Rapid Sequence Intubation (RSI)

Quick Answer

Critical: Rapid Sequence Intubation (RSI) is the simultaneous administration of a potent induction agent and neuromuscular blocking agent to facilitate emergency endotracheal intubation. First-pass success is the primary quality metric, achievable in greater than 85% of cases with optimal preparation and technique.

RSI is the gold standard for emergency airway management in the ED, used in greater than 90% of intubations. The 7 Ps framework (Preparation, Preoxygenation, Pretreatment, Paralysis with induction, Protection/positioning, Placement, Post-intubation care) provides a systematic approach. Australian practice emphasises video laryngoscopy as first-line, bougie-first technique, and aggressive preoxygenation including apnoeic oxygenation. Drug choice has evolved toward ketamine/rocuronium due to superior haemodynamic stability [1,2].

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Upper airway anatomy, laryngeal structures, cricothyroid membrane, cervical spine considerations
• Physiology: Oxygen-haemoglobin dissociation, functional residual capacity, safe apnoea time, cardiovascular reflexes
• Pharmacology: Mechanism of action for induction agents (ketamine, propofol, thiopentone) and NMBAs (rocuronium, suxamethonium), drug interactions

Fellowship Exam Relevance

• Written: Drug dosing, contraindications, complication management, checklist approach
• OSCE: RSI demonstration (may be procedural or leadership station), managing the failed airway
• Key domains tested: Medical Expert (technical skill), Leader (team coordination), Communicator (closed-loop communication)

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Key Points

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Epidemiology

Australian/NZ Specific

• Australian Emergency Department Airway Registry (NEAR-Australia/ANZEDAR) provides local benchmarks [5]
• Higher rates of video laryngoscopy adoption compared to North America
• Bougie-first culture distinguishes Australian practice from stylet-predominant approaches
• Indigenous populations may have higher rates of cervical spine pathology requiring modified technique

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Pathophysiology

Physiological Rationale for RSI

Why Rapid?

• Minimises aspiration risk by reducing time without airway protection
• Rapid onset paralysis prevents patient movement and improves conditions
• Synchronised drug administration optimises apnoeic window

Safe Apnoea Time The time from cessation of breathing to critical desaturation (SpO2 below 90%) depends on:

• Oxygen reserves (primarily FRC)
• Oxygen consumption (VO2)
• Denitrogenation effectiveness

Cardiovascular Consequences

• Induction agents cause vasodilatation and myocardial depression
• Positive pressure ventilation reduces preload
• Catecholamine-depleted patients at highest risk
• "Push-dose pressors" or dose reduction strategies may be required

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The 7 Ps of RSI

Overview

┌─────────────────────────────────────────────────────────────────┐
│                     THE 7 Ps OF RSI                             │
├─────────────────────────────────────────────────────────────────┤
│  1. PREPARATION         →  Equipment, drugs, team, plan        │
│  2. PREOXYGENATION      →  ≥3 min 100% O2, apnoeic oxygenation │
│  3. PRETREATMENT        →  Specific adjuncts (rarely needed)   │
│  4. PARALYSIS + INDUCTION → Simultaneous agent administration  │
│  5. PROTECTION/POSITIONING → Optimal head/neck, cricoid        │
│  6. PLACEMENT           →  Laryngoscopy + tube placement       │
│  7. POST-INTUBATION     →  Confirm, secure, sedation, vent     │
└─────────────────────────────────────────────────────────────────┘

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Phase 1: Preparation

RSI Checklist

Important Note: Every RSI requires a structured checklist approach to reduce cognitive load and prevent errors [10]

Equipment Checklist (MSOAPP)

Airway Equipment

Rescue Equipment

Team Preparation

Minimum team for ED RSI:

Patient Assessment

Difficult Airway Prediction

LEMON Assessment:

Physiological Optimisation

Before RSI, optimise:

