Art & science |The synthesis of art and science is lived by the nurse in the nursing act

JOSEPHINE G PATERSON

RAPID SEQUENCE INDUCTION

IN URGENT CARE SETTINGS
Rob Fenwick explains why, in providing
emergency anaesthesia to critically ill patients,
failing to plan is planning to fail
Correspondence
robfenwickrn@googlemail.com
Rob Fenwick is a charge nurse
in the emergency department,
Princess Royal Hospital, Telford,
Shropshire
Date submitted
July 23 2013
Date accepted
January 20 2014
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarismsoftware
Author guidelines
en.rcnpublishing.com

Abstract
In the management of critically ill patients in
emergency departments, rapid sequence induction
(RSI) of anaesthesia is often required. This article
examines the elements of RSI that are necessray
before before endotracheal tube placement and
reviews the findings of a national audit project,
conducted by Royal College of Anaesthetists and
Difficult Airway Society. It also considers the role
ofnurses in RSI procedures.
Keywords
Anaesthesia, airway, crew resource management
EMERGENCY DEPARTMENT (ED) staff undertake
rapid sequence induction (RSI) of anaesthesia
to ensure that definitive airways can be secured
in critically ill patients. A definitive airway has
been defined as a cuffed tube in the trachea
(Kummer et al 2007) and most frequently involves
the drug-assisted passing of an oral endotracheal
tube. Some patients can be intubated without drugs
but some have a degree of remaining airway reflex,
which requires pharmacological adjuncts to support
tracheal intubation (Carley et al 2002).
Rapid sequence induction was originally
undertaken in patients if they had eaten shortly
before surgery to ensure that they did not aspirate
their stomach contents. Specialised equipment, and
trained and experienced staff, are needed before
the procedure can be undertaken in EDs (Reid et al
2004), where the clinical conditions of patients can
make the procedure especially difficult.

16 March 2014 | Volume 21 | Number 10

In conducting the fourth national audit project

(NAP4), the Royal College of Anesthetists and
Difficult Airway Society discovered 184 serious
complications associated with anaesthesia had been
reported in the UK over a one-year period (Cook et al
2011). One in three of these complications could
have led to death or brain damage, and 15 (8.1%)
hadtaken place in EDs.
The precise role of nurses in RSI depends on
the requirements of individual patients, but as the
English chief nursing officer has pointed out, in
this procedure as in others, all nurses should be
able to demonstrate care, compassion, competence,
communication, courage and commitment
(Cummings and Bennett 2012). Clinical situations in
which a patient can require a definitive airway and
respiratory support (Reid et al 2004) include:
A Glasgow Coma Scale (GCS) score of less than
eight, which indicates that the patient may have
lost the gag reflex and is therefore unable to
maintain the airway, thereby risking pulmonary
aspiration and gastric insufflation.
A falling GCS score, which can indicate
an intracranial pathology and a need for
neuroprotective ventilation to prevent secondary
brain injury.
Persistent hypoxia despite administration of
highflow oxygen through a facemask.
Respiratory failure, which indicates that the
patient is tiring and may require support for
oxygenation or ventilation.
Transfer within or between hospitals,
during which the patients airway can
become compromised.
EMERGENCY NURSE

Science Photo Library

Art & science | anaesthesia

Figure 1 Pharyngeal structures

Class 2

Class 3

Class 4

Peter Lamb

Class 1

glottis cannot be seen on laryngoscopy (Carley et al

2002), although use of open collars with manual
in-line stabilisation (MILS) improves the view by up
to 20% because it allows the mouth to be opened
wider (Nolan and Wilson 1993).

