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Volume 7, Issue 2 (2026)
J Clinic Care Skill 2026, 7(2): 89-92 |
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Received: 2026/03/14 | Accepted: 2026/04/27 | Published: 2026/05/8
Received: 2026/03/14 | Accepted: 2026/04/27 | Published: 2026/05/8
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Roozbakhshian N, Hakiminia B, Firouzbakht B. Management of Rapid Sequence Induction During Emergency Laparotomy in a Trauma Center in Iran. J Clinic Care Skill 2026; 7 (2) :89-92
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1- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
2- “Physiology Research Center, Neuroscience Research Institute” and “Department of Clinical Pharmacy, Faculty of Pharmacy”, Semnan University of Medical Sciences, Semnan, Iran
3- Department of Anesthesiology, Faculty of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
2- “Physiology Research Center, Neuroscience Research Institute” and “Department of Clinical Pharmacy, Faculty of Pharmacy”, Semnan University of Medical Sciences, Semnan, Iran
3- Department of Anesthesiology, Faculty of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
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Introduction
Emergency laparotomy (EL) is an immediate surgical procedure with various indications that is used to address acute abdominal conditions and pathologies requiring immediate intervention [1]. Although hemorrhage and trauma account for a small percentage of EL cases, EL is one of the most dangerous procedures because of the associated hemodynamic instability [2]. Mortality associated with EL is approximately five times higher than that associated with high-risk elective surgeries and may be attributable to various factors, including hypovolemic shock [3]. Therefore, careful selection of anesthetic agents and techniques is crucial for EL. Although standard drugs are often used, the choice of muscle relaxants may vary [4].
Rapid sequence induction (RSI) is a specialized technique designed to minimize the risk of pulmonary aspiration through the use of specific drugs, tools, and maneuvers [5]. It is indicated in situations such as a non-fasted state, active vomiting, ileus, reduced laryngeal reflexes, gastrointestinal obstruction, pregnancy, and trauma [6]. This technique aims to rapidly induce unconsciousness and muscle relaxation, thereby reducing the time interval between drug administration and intubation [5]. It involves loss of consciousness during the application of cricoid pressure (CP), followed by intubation without face-mask ventilation, allowing the trachea to be intubated as quickly as possible [7]. RSI significantly reduces the potential risk of gastric contents refluxing into the esophagus, thereby enhancing patient safety during the procedure [5].
Rocuronium bromide is a widely used nondepolarizing neuromuscular blocker in clinical anesthesia [8]. Its rapid onset and predictable duration of action make it an attractive option for facilitating airway management and providing muscle relaxation during surgical procedures [8]. Rocuronium exerts its effects by competitively antagonizing nicotinic acetylcholine receptors at the neuromuscular junction. Although traditional reversal agents, such as neostigmine and edrophonium, require the concurrent administration of anticholinergic medications to counteract muscarinic side effects, the advent of sugammadex has significantly improved the safety and efficacy of rocuronium reversal [8].
On the other hand, succinylcholine is a depolarizing neuromuscular-blocking drug that is structurally similar to acetylcholine. This drug binds competitively to acetylcholine receptors and causes a prolonged depolarization phase [9]. At the full dosage (1-2mg/kg), it induces fasciculation and paralysis while providing optimal conditions for intubation within a single circulation time of 15 to 45 seconds [10]. This case report presented a practical and in-depth review of the use of RSI in EL at a trauma center in Iran—a situation requiring rapid decision-making, careful selection of anesthetic agents, and effective airway management. This report may serve as a useful model for anesthesiologists, anesthesia technicians, and emergency teams managing critical situations. In addition, documenting this experience provides a valuable foundation for future empirical research on anesthesia management in trauma and emergency care settings.
This study aimed to evaluate the effectiveness and clinical outcomes of RSI in a patient with abdominal trauma undergoing EL at an Iranian trauma center.
Patients and Methods
This case report presented a 50-year-old man with abdominal trauma and internal bleeding caused by an accident was brought to a trauma center in Shiraz, Iran, in December 2024. Upon arrival, he was immediately transferred to the operating room for emergency surgery. The patient’s weight was estimated at approximately 60kg. No underlying medical conditions or regular medications were documented in his medical records. Because the patient presented to the hospital as an emergency case, the exact time of his last oral intake was unknown. Therefore, he was considered to have a full stomach, and RSI was performed accordingly to minimize the risk of pulmonary aspiration.
Findings
His Glasgow Coma Scale (GCS) score was 13, and he underwent anesthesia for laparotomy surgery with an ASA grade of V-E. The patient had severe hypotension (40/20mmHg), tachycardia (120bpm), and hematuria despite having no known underlying medical conditions, possibly indicating hemorrhage and internal bleeding. Upon arrival in the operating room, an ECG monitor, pulse oximeter, capnograph, and both noninvasive and invasive blood pressure monitors were connected to the patient. Invasive blood pressure monitoring was initiated after induction of anesthesia because of the significant bleeding, as the procedure is painful and requires anesthesia.
