RSI in the ED; should EM be taking the lead?

What is an RSI?

Rapid sequence induction, or RSI, is the preferred method of emergency tracheal intubation outside the operating room because it results in a rapid state of unconsciousness (induction) and neuromuscular blockade (paralysis).

The Scottish Intensive Care Society defines RSI as follows;

‘Rapid sequence intubation is the administration of a potent induction agent (anaesthetic) followed by a rapidly acting neuromuscular blocking agent (usually suxamethonium) to induce unconsciousness and motor paralysis for tracheal intubation. It is assumed that the patient has a full stomach, and is thereforeat risk of aspiration of gastric contents. The aim is to render the patient unconscious and paralysed so that they can be intubated’

Securing the airway by means of RSI is particularly useful in patients with an intact gag reflex, ‘full’ stomach and a life threatening illness requiring immediate airway control. Common indications for RSI include:

  • Inability to maintain airway patency
  • Ventilatory compromise
  • Reduced GCS
  • Status Epilepticus
  • Anticipated loss of airway patency

It is important to remember that RSI performed outside of the operating theatre has many additional challenges. Internationally, there is huge variation in who is performing RSI in this circumstance. In the UK in most institutions, an anaesthetist, regardless of environment, performs RSI most commonly. Reasons for this are historical, political, and educational. Given the importance of emergency airway management however, one might expect emergency physicians (EPs) to perform RSI more regularly.

EM training in the UK involves ST2 which is a year dedicated to anaesthetics and ITU, a whole host of acute skills are learnt which also involves the need to gain the Royal College of Anaesthetist’s IACC (Initial Assessment of Clinical Competency). The IAAC is typically completed by a trainee after 3 months training and includes the ability to perform an RSI and failed intubation drill.

It would seem a shame to devote such time to achieving airway skills to then let them dwindle later on in your practice and once achieving competency one must ensure, as John Hinds stated at the recent RCEM conference in Belfast, that a clinician performing an RSI in the ED has ‘competence, confidence and currency’.

With a relative infrequency of RSI’s to perform in the ED with comparison to the exposure anaesthetists see in the operating theatre, one could be forgiven for thinking there is no place for a laryngoscope in the hand of an EM clinician.

A few issues however fuel the appetite for the EM clinician to remain involved in RSIs. Firstly we perform countless sedations in the ED, guidance from the Royal College of Anaesthesia states;

‘Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence all practitioners intending to produce a certain level of sedation should be able to rescue patients whose level of sedation becomes deeper than originally intended. Practitioners therefore require skills to recognize and manage airway, respiratory and cardiovascular problems caused by over sedation.’

It is unrealistic to expect anaesthetic and ITU colleagues to always be on hand immediately should a patient in the ED need an RSI with little advanced notice and if an EM clinician can perform an immediate safe and effective RSI, expedite care and reduce complications from undue delays then that would seem in everyone’s interests.

A recent online survey that we conducted at HEFT showed that when considering which departments to work in, the draw of an MTC was equally matched by the draw of departments that perform ED led RSIs. And if departments are considering how to be driving EM forward then developing the service is a hugely positive step.

Finally, the ED is a familiar and comfortable environment within which we as a speciality can develop and drill routines for procedures such as RSI. The RCoA set a standard of at least 2 monthly team practices for RSI and major trauma management using case scenarios, simulation and debrief which fits in well with current practices in EM.

As with many things in your EM career there will come a point at which you will need to decide consciously to keep upto date with your skills of RSI. This can either be achieved in an adhoc random fashion or as a structured joint specialty vision and working. If Emergency Medicine in the future is to hold RSI as a competence utilised skill then encorporating it into our regular department practice needs to occur sooner rather than later.

For this reason we’ve waded through some papers on the topic to see whether the aspiration holding on to that laryngoscope by the Emergency Clinician is something that is appropriate and safe for our patients. Make sure you take a look at the recent St Emlyns post on the Kerslake paper we cover as well.

Kovac, 2004.

In this review article the authors tackle the historical precedent that has contributed to the dogma associated with EPs performing RSI using neuromuscular blocking agents (NMBA). The authors provided narrative as well as reviewing the evidence that supports ED RSI.

