RSI is a technique that both emergency physicians and anesthetists should master. Recent literature has indicated that rapid sequence intubation (RSI) with neuromuscular blocking agents has become the most common method emergency physicians use to achieve tracheal intubation [4
]. This survey demonstrates that RSI is mostly being performed by emergency physicians in Turkey. This survey is to be the first to determine the specialties that perform RSI in the emergency department and drug preferences during RSI in Turkey.
According to the responses, frequently preferred premedications were fentanyl, the defasciculating agent vecuronium, the induction agent etomidate, and the neuromuscular blocking agent (NMBA) was succinylcholine. Still, there is no consensus on the ideal induction agent for emergency RSI. A number of pharmacologically distinct medications are presently used for sedation, dissociation, hypnosis, or induction. Likewise, the muscle paralysis achieved by the NMBA is undoubtedly responsible for most of the improvement in ease of intubation using RSI techniques [5
]. The ideal (induction and NMBA) agent would smoothly and quickly render the patient unconscious, unresponsive, and amnestic in one arm/heart/brain circulation time. Such an agent would also provide analgesia, maintain stable cerebral perfusion pressure and cardiovascular hemodynamics, be immediately reversible, and have few, if any, adverse side effects [6
], in other words, have rapid onset, brief duration, and no side effects. Unfortunately, such an agent does not exist.
Pre-oxygenation is almost never used (2.6%) in premedication. This may be because of misunderstanding of the responders or the fault of the authors of this article that happened during construction of the survey. In some questions the responders were allowed to answer more than one option, but in some questions they were not. This may have resulted in confusion during answering the survey.
The concerns with using the nondepolarizing agents for intubation are their slow onset and long duration of action [7
]. From a pharmacodynamic standpoint, succinylcholine’s extremely rapid onset of action and its short duration of action make it the ideal NMBA for RSI. Unfortunately, succinylcholine can cause such adverse effects as fasciculation, increased intracranial pressure, and increased intra-ocular pressure. While many of these side effects are of little clinical significance, succinylcholine also can have some potentially life-threatening effects [4
]. Despite these side effects, succinylcholine was the most preferred NMBA. In our survey, de-fasciculation is frequently performed with succinylcholine that provokes fasciculation.
After the patient has been successfully intubated, consideration of long-term sedation and muscle relaxation must be made. Patients frequently can be managed with sedation alone, but neuromuscular blockade also is required at times [7
]. Propofol, ketamine, benzodiazepines, and opioids all are appropriate choices for sedation, with any of the nondepolarizing agents useful for paralysis. Midazolam and propofol were the commonly preferred agents for maintenance of sedation.
RSI is not without risks. The drugs used have the potential to turn an urgent airway problem into a life-threatening situation [3
]. This survey demonstrated that RSI is currently being performed by emergency physicians. Emergency medicine in Turkey is in its infancy and needs to develop official guidelines in this field.
Limitations of the survey The responders were not requested to define the reason for their drug preferences during RSI. The residency training programs are not supposed to use only one protocol for RSI. Different trainers could perform RSI with different drugs; however, the survey requested only one response from each ED.