The medical personnel observed hypotension and compensatory tachycardia, suggesting significant blood loss. His pulse rate, noninvasive blood pressure, and invasive blood pressure were 120bpm, 40/20mmHg, and 38/19mmHg, respectively. In addition, his end-tidal CO₂ (ETCO₂) and arterial oxygen saturation were 40mmHg and 95%, respectively.
After intravenous access and monitoring had been established, RSI was performed. This included preoxygenation with 100% oxygen at 5L/min, application of CP, and induction with 120mg of ketamine. Succinylcholine (90mg) was administered, and after fasciculations developed, endotracheal intubation was performed using a cuffed endotracheal tube (ETT). After intubation, midazolam (2mg) and fentanyl (100μg) were administered for amnesia and analgesia. Subsequently, four units of packed red blood cells were transfused because of the hypotension and tachycardia.
An arterial blood gas (ABG) sample was collected every hour. The patient’s surgery lasted for four hours, and a total of 4 ABGs were obtained. Accordingly, the metabolic disturbances and acidosis observed on the ABG results were minor and managed and treated by the anesthesiologist.
The patient was also administered 1g of tranexamic acid to help prevent further bleeding. To maintain anesthesia and increase blood pressure, propofol and epinephrine were administered using an infusion pump at doses of 100μg/kg/min and 8μg/min, respectively. During the operation, according to the fluid therapy calculations, the patient received 1000ml of normal saline during the first hour and 800ml during each subsequent hour, alternating between normal saline and Ringer’s solution. Following these measures, the patient’s blood pressure returned to normal, and the surgeon successfully controlled the internal bleeding. The unconscious patient was admitted to the intensive care unit with an ETT, a blood pressure of 110/90mmHg, a heart rate of 80 bpm, and an oxygen saturation of 97%.
Discussion
This study evaluated the effectiveness and clinical outcomes of RSI in a patient with abdominal trauma undergoing EL at an Iranian trauma center. It highlights the importance of RSI in critically injured patients with internal bleeding who require immediate surgical intervention. In such situations, EL is a critical intervention that allows for the diagnosis and control of the bleeding source, thereby preventing further hemorrhage [2].
The patient’s condition necessitated the use of an RSI technique, which differs from the standard procedure for elective laparotomies. This technique involves a single preoxygenation phase followed by the immediate administration of anesthetic agents and a short-acting muscle relaxant [11]. This approach eliminates the waiting period between muscle relaxant administration and intubation, allowing for quicker and safer airway management [12]. The patient was continuously monitored during the procedure, and succinylcholine and CP were used as components of the RSI technique. Successful intubation and connection to the anesthesia machine ensured a continuous oxygen supply throughout the surgery.
Following the induction and administration of medications, particularly ketamine, his blood pressure stabilized. In most cases, propofol and sodium thiopental are the standard anesthetics used [6, 10]. However, ketamine was selected for this patient because the presence of hypovolemic shock increased the risk of cardiac arrest.
In trauma patients, etomidate and ketamine are frequently used anesthetics because of their hemodynamic stability and minimal impact on the cardiovascular system, making them ideal choices for patients with unstable hemodynamics [13]. Conversely, ketamine is particularly suitable for trauma patients experiencing bleeding and significant hypotension because it enhances sympathetic tone and positively influences cardiovascular function [13]. In this case, a dose of 120 mg of ketamine, exactly the same as the induction dose, was administered because of the patient’s unstable hemodynamic condition and significant bleeding. Finally, the patient’s blood pressure stabilized following the induction and administration of medications, particularly ketamine.
Succinylcholine, at a standard dose of 90mg, was selected as the muscle relaxant for this emergency surgery. Its rapid onset of action, typically within 60 seconds [9], is crucial for facilitating immediate intubation and controlling ongoing bleeding.
Rocuronium is a nondepolarizing muscle relaxant used during RSI. The availability of sugammadex, a selective reversal agent for rocuronium, has increased its use in recent years [6]. Although rocuronium has a prolonged duration of action, which is advantageous given the unpredictable timing of surgery, the rapid onset of succinylcholine was preferred in this urgent situation [14].
RSI is a widely used technique in anesthesiology [15]. We illustrated the relationship between the type of anesthesia used and the patient’s health status, demonstrating that this method can be crucial for patients in emergency situations.
Conclusion
Ketamine-based rapid-sequence induction followed by succinylcholine provides effective airway control while helping preserve hemodynamic stability in critically ill patients at high risk of aspiration.
