Part of the ICU Emergencies Hub — browse every related guide in one place.
Rapid sequence intubation (RSI) is the near-simultaneous administration of an induction agent and a paralytic to secure an emergent airway as fast and safely as possible, minimizing the window in which the patient is neither breathing on their own nor protected from aspiration. The provider passes the tube, but the nurse runs the room around it — and how well that room is run is often what decides whether the first pass is smooth or the patient desaturates and crashes. This is a walk through the RSI sequence from the nurse's side of the bed, organized around the classic "7 Ps."
The 7 Ps are a shared mental checklist that keeps a fast, high-stakes event from skipping a step. Different sources phrase them slightly differently, but the sequence is what matters: it moves left to right in time.
| P | What happens | The nurse's piece |
|---|---|---|
| Preparation | Gather people, drugs, equipment | Draw and label meds, set up suction, monitor, IV access |
| Preoxygenation | Fill the lungs with oxygen | Apply high-flow O2, position, watch the sat |
| Pre-optimization | Fix physiology before the tube | Pressors ready, fluids, correct hypotension |
| Paralysis with induction | Push induction + paralytic | Deliver drugs in the ordered sequence, call out times |
| Positioning | Optimize the airway view | Ear-to-sternal-notch, bed height, remove headboard |
| Placement + proof | Pass the tube, confirm it | Watch capnography, listen, secure the tube |
| Post-intubation care | Sedate, ventilate, stabilize | Start sedation/analgesia, watch the pressure, get the x-ray |
Most RSI disasters are traced back to a preparation gap. Before anyone pushes a drug, confirm the airway cart is at the bedside and open, suction is assembled and turned on within arm's reach (a Yankauer tucked under the mattress edge, running), and the patient has at least one reliable, running IV — ideally two. The bag-valve-mask is attached to oxygen with a PEEP valve if your unit uses one, and the ventilator is at the bedside with the respiratory therapist, set and ready. End-tidal CO2 (capnography) should be connected and ready to snap onto the tube the instant it is placed.
The nurse also draws and labels the medications: the induction agent, the paralytic, a push-dose or infusion pressor, and post-intubation sedation and analgesia. Labeling matters enormously here — an induction agent and a paralytic look identical in a syringe, and swapping them (paralyzing an awake patient, or inducing without paralysis) is a genuine harm event. Every syringe gets a label. State out loud what you have drawn and what dose.
Preoxygenation replaces the nitrogen in the lungs with oxygen so the patient has a reservoir to live on during the apneic window. Give the highest FiO2 available for at least three minutes if time allows — non-rebreather at flush rate, or non-invasive positive pressure for the patient who won't come up otherwise. Many teams leave a nasal cannula running underneath at high flow to provide apneic oxygenation during the attempt. (There is a dedicated companion article on preoxygenation and apneic oxygenation.)
Pre-optimization is the step that separates a controlled ICU intubation from a code. A patient who is hypotensive, acidotic, or hypoxic before the tube is a patient who may arrest during it. This is where the nurse's fingers are already on the pressor. (See the companion piece on peri-intubation hemodynamics for why "resuscitate before you intubate" is the single most important idea in this whole sequence.)
In classic RSI the induction agent is pushed first, immediately followed by the paralytic, both given rapidly and without waiting to test whether the patient can be masked. The nurse delivers them in the order the provider calls, announces "induction in… paralytic in…" and starts a mental or spoken clock. Onset differs by drug: succinylcholine produces intubating conditions in roughly 45–60 seconds; rocuronium at RSI dose takes a bit longer. (The rocuronium vs. succinylcholine and etomidate vs. ketamine comparisons cover how the team picks each.)
Once the tube passes, proof is non-negotiable and it is capnography. A sustained waveform with a normal end-tidal CO2 tracing over several breaths is the standard confirmation of tracheal placement — auscultation and chest rise support it but do not replace it. A flat capnograph in a perfusing patient means the tube is not in the trachea until proven otherwise: stop, pull, re-oxygenate. The nurse watches the monitor and calls the number out loud so the whole team hears it. Then secure the tube, note the depth at the lip, and hand off to respiratory therapy for the vent.
The patient is now paralyzed and, depending on the induction agent's duration, may be waking up while still unable to move — a terrifying experience. Post-intubation sedation and analgesia must start promptly; a paralytic is not a sedative. Meanwhile blood pressure commonly drops after the tube from loss of sympathetic tone and the switch to positive-pressure ventilation, so the pressor stays close. Get the confirmatory chest x-ray, recheck the tube depth, and reassess the vent settings against an ABG.
For the physiology of keeping the patient oxygenated through the attempt, read the companion article on preoxygenation and apneic oxygenation; for preventing the peri-intubation crash, see peri-intubation hemodynamics; and for when the first pass fails, the difficult airway.
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