When is rapid sequence induction indicated and what are its key steps?

• A. RSI is indicated for elective low-risk procedures; standard induction without cricoid pressure.
• B. RSI is used for all surgeries regardless of aspiration risk.
• C. RSI should be used only in pediatric patients.
• D. Suspected full stomach or high aspiration risk; apply cricoid pressure, preoxygenation, RSI with endotracheal intubation using suitable agents to minimize aspiration risk.

Answer: (D)

Rapid sequence induction is used when there is a high risk of aspiration, such as a suspected full stomach or other situations where gastric contents could be regurgitated into the airway during airway management. The aim is to secure the airway quickly and protect it from aspiration.

The steps begin with maximizing oxygen reserves through preoxygenation with 100% oxygen. Next, cricoid pressure (the Sellick maneuver) is applied to compress the esophagus and reduce the chance of regurgitation while preparing for intubation. Induction is performed with agents that produce rapid unconsciousness, followed by a rapid-onset neuromuscular blocker to achieve swift intubating conditions. Importantly, you avoid or minimize positive-pressure ventilation before the airway is secured, to prevent forcing air into the stomach; if ventilation is necessary, it should be gentle and low-pressure. The airway is then secured with an endotracheal tube, placement is confirmed (usually by capnography), and the cuff is inflated to seal the airway. Cricoid pressure is maintained until the tube is in place and the airway is protected, after which it can be released carefully. Suction should be ready in case aspiration has occurred or is anticipated, and everything is in place to optimize rapid control of the airway.

This approach is not used for elective low-risk procedures, is not applied to all surgeries regardless of aspiration risk, and is not restricted to pediatric patients. It specifically targets situations with high aspiration risk to minimize the chance of regurgitation and aspiration during airway management.