• Oxygenation: Preoxygenate aggressively
• Blood pressure: MAP greater than 65 mmHg (fluid, pressors if needed)
• Heart rate: Treat extreme bradycardia/tachycardia
• Metabolic: Correct severe acidosis if possible

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Phase 2: Preoxygenation

Goals

1. Denitrogenation of functional residual capacity (FRC)
2. Maximise oxygen reserves
3. Extend safe apnoea time
4. Prevent desaturation during apnoeic period

Standard Preoxygenation

Advanced Preoxygenation

High-Flow Nasal Oxygen (HFNO) [11]:

• Provides continuous oxygen during apnoea
• 60 L/min via nasal cannula
• Can achieve apnoeic oxygenation for extended periods
• Continue during laryngoscopy attempt

Apnoeic Oxygenation [12]:

• Low-flow nasal cannula (15 L/min) left in place during attempt
• Simple and effective adjunct
• Extends safe apnoea time by 2-3 minutes

NIV-Assisted Preoxygenation [13]:

• For patients with SpO2 below 93% despite standard preoxygenation
• CPAP 5-10 cmH2O or BiPAP
• Monitor for gastric insufflation

Special Populations

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Phase 3: Pretreatment

Overview

Pretreatment agents are adjuncts given 3-5 minutes before induction to mitigate specific physiological responses. Modern practice has largely moved away from routine pretreatment [14].

Specific Indications (Limited)

Agents NOT Routinely Recommended

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Phase 4: Paralysis with Induction

Drug Selection Principles

1. Induction agent: Provides unconsciousness/amnesia
2. Neuromuscular blocking agent: Provides paralysis for optimal conditions
3. Both given simultaneously (or induction immediately followed by NMBA)

Induction Agents

Ketamine

The preferred agent for most ED RSI [15,16]

Advantages:

• Haemodynamic stability (preserves sympathetic tone)
• Bronchodilation (excellent for asthma/COPD)
• Analgesic properties
• Preserves airway reflexes longer than others
• Neuroprotective properties

Disadvantages:

• May increase BP/HR (caution in uncontrolled hypertension)
• Emergence phenomena (rare with RSI doses)
• Hypersalivation (clinically insignificant)

Catecholamine-Depleted Patients:

• Reduce dose to 0.5-1 mg/kg
• Prepare push-dose pressors
• Ketamine may still cause hypotension in severely shocked patients

Propofol

Advantages:

• Rapid onset, smooth induction
• Antiemetic properties
• Reduces ICP
• Familiar to anaesthetists

Disadvantages:

• Significant hypotension (avoid in shock)
• Myocardial depression
• Pain on injection
• No analgesic properties

Thiopentone (Thiopental)

Advantages:

• Rapid onset
• Reduces ICP and cerebral metabolic rate
• Historical gold standard for RSI

Disadvantages:

• Significant cardiovascular depression
• Histamine release, bronchospasm risk
• Painful if extravasated
• Limited availability in some centres

Neuromuscular Blocking Agents

Rocuronium

The NMBA of choice for ED RSI [17,18]

Advantages:

• Optimal intubating conditions equivalent to suxamethonium at 1.2 mg/kg [19]
• Reversible with sugammadex (immediately reversible)
• No contraindications except allergy
• Safe in burns, hyperkalaemia, neuromuscular disease

Disadvantages:

• Longer duration (problematic if cannot intubate and sugammadex unavailable)
• Cost of sugammadex

Sugammadex for Reversal:

• Dose: 16 mg/kg for immediate reversal (within 3 min of rocuronium)
• Reverses profound block within 2-3 minutes
• Should be available for all ED RSI with rocuronium

Suxamethonium (Succinylcholine)

Advantages:

• Fastest onset of any NMBA
• Short duration (spontaneous recovery)
• Familiar, widely available

Contraindications:

Relative contraindications:

• Raised ICP (can increase ICP transiently)
• Open globe injury (can increase IOP)
• Neuromuscular disease

Drug Dosing Summary Table

Paediatric Dosing

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Phase 5: Protection and Positioning

