Peri-RSI hypotension: Common causes and interventions

Common causes	Important clinical findings	Interventions	Prevention/preparation
High intrathoracic pressure Poor BMV ventilation technique Improper mechanical ventilation settings	Normal or elevated airway pressures Abnormal breath sounds (eg, wheezing, diminished)	Slow ventilation rate (≤8 bpm) Reduce ventilation force (for BMV) Increase expiration time IV bolus isotonic fluid	Avoid overly rapid or forceful ventilation
Induction agent effects	Occurs within minutes of drug administration Transient effect Resolves with IVF bolus and time	IV bolus isotonic fluid Norepinephrine infusion Exclude other serious causes Monitor for resolution	Prepare norepinephrine infusion prior to giving induction agent to patient with hypotension or signs of hemodynamic instability Consider push-dose pressor*
Significant prior or ongoing fluid loss	Signs of shock SI >0.8 POCUS shows decreased IVC diameter and hyperdynamic heart	IV bolus isotonic fluid; repeat as needed	In hypotensive or high-risk patients, give IVF bolus prior to administering RSI medications
Significant prior or ongoing hemorrhage	Blood loss Signs of shock Pallor	Blood transfusion Hemorrhage control/surgical consultation	In patients with hemorrhagic shock or at risk for hemodynamic instability, initiate blood transfusion prior to administering RSI medications
Obstructive shock
Pulmonary embolism	Possible hypoxemia Lower extremity swelling Dilated RV on POCUS or bedside echo	Norepinephrine infusion iNO or epoprostenol (reduce PVR)	Give norepinephrine early as needed Consider push-dose pressor* For shock caused by PE, avoid intubation if possible; use BPAP or iNO to improve oxygenation/ventilation Ketamine is preferred induction agent for patients in non-cardiogenic shock; avoid propofol Reduce dose of induction agent^¶ In hypotensive or high-risk patients with tamponade, give IVF bolus prior to administering RSI medications
Cardiac tamponade	Distended neck veins, if patient not volume depleted POCUS shows pericardial effusion and compression of RA and RV	IV bolus isotonic fluid Pericardiocentesis
Cardiogenic shock	Crackles, distended neck veins, cool extremities ECG may show ischemia POCUS shows poor contractility, B lines Chest radiograph may show signs of ADHF	Minimize PEEP Vasopressor (norepinephrine) and inotrope (dobutamine) infusions Interventional cardiology consult (catheterization; IABP; LVAD)	BPAP as indicated before RSI Etomidate is preferred induction agent for patients in cardiogenic shock; avoid propofol Prepare norepinephrine infusion prior to giving induction agent Consider push-dose pressor*
Distributive shock
Sepsis	Fever, hypotension, tachycardia, focal signs of infection	IV bolus isotonic fluid; repeat as needed Norepinephrine infusion for sepsis	In hypotensive or high-risk patients, give IVF bolus prior to administering RSI medications Ketamine is preferred induction agent for patients in non-cardiogenic shock; avoid propofol Give norepinephrine for sepsis early as needed Reduce dose of induction agent^¶ Consider push-dose pressor*
Anaphylaxis	Skin and mucosal signs (hives, flushing, edema) Respiratory signs (wheeze, cough, congestion)	IV bolus isotonic fluid; repeat as needed Epinephrine for anaphylaxis
Older adult patient with poor CV reserve	Frail appearing ECG may show ischemia History of CAD or reduced EF	IV bolus isotonic fluid Norepinehrine infusion	Prepare norepinephrine infusion prior to giving induction agent Reduce dose of induction agent^¶ Consider push-dose pressor*

RSI: rapid sequence intubation; BMV: bag-mask ventilation; bpm: beats per minute; IV: intravenous; IVF: intravenous fluid; SI: shock index; POCUS: point-of-care ultrasound; IVC: inferior vena cava; RV: right ventricle; iNO: inhaled nitric oxide; PVR: pulmonary vascular resistance; PE: pulmonary embolism; BPAP: bilevel positive airway pressure; RA: right atrium; ECG: electrocardiogram; ADHF: acute decompensated heart failure; PEEP: peak end-expiratory pressure; IABP: intra-aortic balloon pump; LVAD: left-ventricular assist device; CV: cardiovascular; CAD: coronary artery disease; EF: ejection fraction; SBP: systolic blood pressure.
* The use of a push-dose pressor is based on clinical judgement. It is most appropriate for patients with overt shock (eg, SBP <90 mmHg, SI >1) but may be useful in any hemodynamically unstable patient being intubated. Options include phenylephrine 100 microgram (50 to 200 microgram) IV or epinephrine 10 microgram (5 to 20 microgram) IV, depending upon whether vasoconstriction alone or vasoconstriction and inotropic support is desired. Appropriate measures to improve hemodynamics as much as possible should be taken prior to intubation and push-dose pressor use.
¶ Reductions in the dose of the induction agent depend upon clinical circumstance. In general, the authors reduce the ketamine dose by 50% when a reduction is needed. Reductions in the etomidate dose are generally not necessary.

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Peri-RSI hypotension: Common causes and interventions