Aspiration risk: full stomach, ileus, pregnancy, emergency surgery. Have suction, two operators, and difficult airway plan before induction.
Preoxygenation
- 3 to 5 min tidal breathing or 8 vital capacity breaths
- Target expired O2 if monitored
- Head-up improves FRC in obesity
Typical drugs (examples)
- Induction: propofol or ketamine (haemodynamics)
- Relaxant: suxamethonium 1 to 1.5 mg/kg or rocuronium 1.2 mg/kg
- Post-intubation: long-acting relaxant if rocuronium used
Standard preoxygenation
- 3 to 5 min tidal or 8 vital capacity breaths
- Head-up improves FRC
- Full monitoring and suction ready
High aspiration risk
- Full stomach, ileus, pregnancy, obesity
- Apnoeic oxygenation, ramp
- Two operators, airway kit
Failed intubation
- Maintain oxygenation, call for help
- Supraglottic airway rescue
- Sugammadex if rocuronium; DAS plan
RSI sequence
1
1. Prepare
Working laryngoscope, tube, bougie, drugs drawn and labelled. Assign cricoid if used (team policy).
Working laryngoscope, tube, bougie, drugs drawn and labelled. Assign cricoid if used (team policy).
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2
2. Preoxygenate
Then induction agent, immediately followed by relaxant. No mask ventilation unless desaturation (gentle if needed).
Then induction agent, immediately followed by relaxant. No mask ventilation unless desaturation (gentle if needed).
↓
3
3. Intubate
Direct or video laryngoscopy. Confirm ETCO2 waveform, bilateral chest movement, secure tube.
Direct or video laryngoscopy. Confirm ETCO2 waveform, bilateral chest movement, secure tube.
↓
4
4. Maintain
Analgesia and amnesia as required. Cricoid released after cuff inflated and placement confirmed.
Analgesia and amnesia as required. Cricoid released after cuff inflated and placement confirmed.
Rocuronium RSI
- Sugammadex rescue if cannot intubate (if trained and available)
- Sux contraindications: personal/family MH, hyperkalaemia risk
Pitfalls
- Induction without airway checklist
- Forgotten post-intubation sedation
- No backup SGA before paralysing
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026