Acknowledgments: The authors acknowledge the collaboration of the anesthesia and trauma teams at Rajaee Trauma Hospital, Shiraz, Iran.
Ethical Permissions: The patient provided informed consent for the publication of this report.
Conflicts of Interests: There are no conflicts of interest.
Authors' Contribution: Roozbakhshian N (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer (40%); Hakiminia B (Second Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (30%); Firouzbakht B (Third Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer (30%)
Funding/Support: The authors received no financial support.
Emergency laparotomy (EL) is an immediate surgical procedure with various indications that is used to address acute abdominal conditions and pathologies requiring immediate intervention [1]. Although hemorrhage and trauma account for a small percentage of EL cases, EL is one of the most dangerous procedures because of the associated hemodynamic instability [2]. Mortality associated with EL is approximately five times higher than that associated with high-risk elective surgeries and may be attributable to various factors, including hypovolemic shock [3]. Therefore, careful selection of anesthetic agents and techniques is crucial for EL. Although standard drugs are often used, the choice of muscle relaxants may vary [4].
Rapid sequence induction (RSI) is a specialized technique designed to minimize the risk of pulmonary aspiration through the use of specific drugs, tools, and maneuvers [5]. It is indicated in situations such as a non-fasted state, active vomiting, ileus, reduced laryngeal reflexes, gastrointestinal obstruction, pregnancy, and trauma [6]. This technique aims to rapidly induce unconsciousness and muscle relaxation, thereby reducing the time interval between drug administration and intubation [5]. It involves loss of consciousness during the application of cricoid pressure (CP), followed by intubation without face-mask ventilation, allowing the trachea to be intubated as quickly as possible [7]. RSI significantly reduces the potential risk of gastric contents refluxing into the esophagus, thereby enhancing patient safety during the procedure [5].
Rocuronium bromide is a widely used nondepolarizing neuromuscular blocker in clinical anesthesia [8]. Its rapid onset and predictable duration of action make it an attractive option for facilitating airway management and providing muscle relaxation during surgical procedures [8]. Rocuronium exerts its effects by competitively antagonizing nicotinic acetylcholine receptors at the neuromuscular junction. Although traditional reversal agents, such as neostigmine and edrophonium, require the concurrent administration of anticholinergic medications to counteract muscarinic side effects, the advent of sugammadex has significantly improved the safety and efficacy of rocuronium reversal [8].
On the other hand, succinylcholine is a depolarizing neuromuscular-blocking drug that is structurally similar to acetylcholine. This drug binds competitively to acetylcholine receptors and causes a prolonged depolarization phase [9]. At the full dosage (1-2mg/kg), it induces fasciculation and paralysis while providing optimal conditions for intubation within a single circulation time of 15 to 45 seconds [10]. This case report presented a practical and in-depth review of the use of RSI in EL at a trauma center in Iran—a situation requiring rapid decision-making, careful selection of anesthetic agents, and effective airway management. This report may serve as a useful model for anesthesiologists, anesthesia technicians, and emergency teams managing critical situations. In addition, documenting this experience provides a valuable foundation for future empirical research on anesthesia management in trauma and emergency care settings.
This study aimed to evaluate the effectiveness and clinical outcomes of RSI in a patient with abdominal trauma undergoing EL at an Iranian trauma center.
Patients and Methods
This case report presented a 50-year-old man with abdominal trauma and internal bleeding caused by an accident was brought to a trauma center in Shiraz, Iran, in December 2024. Upon arrival, he was immediately transferred to the operating room for emergency surgery. The patient’s weight was estimated at approximately 60kg. No underlying medical conditions or regular medications were documented in his medical records. Because the patient presented to the hospital as an emergency case, the exact time of his last oral intake was unknown. Therefore, he was considered to have a full stomach, and RSI was performed accordingly to minimize the risk of pulmonary aspiration.
Findings
His Glasgow Coma Scale (GCS) score was 13, and he underwent anesthesia for laparotomy surgery with an ASA grade of V-E. The patient had severe hypotension (40/20mmHg), tachycardia (120bpm), and hematuria despite having no known underlying medical conditions, possibly indicating hemorrhage and internal bleeding. Upon arrival in the operating room, an ECG monitor, pulse oximeter, capnograph, and both noninvasive and invasive blood pressure monitors were connected to the patient. Invasive blood pressure monitoring was initiated after induction of anesthesia because of the significant bleeding, as the procedure is painful and requires anesthesia.
The medical personnel observed hypotension and compensatory tachycardia, suggesting significant blood loss. His pulse rate, noninvasive blood pressure, and invasive blood pressure were 120bpm, 40/20mmHg, and 38/19mmHg, respectively. In addition, his end-tidal CO₂ (ETCO₂) and arterial oxygen saturation were 40mmHg and 95%, respectively.