Examinations of the airway to predict difficult

intubation and ventilation are essential components
of patient assessment before elective surgery,
and should include assessments of neck mobility
and thyromental distance. However, the ability of
clinicians to make these assessments in critically ill
patients who require emergency intubation has not
been evaluated (Reynolds and Heffner 2005).
If patients are conscious and co-operative,
clinicians can examine inside their mouths to assess
whether laryngoscopy will be difficult. The patient is
asked to sit up, open his or her mouth and pose in
the sniffing position with tongue protruded, and the
clinician assesses the pharyngeal structures according
to Mallampatis (1983) system of classification.
If the structures are assessed to be class 1 or 2,
laryngoscopy should be easy; if they are assessed to
be classes 3 or 4, laryngoscopy should be difficult
(Reynolds and Heffner 2005) (Figure 1).
Up to two thirds of patients who require RSI
in EDs cannot be assessed this way because their
conditions prevent them from being moved into
the required position or to follow the required
commands (Levitan et al 2004). According to
Carley et al (2002), such patients should be observed
for syndromes and conditions that are indicative of
difficult intubation, such as:
Acromegaly.
Airway obstruction.
Ankylosing spondylitis.
Bull neck.
Laryngeal, maxillary facial or neck trauma.
Obesity.
Pierre Robins syndrome.
Poor dentition or prominent teeth.
Pregnancy.
Rheumatoid arthritis.
Intubation is especially difficult in patients with
major trauma who must wear semi-rigid collars,
blocks and tape in case they have cervical spine
injuries. In more than 60% of such patients the
18 March 2014 | Volume 21 | Number 10

Teamwork Teams that provide RSI should comprise

at least three practitioners:
An intubator and team leader.
An airway assistant who is responsible for the
equipment and, usually, drugs administration.
A practitioner who applies cricoid pressure,
watches the monitor and prepares medications.
Where necessary, teams also include a fourth
practitioner who is dedicated to providing MILS.
Some teams include a separate drugs administrator.
In the authors experience, the ideal positioning
of four members of an RSI team providing MILS is
shown in Figure 2. The intubator (1) is positioned
near the patients head, where he or she can
oversee preparations and provide pre-oxygenation
before intubation. The equipment is usually
positioned immediately to the intubators right and
the airway assistants left so that it can be passed
by the airway assistant (2) into the intubators
right hand. The practitioner providing MILS (3) is
positioned immediately to the intubators left so
that he or she is close to the patients head without
standing between the intubator and the equipment,
and the practitioner who applies cricoid pressure (4)
is positioned so that he or she can see the monitor
clearly and relay findings to the team. If the team
Figure 2 Ideal positioning of team members
Monitor

1
3

Equipment

Patient

EMERGENCY NURSE

Pre-oxygenationWhile the airway is being secured,

apnoea and hypoventilation can occur and preoxygenation, also known as alveolar denitrogenation,
must be undertaken to prevent hypoxia (Reynolds
and Heffner 2005). Pre-oxygenation prolongs the
period of safe apnoea until the patients oxygen
saturation has reached between 88% and 90%. If
saturation levels fall below 88%, the patient is said
to be on the steep portion of the oxyhaemoglobin
dissociation curve and the saturation level
can fall toa critical level quickly (Weingart
and Levitan 2012). This propensity of oxygen
saturations to decrease rapidly is illustrated by the
oxyhaemoglobin dissociation curve in Figure 3.
Breathing a high fraction of inspired oxygen
(FiO2) increases stores of oxygen in the alveoli and
bloodstream (Mort 2005), as Table 1 demonstrates.
While oxygen consumption in healthy adults is
usually about 250mL/minute, it is likely to be much
higher in patients who receive RSI in EDs. Farmery
and Roe (1996) found desaturation to 85% can take
as little as 23 seconds in critically ill patients but
502 seconds in healthy patients. This difference is
due mainly to the effects of shunting as a result,
for example, of pulmonary oedema or pneumonia,
increased metabolic demand, volume depletion,
anaemia or decreased cardiac output, all of which
reduce oxygen storage in the lungs.
To provide optimum pre-oxygenation, each
patient with an adequate respiratory drive should
receive high FiO2 through a non-rebreather mask
for three minutes (Weingart and Levitan 2012).
Theoxygen flow rate should be between 30 and
Table 1

Figure 3 Oxyhaemoglobin dissociation curve

100 90 Saturation level of oxygen in haemoglobin (%)

includes a separate drugs administrator (5), he or

she should stand to the right of the airway assistant.
This positioning ensures that practitioners focus on
the patient and his or her needs, and all members
should have the courage to challenge practice that
detracts from patient-centred care.

