RSI: made stupidly simple

The Rapid Sequence Intubation is one of those “gotta have” skills for clinicians who work in frontline medicine. Fair to say there are a lot of sequences out there, but they all follow the same basic plan – prepare, inject the juice, and get the airway secured ASAP.  In recent years there have been a few changes to the long-held anaesthetic dogma, based on good evidence.  So I thought I would take a look at a few, see what is new in RSI.

 Pre-oxygenation strategy:

In case you have been living under a rock and missed the Weingart & Levitan paper on Pre-oxygenation and Avoiding Desaturation in Emergency Airway Management here it is.  The practice of throwing on a Hudson mask at 6 litres/min for 5 minutes is no longer the standard of pre-ox we should be aiming for.   Weingart and Levitan have broken down the evidence and created a 3 tier risk-stratification of sick patients with incredibly practical strategies to optimise the pre-ox and decrease the rate of desaturation that inevitably occurs in the sick patients.

  • NIV as pre-oxygenation device – minimise the shunt, maximise the alveolar recruitment
  • Use of a viva-bag with a cheap PEEP vlave as a poor mans CPAP device
  • USe of high flow (15l/min) nasla cannula oxygen to keep the flow of oxygen throughout the procedure and make your apnoeic time much safer for longer.
  • Check out the tables on the last page of the above paper – it is pretty simple and self-explanatory



The role of cricoid pressure in emergency airway management has come under a lot of scrutiny in recent years.  As is often the case when we look back at the original data – it seemed like a good idea, had some experimental data to support it – but there was no good large-scale evidence that it made a difference to the outcome which we and patients care about!

There was a good review published last month taht asked the hard questions – in Trends in Anaesthesia and Critical Care 2012, Priebe looked at the data in a systematic manner and tried to separate facts from fiction.

In summary: 

  • Cricoid pressure does not have the evidence to make it a mandatory manouvre
  • Clinicians should use individual judgement to guide its use
  • It may be applied, and may help prevent gastric insufflation during BM ventilation
  • If your glottic view is obscured / inadequate – remove it ASAP, then consider BURP instead
  • There is a paucity of good, reliable evidence to support or deny the use of cricoid pressure!


There have been a few recent debates on the use of muscle relaxants.

  1. Should they be used at all in critical care settings?  For me this was a surprise, as I was trained by anaesthesia docs who always used them, but there is a tendency to avoid them in some ICUs.  If you want to hear the low-down on the debate in a very enertaining deabte go to Emcrit and listen to the Paralytics debate. Fair to say it has yet to be decided – but I think for the average GP-intubation it remains the standard to use a muscle relaxant.
  2. Which muscle relaxant?  Roc vs. Sux?   well there have been a few posts and opinions out there – check out my post from last year and links to other resources.
    • In summary – Roc seems to prolong the time to desaturation
    • Give it in a big dose ~ 1.2mg/kg and its onset is comparable to Sux
    • The “back out” plan that Sux ‘allows’ usually is not an option in true critical / emergency RSI
    • You don’y have to worry about the patient fighting the vent anytime soon if you use Roc!

 Last point – The PPPPPPP rule [proper planning and preparation prevents piss poor performance]

Having a well thought-out team-orientated approach to emergency airways is the most important thing to do to make your RSIs go well.  This should be done as part of your departments training / drills and education programme.

Dr Tim (KI Docs) has sent me this nifty little aide-memoir to help get your preparation right and to jog one’s thoughts with asimple checklist included.  I will put it in the Resources section at the bottom of the blog, but click here to have a look at the RSI DUMP kit mat.  Print it out in A# or bigger and put it on your resus room trolley.  Thanks Tim

Let me know if this helps – or if you have other new pearls for the old RSI setup.



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