Optimal Positioning

Sniffing Position / Ramped Position [20]:

• Align external auditory meatus with sternal notch
• Ear-to-sternal-notch alignment ("the sniff")
• Achieves optimal axes alignment for laryngoscopy

Ramping for Obesity:

• Towels/blankets under shoulders and head
• Commercial ramps available
• "Head-elevated laryngoscopy position" (HELP)
• Critical for obese patients to achieve adequate view

External Laryngeal Manipulation (ELM)

BURP Manoeuvre [21]:

• Backward pressure on larynx
• Upward pressure
• Rightward pressure
• Pressure applied by assistant

Optimal ELM:

• Laryngoscopist directs assistant's hand
• "Bimanual laryngoscopy"
• operator controls ELM with right hand
• Transfer control to assistant once view optimised

Cricoid Pressure

Important Note: Cricoid Pressure (Sellick Manoeuvre):

• Historical practice to prevent aspiration
• Evidence of benefit is weak [22]
• May worsen laryngoscopic view
• May impede ventilation if applied too firmly
• Current recommendation: Not routinely required; release if impeding view

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Phase 6: Placement

First-Pass Success Strategies

Australian Emergency Airway Registry benchmarks [5,7]:

• First-pass success: 82-85%
• Target: greater than 90% with optimised technique

Video Laryngoscopy First [23]

Advantages of VL:

• Superior glottic view
• Training advantage (shared view)
• Better first-pass success, especially for trainees
• Reduced cervical spine movement

Bougie-First Approach [24]

Evidence:

• Higher first-pass success than stylet [7]
• Particularly beneficial for Cormack-Lehane 2-3 views
• Lower oesophageal intubation rate
• Bougie as default improves outcomes

Laryngoscopy Technique

Video Laryngoscopy Steps:

1. Insert blade in midline
2. Advance to vallecula (standard geometry) or lift epiglottis (hyperangulated)
3. Optimise view with ELM/BURP
4. Identify arytenoids, vocal cords
5. Pass bougie/tube through cords under direct vision
6. Watch cuff pass through cords
7. Remove stylet/bougie, inflate cuff

Troubleshooting Poor View:

ETT Sizing and Depth

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Phase 7: Post-Intubation Care

Confirmation of Placement

Primary Confirmation:

Secondary Confirmation:

Secure the Tube

• Tape or commercial tube holder
• Note depth at lip/teeth
• Document position

Post-Intubation Hypotension

Incidence: 20-40% of critically ill patients [9,26]

Risk Factors:

• Pre-existing shock/hypotension
• Propofol use
• High airway pressures
• Catecholamine depletion
• Tension pneumothorax

Management:

1. Fluid bolus 250-500mL crystalloid (if fluid-responsive)
2. Push-dose pressors:
   • Phenylephrine 100-200 mcg IV
   • Adrenaline 10-20 mcg IV
   • Metaraminol 0.5-1 mg IV (Australian)
3. Vasopressor infusion if persistent:
   • Noradrenaline 0.05-0.3 mcg/kg/min
4. Exclude tension pneumothorax

Post-Intubation Sedation and Analgesia

Important Note: Paralysis is NOT anaesthesia - patients require ongoing sedation immediately post-RSI

Immediate Post-Intubation:

RASS Target: -2 to -3 (light to moderate sedation)

Avoid:

• Deep sedation unless indicated
• Propofol in shocked patients
• Unparalysed awareness

Ventilator Settings

Initial Settings:

Targets:

• SpO2 94-98%
• EtCO2 35-45 mmHg
• Avoid hyperventilation

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Complications

Immediate Complications

Delayed Complications

Multiple Attempts Risk

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Special Populations

Paediatric RSI [28,29]

Key Differences:

Drug Modifications:

• Ketamine: 2 mg/kg (may cause more secretions)
• Propofol: 2.5-3 mg/kg (higher requirement)
• Rocuronium: 1.2 mg/kg (same as adult)
• Suxamethonium: 2 mg/kg + atropine 20 mcg/kg