80 70 60 50 -

Patient is
hypoxaemic

40 -

Patient is
at high risk

Patient is
at low risk

30 20 10 0









10 20 30 40 50 60 70 80 90 100
Partial pressure of oxygen in the blood (%)

(Adapted from Weingart and Levitan 2012)

60L/minute, which is achieved on a flow regulator

with no calibrated markings beyond 15L/minute by
keeping its valve fully open for as long as possible
(Weingart and Levitan 2012).
Self-inflating bag-valve-mask devices can be
used in patients with inadequate respiratory drive,
but they will deliver oxygen only if the patients
can generate enough inspiratory force to open the
devices valves or if practitioners squeeze the bags
in time with patients respirations. The masks must
be applied tightly, usually by use of a two-handed
technique, or only ambient FiO2 will be provided
(Weingart and Levitan 2012).
Application of tight-fitting face masks can distress
patients, who may be already anxious or confused,

Example of prolonged safe-apnoea period after pre-oxygenation

Oxygen present in the lungs

Total oxygen reservoir in the lungs and bloodstream
Oxygen consumption during apnoea in healthy patients
Approximate duration of safe apnoea

Patient
breathingair

Patient fully preoxygenated

on100% oxygen

450mL

3,000mL

1,000-1,500mL

3,500-4,000mL

250mL/minute

250mL/minute

1 minute

8 minutes

(Adapted from Weingart and Levitan 2012)

EMERGENCY NURSE

March 2014 | Volume 21 | Number 10 19

Art & science | anaesthesia

Table 2

Common induction agents

Drug

Syringe Concentration
size (mL)
(mg/mL)

Dosage (mg/kg)
If patient
is stable

Duration

Indications

Cautions

If patient
Of onset Of action
is unstable (seconds) (minutes)
Ischaemic heart
disease.
Hypertensive
emergencies.

Ketamine

20

10

60-120

5-15

Hypotension.
Asthma.
Chronic obstructive
pulmonary disease.

Thiopental

20

25

1.5

30-60

5-30

Hypotension.
Normotensive.
Status epilepticus.
Isolated head injury.

Table 3

Common paralysing agents

Drug

Syringe Concentration
size (mL)
(mg/mL)

Dosage (mg/kg)
If patient
is stable

Duration

Indications

Cautions

If patient
Of onset Of action
is unstable (seconds) (minutes)

Rocuronium

10

10

45-60

45-70

Need for paralysis.

Difficult intubation.

Suxamethonium

50

1.5

1.5

30-60

5-15

Need for paralysis.

Hyperkalaemia.
Myopathy.
Neuropathy or stroke.
Denervation illness.

and their distress often increases because they

must be managed while in a supine position rather
than while sitting up, a more natural position to
adopt by people who are short of breath or hypoxic.
Nursing staff should anticipate this distress and try
to calm patients by talking with them throughout
the procedure. Good communication skills and the

Ear-to-sternal notch
horizontal plane

Peter Lamb

Figure 4 Ideal positioning of patient for rapid sequence induction

ability to show compassion can help ensure optimal

pre-oxygenation and improve patient care.
MonitoringDuring anaesthesia, each patients
physiological state and depth of anaesthesia require
continual assessment (Association of Anaesthetists
of Great Britain and Ireland (AAGBI) 2007), and to
this end practitioners should use monitoring devices
to verify their clinical observations. Monitoring
procedures, which should include capnography,
electrocardiography and pulse oximetry, and
the monitoring of non-invasive blood pressure,
must be in place before induction of anaesthesia
and undertaken continuously throughout the RSI
procedure (AAGBI 2007). Practitioners should not
rely solely on monitoring equipment, which has
limitations and can fail, but should regard it as part
of a holistic assessment process.
DrugsThe drugs used for RSI in UK EDs vary,
but those used for initial management are either
induction or paralysing agents. These medications
should be prepared in syringes with the correctly
coloured labels to reduce administration errors
during stressful situations (Wassef et al 2008).

