OSCE Checklist: Rapid Sequence Intubation (RSI)

📎 RSI.pdf

Identification and Patient Introduction

1. Introduce Yourself: State your name and role clearly.
2. Verify Patient Identity: Confirm the patient's full name and date of birth.
3. Consent: Explain the procedure and gain informed consent if possible, considering the urgency.

Indications for Intubation

• Failure to maintain/protect airway.
• Failure to oxygenate or ventilate.
• Anticipated clinical course deterioration.

Complications and Risk Disclosure

1. Trauma Risks:
   • Oral, nasal, or pharyngeal injuries.
   • Fractured teeth.
   • Tracheal or esophageal damage from excessive stylet or force.
2. Physiological Risks:
   • Hypoxia during prolonged attempts.
   • Aspiration of gastric contents.
   • Cardiovascular instability.

Contraindications

1. Near-death scenarios where intubation is non-beneficial.
2. Difficult airway assessment:
   • L: Look externally for predictors (facial trauma, small mouth).
   • E: Evaluate 3-3-2 rule (mouth opening, thyromental distance).
   • M: Mallampati score.
   • O: Obstruction or obesity.
   • N: Neck mobility limitations.

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Steps of RSI ("7 Ps")

1. Preparation:
   • Ensure suction, oxygen, airway equipment, pharmacology, and monitoring devices are ready.
   • Check laryngoscope (Macintosh/Miller), endotracheal tubes (ETT 7.0-8.0 mm), syringes, and backups (e.g., video laryngoscope).
2. Preoxygenation:
   • 100% oxygen for 3 minutes or 8 deep breaths with high-flow O2.
   • Consider bag-mask ventilation if SpO2 < 90%.
3. Pretreatment:
   • Lidocaine: 1.5-2 mg/kg (blunts cough reflex).
   • Fentanyl: 2-3 mcg/kg (reduces sympathetic response).
   • Atropine: 0.01 mg/kg in pediatric cases.
   • Defasciculating agent for succinylcholine use.
4. Paralysis and Induction:
   • Sedative: Etomidate (0.3 mg/kg), Ketamine (1-2 mg/kg), or Propofol (2 mg/kg).
   • Neuromuscular blocker: Succinylcholine (1.5 mg/kg) or Rocuronium (1.2 mg/kg).
5. Positioning:
   • Sniffing position for standard cases.
   • RAMP position for obese patients.
6. Placement:
   • Crossed-finger technique for mouth opening.
   • Insert laryngoscope, visualize glottis, and advance ETT 3-4 cm past vocal cords.
   • Confirm placement with capnography (EtCO2), bilateral chest auscultation, and chest rise.
7. Postintubation Management:
   • Inflate cuff, secure ETT, confirm placement with imaging (CXR).
   • Initiate ventilation settings and monitor continuously.

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Post-Procedure Management

1. Secure Tube:
   • Confirm tube depth (e.g., 21-24 cm at the lips).
   • Secure with tape or commercial holder.
2. Monitor:
   • Continuous pulse oximetry and EtCO2.
   • Regular chest auscultation.
3. Documentation:
   • Record medications, doses, time of intubation, and complications.

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Checklist Summary

This checklist ensures adherence to protocols and structured documentation of the RSI process. Modify per institutional guidelines and patient-specific conditions for the best outcomes.