Equipment:

• Uncuffed tubes acceptable in neonates/infants if cuffed unavailable
• Miller blade (straight) often preferred for infants
• Paediatric bougie (smaller gauge)

Pregnancy

Physiological Changes:

• Reduced FRC (decreased O2 reserve)
• Increased oxygen consumption
• Full stomach (aspiration risk)
• Oedematous airway
• Rapid desaturation

Modifications:

• Aggressive preoxygenation (may not achieve 100%)
• Ramped position with left lateral tilt
• Smaller ETT (6.0-7.0)
• Prepare for rapid desaturation
• MILS if recent anaesthesia
• Prepared for surgical airway

Obese Patients [30]

Challenges:

• Reduced FRC, rapid desaturation
• Difficult positioning
• Difficult bag-mask ventilation
• Potentially difficult laryngoscopy
• Post-intubation atelectasis

Modifications:

• Ramped/HELP position (essential)
• Aggressive preoxygenation with PEEP
• Consider HFNO
• Higher PEEP post-intubation
• Weight-based dosing on ideal body weight (propofol) or total body weight (NMBAs)

Traumatic Brain Injury

Goals:

• Prevent secondary brain injury
• Avoid hypoxia, hypotension, hypercapnia
• MAP greater than 80 mmHg, CPP greater than 60 mmHg

Modifications:

• Avoid hypotension (prepared pressors)
• Target normocapnia (EtCO2 35-40)
• Consider fentanyl pretreatment (attenuate hypertensive response)
• Ketamine is safe and neuroprotective [31]
• MILS for suspected C-spine injury

C-Spine Injury

Modifications:

• Manual inline stabilisation (MILS)
• Video laryngoscopy preferred
• Avoid excessive neck extension
• Consider fibreoptic if stable
• Document neurological status pre/post

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Indigenous Health Considerations

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

• Higher rates of chronic disease affecting airway (rheumatoid arthritis, diabetes with limited joint mobility)
• May have higher rates of cervical spine pathology
• Cultural considerations for end-of-life decisions if complications occur
• Family involvement in consent discussions where possible
• Aboriginal Health Worker or liaison officer for communication support
• Remote communities may have delayed access to retrieval services

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Failed Airway Algorithm

Definition

Failed intubation: Unable to intubate after optimal attempts (usually 3 attempts maximum) Can't intubate, can't oxygenate (CICO): Unable to intubate AND unable to maintain SpO2 with BMV/SGA

Rescue Strategy

┌─────────────────────────────────────────────────────────────────┐
│               FAILED INTUBATION ALGORITHM                       │
├─────────────────────────────────────────────────────────────────┤
│  OPTIMAL FIRST ATTEMPT FAILED                                   │
│           ↓                                                     │
│  SECOND ATTEMPT (modified: different blade, position, operator) │
│           ↓                                                     │
│  IF FAILS → THIRD ATTEMPT (final intubation attempt)            │
│           ↓                                                     │
│  DECLARE FAILED INTUBATION                                      │
│           ↓                                                     │
│  CAN OXYGENATE?                                                 │
│     ├── YES → SUPRAGLOTTIC AIRWAY (i-gel, LMA)                  │
│     │         Wake patient or proceed with SGA                  │
│     │                                                           │
│     └── NO → CICO - FRONT OF NECK ACCESS                        │
│              SCALPEL CRICOTHYROIDOTOMY                          │
└─────────────────────────────────────────────────────────────────┘

Supraglottic Airways

Front-of-Neck Access (FONA)

Scalpel-Bougie-Tube Technique [32]:

1. Palpate cricothyroid membrane
2. Horizontal stab incision through membrane
3. Turn scalpel 90° (blade edge caudally)
4. Insert bougie through incision
5. Railroad 6.0 cuffed ETT
6. Inflate cuff, confirm with capnography

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: RSI Procedure Demonstration

Format: Procedural skills with manikin Time: 11 minutes Setting: ED resuscitation bay with manikin

Candidate Instructions:

You are the Emergency Registrar. A 55-year-old male with severe community-acquired pneumonia requires intubation for respiratory failure. His SpO2 is 88% on 15L oxygen, BP 100/60, HR 110. Demonstrate your approach to RSI. Equipment and a team are available. The manikin simulates the patient.