20 March 2014 | Volume 21 | Number 10

EMERGENCY NURSE

Equipment All equipment required for RSI should

be prepared and checked before use, and should
be clearly visible and accessible to the airway
assistant when the intubator requires it. All staff
should ensure they have maintained competence
in the preparation and operation of the essential
equipment because delays in its preparation or
provision can affect patient care.
Equipment required in all RSI procedures includes
a self-inflating bag-valve-mask, suction, two working
laryngoscopes with differently sized blades,
two endotracheal (ET) tubes of different sizes and
ties to secure them, a syringe containing air to inflate
the ET tube balloon, a bougie and a catheter mount.
Patient positioning The importance of accurate head
and neck positioning for optimal laryngeal view
during laryngoscopy has been recognised since the
procedure was first described in 1895 by German
surgeon Alfred Kirstein (Levitan et al 2003).
If possible, patients should be placed in an
ear-to-sternal notch position, so that the external
auditory meatus is on the same horizontal plane as
the sternal notch (Figure 4). This position maximises
the upper airway dimensions and supports direct
laryngoscopy better than the standard position
of slight elevation of the head and extreme
atlanto-occipital extension (Levitan et al 2003).
Although about 4% of patients who present to
major trauma centres have cervical spine injuries
EMERGENCY NURSE

Figure 5 Patient in reverse Trendelenburg position

Peter Lamb

Induction agents are administered to bring on

unconsciousness rapidly (Reynolds and Heffner 2005)
and are always used first to ensure that patients
are unconscious before paralysis is induced. Two
commonly used induction agents along with dosing
and supporting information are shown in Table 2.
Paralysing, or neuromuscular blocking, agents
are administered to relax the skeletal muscles
profoundly (Reynolds and Heffner 2005). It is
important to pay attention to the onset time of
the chosen paralysing drug, which is equivalent to
how long it takes to establish optimal laryngoscopy
conditions. Adverse events such as laryngospasm
can occur if laryngoscopy is attempted too quickly.
Two common paralysing agents and supporting
information are shown in Table 3.
Administration of an induction agent followed
by a paralysing agent is undertaken only after all
preparatory steps have been completed, and when
the team has assembled and is ready to proceed.
Conscious patients are likely to be anxious and
frightened so, if possible, a member of staff should
be available to reassure them that they will receive
the best care from a clinically competent team.

30

(Grossman et al 1999), the proportion with unstable

injuries is considerably lower (Patterson 2004).
Nevertheless, the ability of RSI teams to alter
patients positions is reduced if patients are supine
with spinal precautions. In such situations, patients
can be placed in the reverse Trendelenburg position,
with the head of the stretcher 30 higher than the
foot (Figure 5). This allows for spinal immobilisation
while maximising pulmonary function (Weingart and
Levitan 2012).
Direct laryngoscopy and orotracheal intubation
rarely cause dangerous cervical spine movements
and the risk of their doing so should be balanced
against the probability of hypoxic brain injury due
to difficult laryngoscopy caused by immobilisation
(Manoach and Paladino 2007). As patient advocates,
emergency nurses may have to discuss this balance
with the team before RSI is started.
Cricoid pressure The aim of applying cricoid
pressure is to reduce the risk of pulmonary aspiration
of patients gastric contents while they undergo
emergency anaesthesia. The practitioner should use
his or her thumb and index finger to apply sustained
pressure to the patients cricoid cartilage to push it
backwards and compress the oesophagus between
the posterior aspect of the cricoid and the vertebral
body of C5-6 (Sultan 2008) (Figure 6).
Figure 6 Applying pressure between the cricoid and vertebral body of C5-6
to compress the oesophagus

