## Rapid Sequence Induction Protocol **Key Point:** The correct sequence of RSI is **Preoxygenation → Cricoid pressure → Induction agent → Muscle relaxant → Intubation**. This order minimizes aspiration risk and ensures adequate oxygenation before apnea. ### Step-by-Step RSI Sequence 1. **Preoxygenation (3–5 minutes)** - Denitrogenate the lungs to increase functional residual capacity (FRC) of oxygen. - Target SpO₂ ≥95% and end-tidal O₂ ≥90%. - Extends the apneic oxygenation period from ~3 minutes to ~8 minutes. 2. **Cricoid Pressure (Sellick Maneuver)** - Applied BEFORE induction agent is given. - Compresses the esophagus against the cervical vertebrae to prevent gastric insufflation and aspiration. - Maintained until cuff is inflated and tube position confirmed. 3. **Induction Agent** - Thiopental 3–5 mg/kg IV, propofol 1.5–2.5 mg/kg IV, or etomidate 0.2–0.3 mg/kg IV. - Loss of consciousness occurs within 30–40 seconds. 4. **Muscle Relaxant** - Succinylcholine 1.5 mg/kg IV (onset 30–40 sec) OR rocuronium 1.2 mg/kg IV (onset ~60 sec). - Applied after induction agent to achieve paralysis. 5. **Intubation** - Performed once adequate paralysis is achieved (fasciculations cease for succinylcholine). - Cricoid pressure released only after cuff inflation and tube position confirmed. **High-Yield:** Preoxygenation MUST precede all other steps. Cricoid pressure is applied BEFORE induction, not after, to prevent aspiration from the moment consciousness is lost. **Mnemonic:** **PCI-MI** = **P**reoxygenation → **C**ricoid pressure → **I**nduction agent → **M**uscle relaxant → **I**ntubation. **Clinical Pearl:** The timing of cricoid pressure is critical — it must be applied before loss of consciousness to prevent aspiration of gastric contents during the period between loss of airway reflexes and intubation.
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