Examiner Instructions:

• First attempt: Cormack-Lehane Grade 2 view
• Candidate should use bougie
• If good technique, intubation succeeds first attempt
• Post-intubation: Provide EtCO2 waveform, BP drops to 80/50

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Systematic approach, capnography confirmation, manages hypotension

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Station 2: RSI Communication and Leadership

Format: Team leadership with simulated staff Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the Emergency Registrar and team leader. An 80-year-old male with acute pulmonary oedema is deteriorating despite NIV. He now requires intubation. You have an intern and two nurses available. Lead your team through RSI preparation and execution.

Actor/Team Brief:

• Intern has never done RSI, asks questions
• Nurses prepared to assist, await instructions
• Patient manikin will be "intubated" by examiner

Marking Criteria:

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Station 3: Failed Airway Management

Format: Simulated resuscitation Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the Emergency Registrar. You have attempted intubation twice on a 40-year-old male trauma patient. You are unable to visualise the cords. SpO2 is 82% and falling. Continue management of this patient.

Examiner Instructions:

• Third intubation attempt fails
• BVM ventilation possible (SpO2 improves to 90%)
• If SGA placed, ventilation adequate
• If FONA performed, provide positive capnography

Marking Criteria:

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SAQ Practice

Question 1 (6 marks)

Stem: You are preparing for RSI of a 30-year-old male with severe asthma who has failed NIV and is becoming exhausted. He weighs 80kg.

Question: List 6 key equipment items that must be immediately available before proceeding with RSI.

Model Answer:

• Video laryngoscope (primary airway device) (1)
• Bougie (gum elastic bougie, 60cm) (1)
• Endotracheal tube (size 8.0 cuffed, checked) (1)
• Suction (Yankauer catheter, large bore, functioning) (1)
• Supraglottic airway (i-gel or LMA as rescue) (1)
• Surgical airway equipment (scalpel, bougie for cricothyroidotomy) (1)

Examiner Notes:

• Accept: BVM with PEEP, waveform capnography, tube holder
• Do not accept: Generic "airway trolley"

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Question 2 (8 marks)

Stem: A 60-year-old female (70kg) with severe sepsis and hypotension (BP 85/50) requires RSI for airway protection.

Question: (a) Name the most appropriate induction agent for this patient and explain why (2 marks) (b) State the appropriate dose of this agent for this patient (1 mark) (c) Name the neuromuscular blocking agent of choice and state the dose (2 marks) (d) List 3 strategies to prevent or manage post-intubation hypotension (3 marks)

Model Answer:

(a) Induction agent (2 marks):

• Ketamine (1)
• Reason: Maintains haemodynamic stability by preserving sympathetic tone/catecholamine release; safer than propofol or thiopentone in shocked patients (1)

(b) Dose (1 mark):

• 0.5-1 mg/kg (35-70mg) - reduced due to haemodynamic instability (1)

(c) NMBA (2 marks):

• Rocuronium (1)
• 1.2 mg/kg = 84mg (accept 80-90mg) (1)

(d) Strategies to prevent/manage hypotension (3 marks):

• Pre-RSI vasopressor (noradrenaline infusion before induction) (1)
• Push-dose pressors available (phenylephrine, adrenaline, or metaraminol) (1)
• Reduced dose of induction agent (1)
• Fluid bolus if fluid-responsive (1)
• Avoid propofol (1)

Examiner Notes:

• Accept any 3 valid strategies for part (d)
• Do not accept: "Give more fluids" without specifying fluid-responsive assessment

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Question 3 (8 marks)

Stem: A 25-year-old male is brought to ED following a high-speed motor vehicle collision. He has a GCS of 6 (E1V2M3), suspected cervical spine injury, and requires intubation.

