Section 1
The 60-Second Resuscitation Card (First 5 Minutes)
Rapid Sequence Intubation (RSI) is the virtually simultaneous administration of a potent sedative-hypnotic induction agent and a fast-acting neuromuscular blocking agent (NMBA) to render a patient rapidly unconscious and flaccid for first-pass tracheal intubation without aspirating gastric contents [1,2]. When agitation or delirium prevents preoxygenation, Delayed Sequence Intubation (DSI) decouples dissociation from paralysis [3].
0:00
Immediate Bedside Action & Exact Dosing
7 Ps Preparation & Weight-
Compartment Calculation: Estimate Ideal Body Weight (IBW) vs. Total Body Weight (TBW) [1,4]. Screen for Succinylcholine absolute contraindications (hyperkalemia K⁺ ≥ 5.5 mEq/L, subacute denervation/stroke/spinal cord injury > 72 hours, burns > 24–72 hours, crush injury/rhabdomyolysis, personal/family history of malignant hyperthermia, pseudocholinesterase deficiency) [1,4].
Compartment Calculation: Estimate Ideal Body Weight (IBW) vs. Total Body Weight (TBW) [1,4]. Screen for Succinylcholine absolute contraindications (hyperkalemia K⁺ ≥ 5.5 mEq/L, subacute denervation/stroke/spinal cord injury > 72 hours, burns > 24–72 hours, crush injury/rhabdomyolysis, personal/family history of malignant hyperthermia, pseudocholinesterase deficiency) [1,4].
Equipment / Setup Specification
SOAP-ME Checklist verified: Suction (DuCanto catheter at −300 mmHg), Oxygen (flush-rate NRB or BiPAP), Airway (VL + ETT + Bougie + i-gel SGA + CTM scalpel), Pharmacology labeled in syringes, Monitoring (ETCO₂, ECG, NIBP q2min).
Physiological & Mechanical Objective
Prevents underdosing of hydrophilic paralytics in obesity or lethal hyperkalemic ventricular fibrillation from extrajunctional nicotinic ACh receptor upregulation [1,4].
0:30
Immediate Bedside Action & Exact Dosing
Preoxygenation OR Delayed Sequence
Intubation (DSI): If cooperative, preoxygenate for 3 min via NIPPV (IPAP 14 / EPAP 8 cmH₂O, FiO₂ 1.0) or flush-rate NRB [5]. If delirious/combative and ripping off masks, execute DSI: push Ketamine 1.0 mg/kg IV (IBW) slowly over 45–60 sec (may repeat 0.5 mg/kg IV) until dissociated, then apply BiPAP for 3 min [1,3].
Intubation (DSI): If cooperative, preoxygenate for 3 min via NIPPV (IPAP 14 / EPAP 8 cmH₂O, FiO₂ 1.0) or flush-rate NRB [5]. If delirious/combative and ripping off masks, execute DSI: push Ketamine 1.0 mg/kg IV (IBW) slowly over 45–60 sec (may repeat 0.5 mg/kg IV) until dissociated, then apply BiPAP for 3 min [1,3].
Equipment / Setup Specification
Dedicated IV line flushed with 20 mL NS; tight-fitting NIPPV mask with PEEP valve; Rocuronium syringe held in hand during DSI (in case rapid IV push Ketamine triggers transient laryngospasm or apnea) [3].
Physiological & Mechanical Objective
Dissociates the thalamocortical and limbic systems while preserving brainstem respiratory rhythmogenesis and glossopharyngeal tone, enabling denitrogenation of the FRC [3,5].
1:30
Immediate Bedside Action & Exact Dosing
Hemodynamic & ICP Optimization
(Targeted Pre-Treatment): Standard “LOAD” pre-treatment (Lidocaine, Opioid, Atropine, Defasciculating dose) is obsolete [1,2]. Exceptions: (1) In Shock (SI ≥ 0.8), start Norepinephrine 0.05–0.3 mcg/kg/min + prepare Push-Dose Epinephrine (10–20 mcg IV) [1]; (2) In Sympathetic Crisis (TBI with herniation, SAH, aortic dissection, preeclampsia), give Fentanyl 2–3 mcg/kg IV slow push 3 min prior to laryngoscopy [2].