Cricoid:
posterior
aspect

Oesophagus
March 2014 | Volume 21 | Number 10 21

Art & science | anaesthesia

The ideal pressure is between 30 and 40N,
although only 20% of clinicians apply this consistently
(May and Trethewy 2007). The amount of force
required can be demonstrated to junior staff by
using the thumb and index finger to apply between
3kg and 4kg of mass on an electronic scale (May and
Trethewy 2007). This is an easy way for practitioners
who do not perform the technique regularly to
practise it and retain competence.
First described by Sellick (1961), the application
of cricoid pressure has become widely accepted as
an important component of RSI. However, because
applying cricoid pressure does not always compress
the oesophagus, the practice has come under scrutiny
(Weingart and Levitan 2012). Computed tomography
(CT) and magnetic resonance imaging have
demonstrated that, among patients who are subject
to cricoid pressure, more than 90% have lateral
displacement of the oesophagus and about 80% have
laryngeal or tracheal compression (Ellis et al 2007).
Other studies have demonstrated that cricoid
pressure applied poorly can hinder bag-valve-mask
ventilation and laryngoscopy (Levitan et al 2006,
Weingart and Levitan 2012).

All staff involved in RSI should be aware of the

principles of applying cricoid pressure, but should
also be aware that it can make passing ET tubes
difficult. If the intubator encounters difficulties in
this area, the application of cricoid pressure may
have to be reduced or halted.
ChecklistsOne of the NAP4 papers main
recommendations is that practitioners should follow
a safety checklist when intubating patients in EDs
and during surgery (Cook et al 2011).
The World Health Organization (2008) and the
National Patient Safety Agency (2009) have called for
checklists to be used before all surgery in hospitals
in the UK. Haynes et al (2009) demonstrate that the
use of such checklists during high-risk procedures
reduced operative complications from 11% to 7%
andhospital death rates from 1.5% to 0.8%.
The introduction of RSI checklists is part of an
acknowledgement that human factors can cause
error and patient harm (Bleetman et al 2012), and
their value is increased greatly if the practitioners
using them understand the importance of, for
example, effective communication and planning.

Figure 7 Rapid sequence induction checklist

Prepare patient

Prepare equipment

Prepare team

Is preoxygenation optimal

(ideally three minutes
at15L O2)?

What is being monitored?

Electrocardiography.
Blood pressure (twominute cycles).
Oxygen saturation.
Capnography.

Name the team members

Team leader...........................

Is there adeqaute

intravenous (IV)
orintraosseous (IO) access
(ideally two lines)?
Flush now
Is the patients
position optimal?
Can the patients condition
be optimised further
before intubation?
How will anaesthesia
be maintained after
induction?
Show the team leader

Are all drugs, including vasopressors,

available?
Show the team leader

If the airway is

difficult, can the
patient be woken?

Intubator................................
Airway assistant .....................

What equipment is available and has

been checked?
Self-inflating bag.
Suction device.
Two endotracheal tubes and ties.
Air syringe.
Two laryngoscopes.
B
 ougie.

Prepare for difficulty

 ricoid pressure practitioner

C
and monitor............................
Check technique

If the intubation is

difficult, how will
oxygenation be
maintained.
Verbalise plans

 rugs administrator ................

D

Where is the relevant

equipment, such as
an alternative airway?
Hasit been checked?
Show the team leader

W
 ho should be contacted ifmore
help is needed?
Bleep number............................

Are specific
complications
anticipated?

 ractitioner providing manual

P
in-line stabilisation..................

Name of sedative drug...........................

Name of paralysis drug..........................

Is the emergency department

coordinator present?

Patient name......................... Unit number.......................................... Completed by................................ Date...............................

(Adapted from Regional Trainee-Led Collective Severn 2012)

