequence intubation in adults" and "Neuromuscular blocking agents
(NMBA) for rapid sequence intubation in adults".)
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Protection and positioning This step refers to protecting the airway prior to placement of the endotracheal
tube by avoiding bag-mask ventilation. Bag-mask ventilation is unnecessary if the patient has been
successfully preoxygenated. Ventilation interposed between paralysis and intubation creates a potential risk for
regurgitation and aspiration. (See 'Protection (cricoid pressure) and positioning' above.)
Placement with proof Once the intubation is performed, confirmation of proper endotracheal tube placement
is crucial; unrecognized esophageal intubation leads to devastating complications. End-tidal CO2 determination
(either colorimetric or quantitative) must be performed to determine proper placement. In cardiac arrest patients
not producing CO2, alternative means of confirmation may be needed. A single-view chest radiograph is only
useful to determine depth of placement; it cannot distinguish endotracheal from esophageal intubation. (See
'Placement with proof' above.)
Postintubation management The endotracheal tube must be secured, a postintubation chest radiograph
checked for evidence of complications, and appropriate ventilator management started. Drugs used for RSI are
generally short-acting, and the clinician must provide adequate longer-term sedation, analgesia, and
sometimes paralysis. (See 'Postintubation management' above.)
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GRAPHICS
Summary: The Seven Ps of rapid sequence intubation
Action
Time
Preparation
10 minutes before intubation
Preoxygenation
Pretreatment
Paralysis with induction
Induction
Protection
30 seconds after induction
Placement (Intubation)
Post-intubation management
Graphic 77060 Version 3.0
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Mnemonic for tracheal intubation preparation

S: Suction
T: Tools for intubation (laryngoscope blades, handle, other devices such as video laryngoscope)
O: Oxygen source for preoxygenation and ongoing ventilation
P: Positioning
M: Monitors, including ECG, pulse oximetry, blood pressure, end-tidal CO 2 , and esophageal detectors
A: Assistant; Ambu bag with face mask; Airway devices (endotracheal tubes, syringe, stylets,
LMA); Airway assessment
I: Intravenous access
D: Drugs, including induction agent, neuromuscular blocking agent, and desired adjuncts
ECG: electrocardiogram; LMA: laryngeal mask airway
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Time to oxygen desaturation
Preoxygenation prolongs the period between paralysis with

succinlycholine and oxygen desaturation in all patients, but to varying
degrees depending on patient attributes. This diagram shows the time
to desaturation for several different clinical conditions.
Reproduced with permission from: Benumof JL, Dagg R, Benumof R. Critical
hemoglobin desaturation will occur before return to an unparalyzed state
following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997; 87:979.
Copyright 1997 Lippincott Williams & Wilkins.
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Rapid sequence intubation induction agents

Drug
name
Class
Benefits
Contraindications
Notes
Dose
Etomidate
Imidazole
derivative
Excellent
sedation with
little hypotension
Known to suppress
adrenal cortisol
production
Use cautiously
if patient has
sepsis; initial
dose of
glucocorticoid
may be
needed
0.3
mg/kg
Ketamine
Phencyclidine
derivative,
dissociative
anesthetic
Stimulates
catecholamine
release
Use in patients with

elevated ICP or
elevated blood pressure
is controversial
May be an
excellent
induction
agent for
patients with
1 to 2
mg/kg
Bronchodilation
bronchospasm,
septic shock,
AND
hemodynamic
compromise
Midazolam
Benzodiazepines
Potent
dose-related
amnesic
properties
Dose-related
myocardial depression
can result in
hypotension
Propofol
Alkylphenol
derivative
Bronchodilation
No absolute
contraindications
Frequently
underdosed
1.5 to
3
mg/kg
Dose-related
hypotension
Thiopental
sodium
Ultrashortacting
barbiturate
Cerebroprotective
and
anti-convulsive
properties
Potent venodilator and

myocardial depressant;
can cause hypotension
0.2 to
0.3
mg/kg
May not be
commercially
available
3 to 5
mg/kg
Rarely used
1 to 3
mg/kg
Relatively
contraindicated in
reactive airway disease
due to histamine
release
Acute intermittent and
variegate porphyrias
Methohexital
Barbiturate
Cerebroprotective
Acute intermittent and

variegate porphyrias
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Cricoid pressure (Sellick's maneuver)
Cricoid pressure (Sellick maneuver). Posterior displacement of the airway cartilages

occludes the compliant esophagus. In infants and young children, the tracheal
cartilage is also very compliant, and excessive force while applying cricoid pressure
may impair airway patency.
Reproduced with permission from: King C, Rappaport LD. Emergent endotracheal
intubation. In: Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM
(Eds), Lippincott Williams & Wilkins, Philadelphia 2008. Copyright 2008 Lippincott
Williams & Wilkins. www.lww.com.
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