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.



  1. Minh Le Cong says

    great topic to discuss Casey!
    interesting title..RSI made stupidly simple…
    just to be a bit controversial along the same vein..check out my lecture on this at


  2. Thought your readers might like to know about the resources available from Airway Management Education Center for help with RSI. We offer The Difficult Airway Course: Emergency (22 hour CME), The Difficult Airway App (for iPhone), The Airway card (a pocket guide) and a free on-line knowledge center called Airway World ( with live events and tons of educational resources. These are great resources for MDs who don’t do a lot of airways but have to be prepared for the nightmare scenario at all times! More info at Thanks!

  3. Minh Le Cong says

    let me try to provide some literature to support my argument that RSI is not all what its made up to be.Read this article thoroughly.

    Dr Paul Mayo’s work and concept of sedative only intubation should not be ridiculed by RSI devotees. Check out his latest lecture on this at

    Yes he actually came to Australia to teach on critical care USS but also gave a lecture on his airway concepts. The slides are gold.

  4. Minh Le Cong says

    another article highlighting the changing dogma of RSI

    how is a rural doc supposed to keep up with all this?

  5. How to keep up? Well – blogs like Broome Docs, Scancrit, Em-crit and are gold

    There’s also potential in developing a rural doctor ‘masterclass’ course to demonstrate and share these ideas with hands-on sessions

    I teach on EMST but let’s face it, it’s an entry-level course. Ditto RESP/REST/ELS and the rest

    We need a Le Cong-Parker-Reid masterclass to be developed and rolled out locally to each of the States by enthusiasts

    Better stop now before those Vikings on scancrit accuse another ‘bromance’

  6. Great writeup! I won’t get into the RSI good vs bad debate (although as an emcritter I am a big advocate of RSI in the ED; not sure how that extends to rural docs)

    However, you suggest a trial of BURP – I am a much bigger fan of external laryngeal manipulation (ELM) above BURP

    Put simply:
    Sellick: pressure on cricoid
    BURP: assistant puts backwards-upward-rightward pressure on larynx
    ELM: laryngoscopist moves around the larynx with their right hand in any direction

    As you mention, the goal of Sellick is to gastric insufflation and passive regurgitation, while BURP and ELM are laryngoscopy aides

    I think of a BURP as a “good guess” at the optimal movement (I would guess about 60% accurate)

    The technique I learned from Reuben Strayer is to have the assistant put their hand on the thyroid cartilage; the laryngoscopist then moves the neck AND the assistant’s hand in any/every direction until the view is optimized; the laryngoscopist can then remove their hand, leaving the assistant holding the thyroid in the correct place

    Reuben discusses this (briefly) in his excellent airway lecture just before the 27 min mark at

    One note on nomenclature:
    Some people have called this “bimanual laryngoscopy”; others use that term to describe the laryngoscopist moving the patient’s head during laryngoscopy

    I don’t know if I’m right or not, but I think of BOTH of those maneuvers (ELM + head mobilization) as bimanual laryngoscopy, as they are both activities that the laryngoscopist does with their right hand — conceptually, for me that makes me think of both of those very helpful maneuvers together instead of as separate entities.

    it’s also a gentle reminder that to use 2 hands on the thyroid cartilage (and oftentimes large-headed patients might need an extra hand under the head as well!)

Speak Your Mind