Question: (a) List 4 modifications to standard RSI technique required for this patient (4 marks) (b) Describe how you would confirm correct ETT placement (2 marks) (c) What is your target blood pressure and PaCO2 post-intubation for suspected traumatic brain injury? (2 marks)

Model Answer:

(a) Modifications (4 marks):

• Manual inline stabilisation (MILS) during laryngoscopy (1)
• Video laryngoscopy as first-line (reduces cervical spine movement) (1)
• Avoid extension of neck (remove front of collar, assistant provides MILS) (1)
• Prepare for difficult airway (anticipated higher failure rate) (1)
• Accept: Have surgical airway immediately available, senior operator

(b) Confirmation (2 marks):

• Waveform capnography (continuous EtCO2 trace) - gold standard (1)
• Secondary: Bilateral auscultation, SpO2 maintenance, chest rise, chest X-ray for depth (1)

(c) Targets (2 marks):

• Blood pressure: MAP greater than 80 mmHg (or SBP greater than 100 mmHg) (1)
• PaCO2: 35-40 mmHg (normocapnia) or EtCO2 35-40 mmHg (1)

Examiner Notes:

• Accept reasonable BP targets (MAP 80-90, SBP 100-120)
• Do not accept: Hyperventilation/hypocapnia (harmful in TBI)

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Remote/Rural Considerations

Pre-Hospital

Ambulance/Retrieval Considerations:

• Paramedic RSI capability varies by jurisdiction
• Intensive care paramedics may perform RSI
• Some states restrict to doctor-led retrieval teams
• Pre-notify receiving hospital of anticipated intubation

Resource-Limited Settings

Modifications for Remote EDs:

• May lack video laryngoscopy - direct laryngoscopy skills essential
• Limited drug availability - may use ketamine/suxamethonium
• Sugammadex may not be available - implications for rocuronium use
• Surgical airway capability essential (may not have ENT backup)
• Telemedicine support for decision-making

Retrieval

Criteria for Retrieval Service Involvement:

• Any intubated patient requiring higher-level care
• Failed intubation requiring airway expertise
• Anticipated difficult airway
• Paediatric intubation in rural setting

RFDS/Retrieval Considerations:

• Secure airway before transport
• Confirm ETT position with capnography
• Adequate sedation for transport
• Backup airway equipment
• Pre-departure checklist

Telemedicine

Remote Support:

• Video consultation for difficult airway decisions
• Guidance on drug selection
• Support for surgical airway decision
• Post-intubation ventilator guidance

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Australian Guidelines

ARC/ANZCOR Guidelines

Relevant Guidelines:

• ANZCOR Guideline 4: Airway Management
• ANZCOR Guideline 11: Adult Advanced Life Support

Key Points:

• Waveform capnography mandatory for confirmation
• Video laryngoscopy recommended as first-line
• Checklist approach recommended

Therapeutic Guidelines Australia

Relevant Sections:

• Antibiotic Guidelines: VAP prophylaxis
• Analgesic Guidelines: Post-intubation sedation

State-Specific Protocols

Variations:

• Some states have mandatory RSI checklists
• Drug availability may vary (PBS restrictions)
• Retrieval thresholds differ by geography
• Paramedic RSI scope varies by state

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 4: Airway. 2023.
2. Australian Resuscitation Council. ANZCOR Guideline 11: Adult Advanced Life Support. 2023.

