RSI: Safe RSI in the ED

Performing Rapid Sequence Intubation safely in the ED.

Key points:

RSI in the ED is a dangerous undertaking. Focus on these 4 areas to improve safety:

  1. Patient
  2. Team
  3. Plans
  4. Equipment


Show Notes:

ED vs Anaesthesia

Higher complication rate in ED, with higher case fatality rate when complications develop.

Incidence of death or brain damage from an airway event 38x higher in ED, and 58x higher in ICU, compared with anaesthesia.

Anaesthesia 1:150,000, ED 1:4000, ICU 1:2600

More can be found here (EMCrit) and here (NAP4)



Read Tim Leeuwenburg evidence-based talk here

Other checklist links available here


Risk Assessment

We don’t have evidence that doing a risk assessment in beneficial, but we have evidence that not doing it is harmful (NAP4)



Levitan’s ear-to-sternal notch positioning

Find out about ramping here and here (EMUpdates)

See also the PreOx, ReOx paper by Weingart & Levitan



Preoxygenation, Reoxygenation and Deoxygenation – EMCrit

Covers Pre-oxygenation with CPAP in the hypoxic patient – watch the 2 videos

Preoxygenation and Prevention of Desaturation During Emergency Airway Management article by Scott Weingart and Rich Levitan – a must read

RebelEM – a nice summary and explanation of the above paper – LITFL’s overview

The problem with the BVM for pre-oxygenation – Nick Crimes


Apnoeic oxygenation

NO DESAT! – Rich Levitan

PulmCrit – an in-depth discussion by Josh Farkas, including the THRIVE study – LITFL’s overview

Apnoeic oxygen relies on an open airway, so we have to maintain a jaw thrust.

NCs buy you more time, in normal, obese and hypoxic patients.

High-flow NC would be even better, but are complicated because getting a BVM seal over them is not possible


Failed Airway Plans

Failing to plan for failure increases risk (NAP4)

Vortex available here and other difficult airway plans available here (LITFL)


Post-Intubation Checklist

Find out more about the post-intubation package from EMCrit and download the checklist here


Lung-protective Ventilation

Protective lung ventilation is the current standard of care for mechanical ventilation, and includes low tidal volumes (4-8 mL/kg predicted/ideal body weight, not actual body weight) as well as low pressures. It reduces mortality both in patients with ARDS and those without. Find out more on LITFL.



Leave a Reply