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What are the 6 "P's" of Rapid Sequence Intubation? - #MEDSHED

Going through the 6 "P's" provides a structured thought process in optimal endotracheal intubation conditions and management -



Emergency medicine is a unique specialty given the wide range of patient presentations. One of the most important initial evaluations of the is airway and ventilation. Rapid Sequence Intubation (RSI) is a well-established technique used by emergency medicine physicians to achieve definitive airway control. To ensure optimal intubating conditions and management, emergency medicine clinicians follow a systematic approach known as the "Six P's." These six key principles guide the process, minimizing the risks associated with intubation while optimizing patient outcomes.


What is Endotracheal Intubation and Indication?

RSI is a technique used to facilitate passing an endotracheal tube through the trachea or nostril for airway securement and optmial ventilation.

Indications for Endotracheal Intubation

  • Airway obstruction or compromise

    • Angioedema, Ludwig's angina, foreign body, trauma

  • Respiratory failure/distress

    • Inadequate oxygentation and ventilation

    • Pneumonia, Acute Respiratory Distress Syndrome, COPD/asthnma exacerbations

  • Cardiac arrest

    • Advanced airway management needs to be established to ensure delivery of oxygen and improve likelihood of resuscitation

  • Altered mental status/Airway protection

    • Inability to protect the airway due to decreased levels of consciousness.

    • Objective is to maintain airway patency and prevent aspiration

  • Procedures and surgery

    • Depending on the operation, patients may need to pre-emptively be intubated before heading into the operating room.

  • Anticipated clinical deterioration

    • High risk patients who appear to have impending respiratory failure from maintaining their own airway (Myesthenia Gravis, overdose, hypercarbic respiratory failure, etc)

You can't prepare for the six P's of RSI without knowing the general indications on when you'd secure the airway. Now let's get into them.


The Six P's of RSI

  1. Preparation: Preparation is paramount in any medical procedure. Gather the necessary equipment, including appropriate-sized endotracheal tubes, laryngoscope blades, suction devices, and medications. Ensure monitors are in place to track vital signs and oxygen saturation. Assign roles to team members, clarifying who will manage medications, airway manipulation, and documentation.

  2. Pre-oxygenation: Begin by administering high-flow oxygen to the patient to maximize their oxygen reserves. Pre-oxygenation enhances oxygenation and delays the onset of desaturation during intubation attempts. This is crucial, especially in critically ill patients with compromised respiratory status.

  3. Pretreatment: Pretreatment involves administering medications to minimize potential complications associated with intubation. Administer a rapid-acting sedative, such as etomidate or ketamine, followed by a neuromuscular blocker to facilitate intubation. Pretreatment aims to prevent adverse reactions and ensure patient comfort.

  4. Paralysis with Induction: Induction involves the administration of a sedative, often a short-acting agent like propofol or etomidate, to induce a state of unconsciousness. This is followed by the administration of a neuromuscular blocking agent like succinylcholine or rocuronium to induce muscle paralysis, allowing optimal visualization of the vocal cords during intubation.

  5. Placement of the Tube: The primary goal of RSI is to secure the airway. Visualization of the vocal cords using a laryngoscope is essential for correct tube placement.

  6. Post-intubation Management: Once the endotracheal tube is properly placed, confirm its position using clinical methods and radiography. Secure the tube, ensure appropriate ventilation settings, and connect the patient to appropriate monitoring equipment. Continuously assess the patient's oxygenation, ventilation, and hemodynamic status.


Anticipation is My Name of the Game

RSI is a cornerstone of emergency airway management, and adherence to the Six P's ensures a structured and comprehensive approach to this critical procedure. Through preparation, optimizing oxygenation, reviewing pretreatment indications, patient-centered paralysis and induction, verification of tube placement, and post-intubation management enhances patient-safety and outcomes. Consistently reviewing the Six P's grants you the confidence to anticipate potential intubation complications and have a more proactive approach to your critical patient.

Mark Nguyen, PharmD, BCEMP



  1. Engstrom et al. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med. 2023 Aug;70:19-29. doi: 10.1016/j.ajem.2023.05.004.

  2. Kramer et al. Rapid Sequence Intubation in Traumatic Brain-injured Adults. Cureus. 2018 Apr; 10(4): e2530.

  3. Hampton J. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm. 2011 Jul 15;68(14):1320-30. doi: 10.2146/ajhp100437.

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