22 March 2014 | Volume 21 | Number 10

EMERGENCY NURSE

Intubation The team member performing intubation

must be highly skilled in airway techniques and
practise regularly to maintain the appropriate skill
levels (Carley et al 2002). In UK EDs, intubation is
usually carried out by doctors with backgrounds in
emergency medicine or anaesthesia.
When performing the initial laryngoscopy, it
is common practice for the intubator to verbalise
the grade of view of the glottis according to the
Cormack and Lehane (1984) classification system
(Figure 8), in which grade 1 is the best view and
grade 4 the worst. The team should be aware that
grade 3 or 4 views indicate that intubation will be
difficult and that a difficult airway plan may have
to be activated.
Unrecognised oesophageal placement can have
disastrous consequences (Cook et al 2011), such as
hypoxia and even death so, as soon as the ET tube
has been inserted, its position in the trachea must
be confirmed. There are two methods of reliable
confirmation (Lavery and McCloskey 2008): by sight,
whereby the intubator sees the tube passing directly
through the vocal cords, and by capnography to
detect end-tidal carbon dioxide (ETCO2).
Traditional methods of confirming tube
placement, such as chest and stomach auscultation,
seeing water vapour in the ET tube and
acknowledging a lack of cyanosis, are unreliable
(Cook et al 2011).
The NAP4 group recommends capnography as the
gold standard for confirming correct tube placement
for all intubated patients, including those in cardiac
arrest. It should be noted that, in a patient who has
recently ingested large quantities of carbonated
drinks or bicarbonate-based antacids, capnography
may detect ETCO2 if the ET tube has been placed
incorrectly in the oesophagus. In a patient with
cardiac arrest, the ETCO2 level is usually lower than
in other patients but should still be detectable if the
ET tube has been placed in the trachea correctly.
EMERGENCY NURSE

Figure 8 Cormack Lehane grading of glottis view on laryngoscopy

Peter Lamb

The introduction of checklists should be

accompanied by training in crew resource
management to ensure that team members feel
empowered to create a patient-centred working
environment in which potentially unsafe practice
is always challenged.
Ideally, checklists should take the form of a series
of challenges and responses. Before RSI begins,
the team leader should read aloud each of the
challenges and the rest of the team should respond.
The RSI checklist used in the authors hospital
covers patient preparation, equipment, drugs, team
and back-up plans, as recommended by Cook et al
(2011). This checklist has been adapted for Figure 7.

Grade 1

Grade 2

Grade 3

Grade 4

As previously discussed, monitoring should be

part of a holistic patient assessment rather than a
stand-alone procedure, and nurses are ideally placed
to notice subtle but clinically significant changes
in patients appearances or conditions even when
monitoring parameters are unchanged, and to raise
concerns about them.
Difficult airway planning Up to 8.5% of intubations
in EDs are difficult, and 0.5% of ED intubations
require surgical airway techniques (Cook et al 2011).
If such difficulties are not identified early, and if
no strategy to deal with them is in place, critical
events may occur. The NAP4 group recommends,
therefore, that all staff involved in ED RSI discuss
difficult airway strategies before undertaking RSI.
One way to deal with difficult airways is to adopt
Chrimes and Fritzs (2013) vortex approach, in
which the green area (Figure 9, page 24) signifies
that an airway is patent with or without adjuncts,
the three bounded areas in the blue area signify
three airway-management techniques and the area
in the centre signifies a need for surgical techniques.
The yellow arrow signifies the teams progress as
they try the three airway-management techniques,
namely face mask, laryngeal mask airway and
endotracheal tube, before proceeding to a surgical
airway, should the preceding technique fail.
March 2014 | Volume 21 | Number 10 23

Art & science | anaesthesia

Figure 9 Vortex approach: top view

Laryngeal
mask airway

urgica

n iq u e

l te c h

Endotracheal
tube

Face
mask

(Adapted from Chrimes and Fritz 2013)

The techniques and their order should be decided

on, and necessary equipment prepared, before the
process begins. If intubation is not straightforward
and progression to the difficult-airway plan

is required, nurses must have the courage to

communicate their opinions. Assistants should
ensure that all team members understand the
potential for adverse events in these situations
and that they progress to the difficult-airway plan
before the patients condition deteriorates. If team
members are familiar with a failed-intubation plan,
they can react promptly and ensure that time-critical
management options are considered on time.
One important feature of all protocols and
algorithms is that all staff receive adequate training
in their use, and are familiar with the equipment and
processes involved.

Conclusion
As the NAP4 study demonstrates, there is a need for
improvements in RSI conducted outside operating
theatres (Cook et al 2011). Patient safety can be
improved if team members are trained appropriately
and if methods that are proven to reduce errors,
such as the use of checklists and other cognitive
aids, are adopted by teams managing critically
ill patients. Above all, RSI procedures should be
planned and prepared meticulously: failing to plan
is planning to fail.

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