Objectives

The objectives of this chapter are to understand how to:

• prepare thoroughly for rapid sequence induction (RSI) and tracheal intubation

• position patients optimally to maximize the success of laryngoscopy and intubation

• assemble and check the equipment and drugs required for RSI and tracheal intubation

• use appropriate monitoring and know its strengths and limitations

• reassess the patient rapidly and ascertain all the required information before undertaking RSI

• identify and use team resources appropriately to maximize team co-operation and understanding.

Introduction

Making the decision that a patient requires a rapid sequence induction (RSI) is the entry point to the sequence of preparation for this procedure. While there may be times when intubation of the patient needs to be achieved immediately, there are very few instances in which placement of the tracheal tube is so time critical that these basic preparatory steps cannot be followed. With a systematic approach and good team working, this will take only a few minutes and avoid many possible problems and complications.

The PEACH approach (Box 6.1) provides a useful mnemonic.

Positioning

Correct positioning of the patient's head and neck improves the view of the larynx at laryngoscopy and the likelihood of successful intubation. Alignment of the oral, pharyngeal and laryngeal axes during laryngoscopy provides a clear view from the incisors to the laryngeal inlet (see Chapter 4).

Approximately 20% of RSI undertaken in the emergency department require stabilization of the cervical spine: in almost all other cases the patient should be placed in the optimum intubating position, unless spinal deformity or arthritis makes this impractical or inadvisable.