RSI Intubation: A Nurse's Guide to Rapid Sequence Intubation
Rapid Sequence Intubation (RSI) is the process of intubating a patient while they are awake — in the hospital, pre-hospital, or emergency setting. It involves several steps in quick succession: first sedation, then paralysis, then insertion of the endotracheal tube into the trachea.
This guide covers the indications, the nurse's role, the sedatives and paralytics, the step-by-step procedure, and the complications to monitor for at the bedside.
Indications for RSI Intubation
Emergent intubations often involve severe respiratory distress. Patients in acute respiratory failure typically present with:
Tripod Position
When a patient sits leaning forward, hands on their knees to support the upper body, it helps the accessory muscles breathe — but it's an ominous sign of respiratory distress. Think COPD.
The Nurse's Role During RSI
You shouldn't be the one physically placing the tube (with exceptions like NICU and flight nurses). The intubator is usually an EM physician, an IM physician, anesthesia, or sometimes an advanced practice provider (PA, NP, or CRNA). But nurses are essential to a safe, smooth intubation — and you're on the front lines to catch and intervene when things go wrong.
It takes a team — nurses, respiratory therapists, and physicians — to intubate safely, so understanding the whole process matters even if you're not placing the tube.
Alternatives to RSI Intubation
There are treatments to try before intubating: nebulizers, certain IM/SQ meds, a non-rebreather, high-flow nasal cannula, and CPAP or BiPAP. But by the time intubation is chosen, the patient is usually in impending respiratory arrest or the other treatments aren't enough. RSI is often the last measure to stabilize the respiratory system and save the patient's life.
RSI Sedatives (Induction Agents)
A sedative is a CNS depressant that puts the patient to sleep. Sedatives — also called induction agents — also blunt the sympathetic response so the body tolerates intubation better.
- Myoclonus: brief and harmless, but can mimic a seizure.
- Adrenal suppression: for 12–24 hours, which may affect BP in at-risk patients (adrenal insufficiency, severe sepsis).
- HF exacerbation: may worsen underlying myocardial dysfunction in pre-existing heart failure.
- Laryngospasm: increased risk, especially with upper-airway disease or asthma (fentanyl can help).
- Ketofol: a 1:1 combination of ketamine and propofol — provides analgesia, sedation, and amnesia; useful in severe bronchospasm.
- Emergence reactions: vivid or disturbing dreams, hallucinations, or delirium on waking (mainly with procedural sedation, not in patients sedated >24 h).
- Hypotension: drops MAP ~10% (sometimes ≥30%); caution with borderline pressures.
- Bradyarrhythmias & QT prolongation: more likely at high doses, in the elderly, with structural heart disease, or with QT-prolonging drugs/electrolyte disturbances.
- Elevated triglycerides/lipase: it's a lipid emulsion; can cause pancreatitis after 2–4 days.
- PRIS (Propofol Infusion Syndrome): rare but deadly — refractory bradycardia → asystole, severe metabolic acidosis, rhabdomyolysis, and cardiovascular collapse. More likely at >4 mg/kg/hr for >48 hours.
Propofol IV Push? Protect Your License
Confirm your state and facility allow RNs to give IV boluses of propofol — and if so, ensure the provider is at the bedside. Because it causes deep sedation, pushing it may be outside your scope.
Choosing the Right Sedative
Some scenarios favor one agent, though it ultimately comes down to provider preference and familiarity:
Paralytics (Neuromuscular Blockers)
Paralytics (NMBAs) are given immediately after the sedative kicks in, relaxing the muscles to ease intubation and minimize complications.
- Malignant hyperthermia (personal/family history)
- Neuromuscular disease with denervation (e.g., MS)
- Muscular dystrophy
- Stroke >72 h old (with significant motor denervation)
- Rhabdomyolysis, significant burns >72 h old, or significant hyperkalemia
- Hypertension: transient BP rise from increased vascular resistance (or transient hypotension in some).
- Tachycardia: temporary, ~5 minutes.
- Right-sided HF: may worsen pulmonary hypertension in predisposed patients.
The RSI Intubation Procedure
Position in the "sniffing" position (supine, neck flexed — a towel under the head/neck helps). Hyper-oxygenate with a non-rebreather or BVM at 100%. Place on the monitor with telemetry, continuous pulse ox, and end-tidal CO₂ if possible. Explain the procedure and obtain consent (often verbal, given the emergency). If altered, check for a DNR/DNI or POLST.
If using a BVM on 100% oxygen, squeeze with each spontaneous breath so the valve opens and oxygen reaches the patient.
Bring the code cart to the bedside (follow facility protocol on pads). Most gear is in the airway drawer: laryngoscope, ET tube, stylet, 10 cc syringe, suction tubing & Yankauer, ETCO₂/CO₂ detector, stethoscope, and BVM. Ask the provider the ET tube size — often 7.0 for females, 8.0 for males. Place the stylet inside the cuffed ET tube (removed once positioned).
Take the verbal order, clarify name and dose, and draw up (some need reconstitution — verify final amounts with another nurse). Label each so you don't confuse sedative and paralytic. On the provider's "ok," give the sedative first (over 5–10 s), then once LOC drops and you get the next ok, give the paralytic. RT bags the patient until the provider is ready — usually 30–60 seconds after the paralytic.
Your main job is done — monitor the patient and follow verbal orders. The provider places the ET tube between the vocal cords, typically 21 cm deep in women and 23 cm in men, measured at the teeth.
Verify in multiple ways: a CO₂ detector changing purple to yellow; ETCO₂ near 35–45 mmHg with each breath; equal breath sounds on auscultation; and a portable CXR (the radiologist may recommend advancing or withdrawing the tube).
Your main job now is keeping the patient sedated so the ventilator can breathe for them — usually a titratable propofol drip, possibly with added analgesics or paralytics. Chart everything, monitor vitals, and (in the ER or med-surg) get the patient admitted/transferred ASAP.
RSI Complications
Not all RSI intubations go smoothly — these are emergent, uncontrolled procedures, and you're often the first to notice trouble.
Clinical Pearls
Related Guides
References
- Rapid sequence intubation for adults outside the operating room. UpToDate.
- Sedation or induction agents for rapid sequence intubation in adults. UpToDate.
- Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults. UpToDate.
- Tintinalli JE, et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide (8th ed.). McGraw-Hill.
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I like your blog; it is very informative and easy to understand. I applied for a CCU RN position and would like to know if you have a PDF file of this lecture. Thank you for your time and effort.
You have an error. Note:
Currently it is widely used as an infusion to provide anaesthesia or sedation, often in association with regional anaesthesia. “Ketofol” is constituted as a 1:1 mixture of ketamine 200 mg and propofol 200 mg to a total volume of 22 ml. This results in propofol and ketamine concentrations of approximately 10 mg/ml each.