When is rapid sequence intubation (RSI) contraindicated?

Updated: Apr 07, 2020
  • Author: Keith A Lafferty, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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RSI is not indicated in a patient who is unconscious and apneic. This situation is considered a "crash" airway, and immediate BVM ventilation and endotracheal intubation without pretreatment, induction, or paralysis is indicated.

RSI should be approached with caution in a patient with a suspected difficult airway. If difficulty is anticipated, then an awake technique or the use of airway adjuncts (eg, fiberoptic intubation) is recommended. Alternatively, anesthesia personnel may be called upon to assist in securing the airway of a difficult-to-intubate patient.

Extrapolating known techniques and procedures that are intuitive and evidence-based from the emergency department to the field often makes sound clinical sense. However, the same standards that govern such modalities should apply wherever they are practiced. Recent literature has questioned the benefit of RSI in the prehospital setting. [5] Contributing factors may be the inducement of hyperventilation and hypoxia, both of which have been shown to increase mortality in trauma patients undergoing prehospital RSI. [6]

Additional studies have shown that the use of prehospital RSI is associated with an increased incidence of transient and prolonged hypoxia (57% of patients with a median hypoxic time of 60 s), often going unnoticed by the paramedic. [7] Lack of initial and ongoing training, national variability in paramedic protocols, and inadequate experience must be studied and monitored. Randomized prospective studies are needed to better delineate and define the use of prehospital RSI. The ubiquitous use of video-assisted laryngoscopes (VALs) in EDs has been shown to decrease complications in RSI, and, as more prehospital personal train in this modality, similar results may be shown. Indeed, the amount of training required in VAL compared with direct laryngoscopy is less and glotic visualization has been proven to be easier.

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