First-Pass Success and Registry Data

3. Sakles JC, et al. The utility of the first attempt success in the emergency department. Acad Emerg Med. 2013;20(1):71-78. PMID: 23574475
4. Brown CA 3rd, et al. Rapid sequence intubation for adults outside the operating room. UpToDate. 2024.
5. Simpson GD, et al. The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR): first report. Emerg Med Australas. 2019;31(2):208-214. PMID: 31102370
6. Olvera DJ, et al. Video vs Direct Laryngoscopy for Endotracheal Intubation in the Emergency Department: A Systematic Review. Acad Emerg Med. 2022;29(10):1220-1231. PMID: 35289456
7. Sakles JC, et al. Effect of bougie use on first attempt success rate in emergency intubation. Ann Emerg Med. 2013;62(5):441-447. PMID: 29017770

Complications

8. Diggs LA, et al. Incidence, outcomes, and risk factors for adverse events during adult emergency department intubation. Ann Emerg Med. 2020;75(6):733-745. PMID: 32679633
9. Heffner AC, et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84(11):1500-1504. PMID: 23851048

Preoxygenation

10. Chrimes N, et al. Vortex: A simplified airway management approach. Br J Anaesth. 2016;117 Suppl 1:i20-i27. PMID: 27440952
11. Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70(3):323-329. PMID: 25388828
12. Ramachandran SK, et al. Apneic oxygenation during prolonged laryngoscopy in obese patients. Anesthesiology. 2010;113(4):873-879. PMID: 20808209
13. Baillard C, et al. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;174(2):171-177. PMID: 16627862

Pretreatment

14. April MD, et al. Evidence-Based Guidelines for Prehospital Emergency Airway Management. Prehosp Emerg Care. 2022;26(sup1):54-63. PMID: 34962858

Drug Selection

15. Brown CA 3rd, et al. First-pass success with ketamine vs etomidate as the induction agent in rapid sequence intubation: A NEAR database study. Ann Emerg Med. 2020;76(3):253-262. PMID: 32305315
16. April MD, et al. Ketamine versus etomidate and peri-intubation hypotension: A national emergency airway registry study. Acad Emerg Med. 2020;27(11):1106-1115. PMID: 33612300
17. Tran DTT, et al. Rocuronium versus succinylcholine for rapid sequence intubation. Cochrane Database Syst Rev. 2017;4(4):CD002788. PMID: 28452035
18. April MD, et al. High-dose rocuronium for rapid sequence intubation in the emergency department. Ann Emerg Med. 2018;71(3):387-393. PMID: 28811122
19. Marsch SC, et al. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial. Crit Care. 2011;15(4):R199. PMID: 21849086

Positioning and Technique

20. Ramkumar V, et al. Effect of preoxygenation with 20° head-up tilt on safe duration of apnoea in obese patients. Eur J Anaesthesiol. 2017;34(4):240-246. PMID: 28257355
21. Knill RL. Difficult laryngoscopy made easy with a "BURP". Can J Anaesth. 1993;40(3):279-282. PMID: 8467551
22. Birenbaum A, et al. Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of anesthesia. JAMA Surg. 2019;154(1):9-17. PMID: 30347106

Video Laryngoscopy

23. Lewis SR, et al. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev. 2016;11(11):CD011136. PMID: 27844477
24. Driver BE, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179-2189. PMID: 29800096

Confirmation

25. Silvestri S, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med. 2005;45(5):497-503. PMID: 15855946

Post-Intubation

26. Green RS, et al. Postintubation hypotension in emergency department patients. CJEM. 2018;20(2):201-210. PMID: 28911353
27. Hasegawa K, et al. Association between repeated intubation attempts and adverse events in emergency departments. Ann Emerg Med. 2020;75(3):320-329. PMID: 31492564

Paediatric

28. Sagarin MJ, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care. 2002;18(6):417-423. PMID: 12488834
29. Nagler J, et al. Pediatric emergency airway management. Emerg Med Clin North Am. 2019;37(3):361-375. PMID: 31262409

Special Populations

30. Mosier JM, et al. Hemodynamic complications following airway management in critically ill patients. Ann Intensive Care. 2020;10(1):73. PMID: 32495234
31. Zeiler FA, et al. The ketamine effect on intracranial pressure in nontraumatic neurological illness: a systematic review. Crit Care. 2019;23(1):219. PMID: 31200758
32. Frerk C, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848. PMID: 26556848