(Targeted Pre-Treatment): Standard “LOAD” pre-treatment (Lidocaine, Opioid, Atropine, Defasciculating dose) is obsolete [1,2]. Exceptions: (1) In Shock (SI ≥ 0.8), start Norepinephrine 0.05–0.3 mcg/kg/min + prepare Push-Dose Epinephrine (10–20 mcg IV) [1]; (2) In Sympathetic Crisis (TBI with herniation, SAH, aortic dissection, preeclampsia), give Fentanyl 2–3 mcg/kg IV slow push 3 min prior to laryngoscopy [2].
Equipment / Setup Specification
Arterial line (if available) or q1min NIBP; head of bed elevated 30° to optimize cerebral venous outflow via internal jugular veins.
Physiological & Mechanical Objective
Fentanyl blunts the glossopharyngeal/vagal afferent surge during vallecular blade pressure, preventing acute spikes in MAP, ICP, and aortic wall shear stress (dP/dt) [2].
3:00
Immediate Bedside Action & Exact Dosing
Induction + Paralysis Execution (Time
Zero of Apnea): Push Induction Agent: Etomidate 0.3 mg/kg IV (TBW; reduce to 0.15–0.2 mg/kg in shock) OR Ketamine 1.5–2.0 mg/kg IV (IBW; reduce to 0.5–1.0 mg/kg in shock) [1,6,7]. Immediately flush line and push Paralytic: Rocuronium 1.2–1.5 mg/kg IV (IBW) OR Succinylcholine 1.5 mg/kg IV (TBW) [1,8].
Zero of Apnea): Push Induction Agent: Etomidate 0.3 mg/kg IV (TBW; reduce to 0.15–0.2 mg/kg in shock) OR Ketamine 1.5–2.0 mg/kg IV (IBW; reduce to 0.5–1.0 mg/kg in shock) [1,6,7]. Immediately flush line and push Paralytic: Rocuronium 1.2–1.5 mg/kg IV (IBW) OR Succinylcholine 1.5 mg/kg IV (TBW) [1,8].
Equipment / Setup Specification
Gently ventilate via BVM with PEEP (5–10 cmH₂O, PIP < 20 cmH₂O) during the 45–60 sec onset window if hypoxemic or acidemic [9]; pass VL blade at exactly 45–60 sec (wait 60–90 sec in low cardiac output).
Physiological & Mechanical Objective
Achieves Bispectral Index (BIS) < 40 prior to neuromuscular blockade and > 95% nicotinic receptor occupancy at the laryngeal adductors and diaphragm [4].
5:00
Immediate Bedside Action & Exact Dosing
Immediate Post-Intubation Analgesia &
Sedation (“Kill Awake Paralysis”): Confirm ETT with square-wave ETCO₂ [2]. Immediately administer Fentanyl 1–2 mcg/kg IV bolus + infusion (50–150 mcg/hr) AND Propofol infusion (10–50 mcg/kg/min) or Ketamine infusion (0.5–2.0 mg/kg/hr) [1]. Have Sugammadex 16 mg/kg IV available if immediate reversal of Rocuronium is required [2,10].
Sedation (“Kill Awake Paralysis”): Confirm ETT with square-wave ETCO₂ [2]. Immediately administer Fentanyl 1–2 mcg/kg IV bolus + infusion (50–150 mcg/hr) AND Propofol infusion (10–50 mcg/kg/min) or Ketamine infusion (0.5–2.0 mg/kg/hr) [1]. Have Sugammadex 16 mg/kg IV available if immediate reversal of Rocuronium is required [2,10].
Equipment / Setup Specification
Infusion pumps pre-programmed and spiked before laryngoscopy; RASS target −2 to 0 (or −4 to −5 while paralyzed under Rocuronium).
Physiological & Mechanical Objective
Prevents Awake Paralysis— because Etomidate (t₁/₂α = 5–10 min) and Ketamine (10–15 min) wear off long before Rocuronium (45–70 min) [1,4].