After intravenous access and monitoring had been established, RSI was performed. This included preoxygenation with 100% oxygen at 5L/min, application of CP, and induction with 120mg of ketamine. Succinylcholine (90mg) was administered, and after fasciculations developed, endotracheal intubation was performed using a cuffed endotracheal tube (ETT). After intubation, midazolam (2mg) and fentanyl (100μg) were administered for amnesia and analgesia. Subsequently, four units of packed red blood cells were transfused because of the hypotension and tachycardia.
An arterial blood gas (ABG) sample was collected every hour. The patient’s surgery lasted for four hours, and a total of 4 ABGs were obtained. Accordingly, the metabolic disturbances and acidosis observed on the ABG results were minor and managed and treated by the anesthesiologist.
The patient was also administered 1g of tranexamic acid to help prevent further bleeding. To maintain anesthesia and increase blood pressure, propofol and epinephrine were administered using an infusion pump at doses of 100μg/kg/min and 8μg/min, respectively. During the operation, according to the fluid therapy calculations, the patient received 1000ml of normal saline during the first hour and 800ml during each subsequent hour, alternating between normal saline and Ringer’s solution. Following these measures, the patient’s blood pressure returned to normal, and the surgeon successfully controlled the internal bleeding. The unconscious patient was admitted to the intensive care unit with an ETT, a blood pressure of 110/90mmHg, a heart rate of 80 bpm, and an oxygen saturation of 97%.
Discussion
This study evaluated the effectiveness and clinical outcomes of RSI in a patient with abdominal trauma undergoing EL at an Iranian trauma center. It highlights the importance of RSI in critically injured patients with internal bleeding who require immediate surgical intervention. In such situations, EL is a critical intervention that allows for the diagnosis and control of the bleeding source, thereby preventing further hemorrhage [2].
The patient’s condition necessitated the use of an RSI technique, which differs from the standard procedure for elective laparotomies. This technique involves a single preoxygenation phase followed by the immediate administration of anesthetic agents and a short-acting muscle relaxant [11]. This approach eliminates the waiting period between muscle relaxant administration and intubation, allowing for quicker and safer airway management [12]. The patient was continuously monitored during the procedure, and succinylcholine and CP were used as components of the RSI technique. Successful intubation and connection to the anesthesia machine ensured a continuous oxygen supply throughout the surgery.
Following the induction and administration of medications, particularly ketamine, his blood pressure stabilized. In most cases, propofol and sodium thiopental are the standard anesthetics used [6, 10]. However, ketamine was selected for this patient because the presence of hypovolemic shock increased the risk of cardiac arrest.
In trauma patients, etomidate and ketamine are frequently used anesthetics because of their hemodynamic stability and minimal impact on the cardiovascular system, making them ideal choices for patients with unstable hemodynamics [13]. Conversely, ketamine is particularly suitable for trauma patients experiencing bleeding and significant hypotension because it enhances sympathetic tone and positively influences cardiovascular function [13]. In this case, a dose of 120 mg of ketamine, exactly the same as the induction dose, was administered because of the patient’s unstable hemodynamic condition and significant bleeding. Finally, the patient’s blood pressure stabilized following the induction and administration of medications, particularly ketamine.
Succinylcholine, at a standard dose of 90mg, was selected as the muscle relaxant for this emergency surgery. Its rapid onset of action, typically within 60 seconds [9], is crucial for facilitating immediate intubation and controlling ongoing bleeding.
Rocuronium is a nondepolarizing muscle relaxant used during RSI. The availability of sugammadex, a selective reversal agent for rocuronium, has increased its use in recent years [6]. Although rocuronium has a prolonged duration of action, which is advantageous given the unpredictable timing of surgery, the rapid onset of succinylcholine was preferred in this urgent situation [14].
RSI is a widely used technique in anesthesiology [15]. We illustrated the relationship between the type of anesthesia used and the patient’s health status, demonstrating that this method can be crucial for patients in emergency situations.
Conclusion
Ketamine-based rapid-sequence induction followed by succinylcholine provides effective airway control while helping preserve hemodynamic stability in critically ill patients at high risk of aspiration.
Acknowledgments: The authors acknowledge the collaboration of the anesthesia and trauma teams at Rajaee Trauma Hospital, Shiraz, Iran.
Ethical Permissions: The patient provided informed consent for the publication of this report.
Conflicts of Interests: There are no conflicts of interest.
Authors' Contribution: Roozbakhshian N (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer (40%); Hakiminia B (Second Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (30%); Firouzbakht B (Third Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer (30%)
Funding/Support: The authors received no financial support.
Keywords:
Emergency [MeSH], Laparotomy [MeSH], Rapid Sequence Induction [MeSH], Succinylcholine [MeSH], Ketamine [MeSH]
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