PHARM Podcast 61 : Rapid Sequence Intubation

Rapid Sequence Intubation beim KindMartin Jöhr, Luzern, CH - KATZ'08
Rapid Sequence Intubation beim Kind
Martin Jöhr, Luzern, CH – KATZ’08

Hi folks!

I interview Canadian ED Physician Yen Chow on RSI! Here is Yen below!

Yen Chow Photo on 13-02-18 at 11.13 PM #2

These are some notes Yen sent me after the interview. Thanks YEN!


This is my short crash-intubation-equipment checklist “BLTS” that I pronounce “blitz” for best attempt first pass crash intubation success
Here is the checklist that I keep in my head, adopted from CAEP AIME
Suction (also makes me think about FB assists like McGills Meconcium aspirator for bloody airways)
Oxygenate (Sat>95%, deN2ate, ApOx, Position head up)
Prepare Preoxygenate Preload (fluids) Pretreatment Paralysis Position Pass tube Proof Post intubation management
Cardiac CO2 monitoring
Best attempt 1st pass success, BVM/OPA/NPAs Bougie Blades
Alternate intubation method (nasal, VL, AirTraq, straight blade etc)
Rescue oxygenation/ventilation #1 BVM/OPA/NPA  #2 SGA
Surgical (scalpel bougie 6.0 ETT)

The rest …Its all on the podcast below. Tune in!

Show note references:

  1. The Original RSI article by Stept & Safar 1970
  2. Rapid Sequence Induction and Intubation:
    Current Controversy Review article 2010
  3. AIME Course – Airway Interventions and Management in Emergencies
  5. EmCrit ED intubation checklist
  6. Dr Toby Fogg’s Airway Registry RSI checklist
  7. Rapid Sequence Induction 2005 review
  8. Dr Bill Hinckley’s DASH1A concept for RSI

But before the podcast, I love this talk by Dr Karel Habig on RSI in Retrieval medicine. Checkit!

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

16 thoughts on “PHARM Podcast 61 : Rapid Sequence Intubation

  1. Thanks Minh, as a footnote about the checklist above: best attempt first pass success intubation includes everything I think about like position of intubator (bed height) and position of patient ear-to-sternal notch, face-plane-parallel-to-ceiling positioning, jaw thrust, remove c-collar anteriorly with in line immobilization if applicable, head elevation, ELM/bimanual laryngoscopy, suction epiglottoscopy/laryngeal exposure (progressive landmark exposure), appropriate blade, tongue and epiglottis control, straight to cuff styletting or bougie (pre-passed!). All these are concepts from Rich Levitan, AIME, Scott Weingart and heard thru many others.

  2. Javier Benítez ‏@jvrbntz brought up a great point about the choice of induction agent and the potential for propofol assassination (hat tip @cliffreid and ERCAST rant

    Ideally I like to use either etomidate or ketamine but due to drug shortages/availability it has not always been around recently. Horrors when we had a ketamine shortage! There was one vial left on one shift to share between ICU and ED! My last shift we still had no etomidate but did have ketamine and propofol.

    I think there is still a use for drugs like thiopental or propofol in the right patient and right dose. Etomidate is a great drug that works ok pretty much in all situations except maybe severe sepsis though that is under hot debate. Ketamine would be my main go to drug otherwise because I ALWAYS worry about hypotension (HOp killers from @emcrit) but it’s sympathomimetic effects may not be so good in the hypertensive head bleed or the dissecting aortic aneurysm etc. Propofol or thiopental might be great for these types of situations where the patient is hypertensive or hemodynamically sound, as well as the status epilepticus patient induction.

    The dosing is a bit of judgement though e.g. those that are elderly, CVS comorbidities should receive a lower than the standard OR induction dose because they are more sensitive to the hypotensive effects and if they are obtunded to begin with, they don’t need as much.

    Scott Weingart’s Checklist dose of propofol if used in the hypotensive patient is 15 mg! “Shock is an anesthetic” too! The prime thing to avoid at all costs is hypotension (especially in the injured brain) and so sometimes it might have to be inadequate induction-paralytic-tube-apology (hat tip @precordialthump).

    The flip side would be doing a titrated induction with slower agents like fentanyl midazolam but you lose the benefits of true RSI with the risk of aspiration, resp depression and the situation may not always allow time for that.

    Comments, controversy and discussion much appreciated as these are just my thoughts and opinions.

    1. they are custom made by a company for the NSW air ambulance I believe. The best way to make your own is either design your own template and take to a plastic bag making company or download a template and take that to the bag company and get a quote for a production run of a hundred or so.

      here is a RSI dump kit template example

      Click to access dumpkit.pdf

    1. Tim, thanks for the offer, but for now it is not necessary. I will go for option number 2 since the amount of bags we need is rather small. thanks

  3. Great podcast Minh, thanks. In particular I’m a big fan of checklists in this arena and agree Cricoid should be dumped. No good evidence of benefit and significant evidence of harm.

    Without wanting to rehash your twitter debate, I do have some concerns still re using Roc for status epilepticus and don’t feel the justifications provided by the two of you were adequate because:
    1. ED docs are notorious for under-dosing post intubation sedation

    2. There is a WIDE variability in patient requirements for post intubation sedation so generally one needs to titrate to effect and this will be even more relevant if titrating to seizure control, not just lack of awareness/comfort. A “standard dosing regime” is not appropriate.

    3. Given the above, if using Roc, “striving” to use appropriate sedation when the pt is paralysed is probably not good enough as there is a very good chance the patient will be having CNS seizure activity and there is simply no way you will know about it (BP/pulse often normal).

    Additionally this reference you provided is salient

    Given this I simply can’t see a justification for using Roc in status epilepticus. You simply have to be able to tell if the patient is seizing. Assuming they are not cause you are running a reasonable infusion can’t be our standard of care here. I fear general Roc bias (probably justified) is colouring the approach here (probably unjustified)

    I also think people often lose sight of why they are intubating status epilepticus patients in the first place. It is not for airway protection primarily. It is because you need to give them really heavy sedation and as a side effect they will require airway protection. So using Roc really looks like people are losing sight of what the main game is – titrating heavy sedation to seizure control. Airway management and minuscule optimisations regarding it (Roc instead of Sux) is a distant secondary issue here.


    1. Thanks Anand ! Great comments. When Sugammadex drops in price this whole roc vs sux debate will be moot!
      Right now u can dispense with sux and still manage status epilepticus fine . Sedation only intubation . Propofol only ETI . Paul Mayo openly declares his preference for this . If u want to keep Sux for one indication that’s your decision but many now just use Roc for all . Maybe time for another PHARM survey ?! Great idea thx!

      1. absolutely – sedation only intubation would be fine and in fact preferable to a roc intubation for SE. As such yeah you could manage your intubation bag with roc alone sure given this. However sux I would be preferable to sedation only intubation in a minority of airways generally – in most there would be no difference.

        In the prehospital arena where there is likely significant value in keeping your bag simple and avoiding confusion then the benefits of having sux in your bag are probably small given the alternatives discussed and downsides of complexity and confusion likely significant. So I could see a strong case for a roc only bag.

        However in the ED arena we simply can’t just choose to drop a drug when there is only 1 not uncommon presentation where it is the superior alternative. We really need to be good enough to prepare for all such expected variant situations in the most optimal manner. Having 1 extra drug in an ED is a non issue.
        And yeah when/if Sugammadex drops in price it will nice to look back through the archives at these outdated debates.

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