Additional Evidence

33. De Jong A, et al. Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: a multicenter cohort study. Crit Care Med. 2018;46(4):532-539. PMID: 29261566
34. Higgs A, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323-352. PMID: 29406182
35. Jaber S, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36(2):248-255. PMID: 19921148
36. Weingart SD, et al. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175. PMID: 22050948
37. Myatra SN, et al. The Intubation Difficulty Scale in critically ill patients. Crit Care. 2023;27(1):456. PMID: 38350171
38. Casey JD, et al. Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med. 2019;380(9):811-821. PMID: 30779528

Sugammadex and Reversal

39. Brueckmann B, et al. Reversal of neuromuscular blockade with sugammadex: a systematic review. Br J Anaesth. 2015;115 Suppl 2:ii41-ii48. PMID: 26658199
40. Lee C, et al. Reversal of profound neuromuscular blockade by sugammadex: a randomized trial. Anesthesiology. 2009;110(5):1020-1025. PMID: 19387176

Delayed Sequence Intubation

41. Weingart SD, et al. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015;65(4):349-355. PMID: 25447557

Airway Assessment

42. Shiga T, et al. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103(2):429-437. PMID: 16052126

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Appendix: RSI Checklist Template

Pre-RSI Briefing Checklist

Patient Assessment:

• Indication for intubation confirmed
• Allergies reviewed
• Difficult airway assessment completed (LEMON)
• Fasting status noted (aspiration risk)
• Current haemodynamic status assessed
• Baseline neurological status documented

Equipment (MSOAPP):

• Monitors: SpO2, ECG, EtCO2, NIBP connected
• Suction: Yankauer + large-bore, tested
• Oxygen: BVM with PEEP, apnoeic cannula, HFNO if available
• Airway: VL primary, DL backup, ETT (checked cuff), bougie, stylet
• Positioning: Bed height correct, ramped position
• Pharmaceuticals: Induction + NMBA drawn, labelled, doses confirmed

Rescue Equipment:

• Supraglottic airway (size selected)
• Surgical airway kit available
• Sugammadex available (if using rocuronium)

Team Preparation:

• Roles assigned: Airway, Assistant, Drugs, Monitor
• Backup airway plan verbalised
• Failed airway protocol understood
• Senior support identified

Drugs Confirmation:

• Induction agent: _______ mg (_____ mg/kg)
• NMBA: _______ mg (_____ mg/kg)
• Push-dose pressor ready: _______
• Post-intubation sedation ready: _______

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Appendix: Drug Quick Reference Cards

Ketamine Quick Reference

Clinical Notes:

• Preserves airway reflexes longer than other agents
• Bronchodilator effect beneficial in asthma
• Safe in raised ICP (neuroprotective)
• May cause transient BP increase (caution in uncontrolled HTN)

Rocuronium Quick Reference

Clinical Notes:

• No contraindications except allergy
• Safe in burns, hyperkalaemia, neuromuscular disease
• Reversible with sugammadex
• Always have sugammadex available when using rocuronium

Suxamethonium Quick Reference

Contraindications (memorise these):

• Hyperkalaemia or risk of hyperkalaemia
• Burns greater than 24 hours
• Crush injury, denervation, prolonged immobilisation
• Personal/family history of malignant hyperthermia
• Myopathy or muscular dystrophy
• History of prolonged paralysis

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Appendix: Paediatric Weight-Based Dosing Chart

Notes:

• ETT size formula (cuffed): (Age/4) + 4
• ETT depth formula: (Age/2) + 12 cm
• Always have one size smaller ETT available
• Cuffed tubes preferred in all ages

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Appendix: Post-Intubation Ventilator Settings

Initial Settings by Patient Type

Targets

Troubleshooting High Pressures

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