A 32-year-old woman with a 6-month history of gastroesophageal reflux disease presents to the emergency department with acute appendicitis. She has not fasted and her last meal was 2 hours ago. Her vitals are: BP 128/82 mmHg, HR 98/min, RR 20/min, SpO₂ 98% on room air. She requires emergency surgery under general anesthesia. During rapid sequence induction, after pre-oxygenation and application of cricoid pressure, which of the following is the MOST appropriate induction agent considering her risk of aspiration?

Explanation

## Rapid Sequence Induction in High Aspiration Risk **Key Point:** Etomidate is the induction agent of choice in patients with high aspiration risk (non-fasted, GERD, emergency surgery) because it maintains airway reflexes better than other agents and causes minimal cardiovascular depression. ### Why Etomidate in This Case **High-Yield:** Etomidate preserves airway protective reflexes and maintains hemodynamic stability—critical in aspiration-prone patients who need rapid intubation with minimal risk of regurgitation during induction. | Agent | Airway Reflexes | Hemodynamics | Aspiration Risk | Use in RSI | | --- | --- | --- | --- | --- | | **Etomidate** | Preserved | Stable | **Lowest** | **Best choice** | | Propofol | Blunted | ↓ BP, ↓ HR | Moderate | Avoid in hemodynamically unstable | | Thiopental | Blunted | ↓ BP, ↓ HR | Moderate–High | Obsolete; rarely used | | Midazolam | Blunted | Minimal | Moderate | Not for RSI (slow onset) | ### RSI Sequence in This Patient 1. **Pre-oxygenation** (3 min or 8 vital capacity breaths) 2. **Apply cricoid pressure** (Sellick maneuver) — 10 N awake, 30 N after loss of consciousness 3. **Induction:** Etomidate 0.2 mg/kg IV 4. **Paralysis:** Succinylcholine 1–1.5 mg/kg IV (rapid onset, short duration) 5. **Intubation** with cuffed endotracheal tube **Clinical Pearl:** Cricoid pressure reduces gastric insufflation and the risk of aspiration by compressing the esophagus against the cervical vertebrae. However, it should be released if it impedes visualization during laryngoscopy. **Warning:** Propofol causes significant hypotension and loss of airway reflexes—dangerous in a non-fasted patient. Thiopental is no longer recommended due to cardiovascular depression and prolonged recovery. **Mnemonic — RSI Agents (Etomidate preferred):** **E**tomidate = **E**xcellent for **E**mergency (preserves reflexes, stable BP).