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Clinical Snapshot - Carl has become obtunded

21 February 2024 - Deb Evans

Carl has arrived in the ICU following a MET call for respiratory failure. He requires intubation for mechanical ventilation. On transit to the ICU he has become obtunded. His BP has dropped to 88/60, SpO2 87% on HCM @ 15 L/min.

Does Carl require rapid sequence induction?


Impending Airway Compromise: Carl is in respiratory distress with airway compromise, including decreased level of consciousness and inadequate oxygenation.

Has not been fasting: The airway is unprotected until intubation is successful leaving the patient at risk of aspiration.

What is required for this procedure

Intubation Plan: Even in an emergency, the intubation plan should be discussed.  Where possible the use of a cognitive aid such as the Vortex model should also be available.


Induction Agents: Rapid acting muscle relaxant & paralysing agents will typically be utilised to minimise the risk of laryngeal spasm. Drugs should be selected based on the clinical condition of the patient with consideration to haemodynamic status, access to reversal agents, and duration of paralysis required. Ketamine & Rocuronium or Propofol and succinylcholine are often used. Narcotics such as Fentanyl may also be given.

Equipment: Appropriate monitoring, intubation equipment and access to emergency equipment including the difficult airway trolley is essential.

RSI and Intubation should follow the 9Ps:

Despite meticulous planning and execution of Rapid Sequence Induction, the initial attempt at securing Carl's airway proved challenging. The team promptly recognizes they are experiencing  difficulty in securing the airway and the Vortex cognitive aid is requested.

To be continued in the CCN: Intubation & Tracheostomy Care in the ICU course.

Further learning and related courses


DAS guidelines for management of unanticipated difficult intubation in adults 2015

Rapid sequence induction (not superseeded by 2015 guidelines) | Difficult Airway Society

PG18(A) Guideline on monitoring during anaesthesia 2017

Rapid Sequence Intubation (RSI) • LITFL • CCC Airway

Deb Evans
Deb Evans

DebEvans, RN, BSc, DipAnaes&PostAnaesNsg, CritCareCert, DipProfStudies, Teach&AssessClin.PractCert, CertIV(TAE) has extensive background in Perioperative education and management. Deb has worked overseas and in several tertiary hospitals in Brisbane as an educator and manager including the Mater & The Wesley Hospital where she was awarded CEO Award for Innovation and Excellence and The Spirit of Wesley Staff Award for commitment to Quality and Safety.

Deb has developed blended education programs within the perioperative environment to include; Graduate transition programs; Clinical mandatory training; Corporate required learning & Point of Care SIMs; Perioperative competency development skills and speciality training programs. She recently worked for Montserrat Day Hospitals as the National Education & Training Manager and implemented a virtual orientation program, LMS & introduced speciality learning pathways. Deb has also been an ALS instructor & involved with a range of universities as a clinical facilitator and a lecturer at TAFE.

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