22.11d Rapid Sequence Airway & Delayed Sequence Intubation

Rapid sequence airway (RSA) is an airway management technique used with selected patients in which the preparation and pharmacology of RSI are paired with intentional placement of an extraglottic airway device (instead of a tube) without prior attempt at direct laryngoscopy.

The theoretical advantages to RSA over RSI include less hypoxemia, less airway trauma, and no risk of tube misplacement.

The major risks are aspiration and ineffective ventilation.

The risk of aspiration is offset by fewer airway attempts and new gastric-isolation extraglottic airway (EGA) devices that achieve an excellent seal pressure and also allow for gastric decompression.

The risk of ineffective ventilation is offset by careful patient and device selection.

Contraindications for RSA: upper airway pathology, blunt/penetrating anterior neck trauma, inhalation injury, angoiedema, anaphylaxis, upper airway tumor, obstructing upper airway infection, caustic ingestion.

As discussed earlier, delayed Sequence Intubation (DSI) is a modification of the RSI procedure.

Its use is indicated in agitated patients in whom the EMS practitioner cannot achieve adequate preoxygenation.

It involves sedation with the use of ketamine to allow interventions aimed at better preoxygenation.

Once these have been achieved and the patient has been adequately denitrogenated, a paralytic is administered and intubation proceeds as in RSI.

In essence, DSI is RSI with a delay between the sedative and paralytic to allow for better preoxygenation.