| Time | Immediate Bedside Action & Exact Dosing | Equipment / Setup Specification | Physiological & Mechanical Objective |
|---|---|---|---|
| 0:00 | 7 Ps Preparation & Weight- Compartment Calculation: Estimate Ideal Body Weight (IBW) vs. Total Body Weight (TBW) [1,4]. Screen for Succinylcholine absolute contraindications (hyperkalemia K⁺ ≥ 5.5 mEq/L, subacute denervation/stroke/spinal cord injury > 72 hours, burns > 24–72 hours, crush injury/rhabdomyolysis, personal/family history of malignant hyperthermia, pseudocholinesterase deficiency) [1,4]. | SOAP-ME Checklist verified: Suction (DuCanto catheter at −300 mmHg), Oxygen (flush-rate NRB or BiPAP), Airway (VL + ETT + Bougie + i-gel SGA + CTM scalpel), Pharmacology labeled in syringes, Monitoring (ETCO₂, ECG, NIBP q2min). | Prevents underdosing of hydrophilic paralytics in obesity or lethal hyperkalemic ventricular fibrillation from extrajunctional nicotinic ACh receptor upregulation [1,4]. |
| 0:30 | Preoxygenation OR Delayed Sequence Intubation (DSI): If cooperative, preoxygenate for 3 min via NIPPV (IPAP 14 / EPAP 8 cmH₂O, FiO₂ 1.0) or flush-rate NRB [5]. If delirious/combative and ripping off masks, execute DSI: push Ketamine 1.0 mg/kg IV (IBW) slowly over 45–60 sec (may repeat 0.5 mg/kg IV) until dissociated, then apply BiPAP for 3 min [1,3]. | Dedicated IV line flushed with 20 mL NS; tight-fitting NIPPV mask with PEEP valve; Rocuronium syringe held in hand during DSI (in case rapid IV push Ketamine triggers transient laryngospasm or apnea) [3]. | Dissociates the thalamocortical and limbic systems while preserving brainstem respiratory rhythmogenesis and glossopharyngeal tone, enabling denitrogenation of the FRC [3,5]. |
| 1:30 | Hemodynamic & ICP Optimization (Targeted Pre-Treatment): Standard “LOAD” pre-treatment (Lidocaine, Opioid, Atropine, Defasciculating dose) is obsolete [1,2]. Exceptions: (1) In Shock (SI ≥ 0.8), start Norepinephrine 0.05–0.3 mcg/kg/min + prepare Push-Dose Epinephrine (10–20 mcg IV) [1]; (2) In Sympathetic Crisis (TBI with herniation, SAH, aortic dissection, preeclampsia), give Fentanyl 2–3 mcg/kg IV slow push 3 min prior to laryngoscopy [2]. | Arterial line (if available) or q1min NIBP; head of bed elevated 30° to optimize cerebral venous outflow via internal jugular veins. | Fentanyl blunts the glossopharyngeal/vagal afferent surge during vallecular blade pressure, preventing acute spikes in MAP, ICP, and aortic wall shear stress (dP/dt) [2]. |
| 3:00 | Induction + Paralysis Execution (Time Zero of Apnea): Push Induction Agent: Etomidate 0.3 mg/kg IV (TBW; reduce to 0.15–0.2 mg/kg in shock) OR Ketamine 1.5–2.0 mg/kg IV (IBW; reduce to 0.5–1.0 mg/kg in shock) [1,6,7]. Immediately flush line and push Paralytic: Rocuronium 1.2–1.5 mg/kg IV (IBW) OR Succinylcholine 1.5 mg/kg IV (TBW) [1,8]. | Gently ventilate via BVM with PEEP (5–10 cmH₂O, PIP < 20 cmH₂O) during the 45–60 sec onset window if hypoxemic or acidemic [9]; pass VL blade at exactly 45–60 sec (wait 60–90 sec in low cardiac output). | Achieves Bispectral Index (BIS) < 40 prior to neuromuscular blockade and > 95% nicotinic receptor occupancy at the laryngeal adductors and diaphragm [4]. |
| 5:00 | Immediate Post-Intubation Analgesia & Sedation (“Kill Awake Paralysis”): Confirm ETT with square-wave ETCO₂ [2]. Immediately administer Fentanyl 1–2 mcg/kg IV bolus + infusion (50–150 mcg/hr) AND Propofol infusion (10–50 mcg/kg/min) or Ketamine infusion (0.5–2.0 mg/kg/hr) [1]. Have Sugammadex 16 mg/kg IV available if immediate reversal of Rocuronium is required [2,10]. | Infusion pumps pre-programmed and spiked before laryngoscopy; RASS target −2 to 0 (or −4 to −5 while paralyzed under Rocuronium). | Prevents Awake Paralysis— because Etomidate (t₁/₂α = 5–10 min) and Ketamine (10–15 min) wear off long before Rocuronium (45–70 min) [1,4]. |
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