Before delving into individual articles the authors spent some time discussing the important topic of airway management training.  In a survey performed by the authors they report that only 16% of EPs reported having received formal airway management education during higher education.  They go on to say that postgraduate education in airway management, including airway courses such as ATLS, are in isolation unlikely to equip clinicians with the necessary skills to competently manage the airway.  They point out that such courses focus on the procedure of RSI and neglect the other important aspects of airway management including:

1) Recognizing the need for airway management

2) Understanding the indications for and contraindications to RSI

3) Developing skills in bag-valve maskventilation and laryngoscopy

4) Developing an approach to the difficult andfailed airway

5) Developing and maintaining cognitive andpsychomotor skills

It’s important to recognise the old saying of ‘use it or lose it’ when thinking about maintaining clinical competency. For an interesting podcast about this go to #RCEMBELFAST podcast with John Hinds where he coins the phrase ‘currency’ when discussing this topic.

The body of the article then goes on to discuss a number of articles looking at RSI performed by the non-anaesthetist.  A summary of the data is presented in the following table:

Author Design Variables RSI (%) Sedation (%) Nastracheal (%)
Walls, et al. 2000 Prospective observational (n=6294) Methods 69.5 6.8 5.1
Success 98.7 90.2 87.2
Attempts (>3) 2.1 10.7 14.3
Complications 15.3% overall
Li, et al.1999 Prospective observational (n=233) Methods 71 29
Success 99 72
Attempts (>3) 2 24
Complications 28 78
Sakles, et al. 1998 Prospective observational (n=610) Methods 83.4 15.2 1.3
Success 99.4 91.4 75
Attempts (>2) 5.3% overall
Complications 9.3% overall
Tayal, et al. 1999 Prospective observational (n=596) Methods 70 NA NA
Success 100 NA NA
Attempts (>3) 3 NA NA
Complications 15.8 NA NA

Table: Airway management in the emergency department

Whilst the table above does not present data directly comparing the success, complication, and failure rates between anaesthetists and non-anaesthetists, it does provide encouraging results to support both the use of RSI over sedation or other techniques as well as the efficacy of RSI performed by the non-anaesthetist.

The authors emphasise the importance of on-going education and collaborative work between departments to ensure EPs are competent and current in managing all aspects of airway management.

Reid, 2004

The next paper we review is by the well known #FOAMed contributor @cliffreid et al.

The authors conducted a prospective observational study looking at RSIs performed by critical care doctors outside the operating theatre over a six month period in a large UK teaching hospital.

Of relevance to UK EPs, this paper presented RSI data for both anaesthetists and non-anaesthetists making comparison between groups possible. Given this methodology, it has the potential to be more relevant and generalisable to UK ACCS training and CME.

For the purpose of the study:

  • An anaesthetist was defined as a doctor with at least six months’ prior training in a pure anaesthesia post
  • A non-anaesthetist was defined as a doctor whose intubation skills were acquired in the intensive care unit or emergency department environment, or both, and who had not been employed as a trainee in anaesthesia at any time

What did they find?

Data was available for 208/211 patients who met the inclusion criteria.

Indication Number (% of total)
GCS <8 67 (26.3)
Falling GCS 30 (11.8)
Hypoxia 67 (26.3)
Respiratory failure 40 (15.7)
Transfer 19 (7.5)
Multiple injuries 9 (3.5)
Other 23 (9.0)

Table: Major indications for emergency RSI

Immediate complications

The intubating doctor was a non-anaesthetist (either unsupervised or supervised by another non-anaesthetist or an anaesthetist) in 75% of intubations. The likelihood of a failed intubation was greater in groups NA and M; p = 0.007 and p = 0.04 respectively.

No deaths occurred during RSI and no patient required a surgical airway. There were no failed intubations. Most common immediate complications were hypoxaemia (19.2%), hypotension (17.8%), and arrhythmia (3.4%).

Difficulty Group A number (%) Group NA number (%) Group M number (%)
>1 attempt at laryngoscopy 4 (7.8) 11 (13.4) 22 (29.3)
Unsuccessful intubation attempt (UIA) 2 (3.9) 9 (10.8) 15 (20)

Table: Difficulties in RSI according to physician group. Groups NA and M have a higer incidence of multiple attempts and UIAs. X2 analysis shows these differences are significant (p=0.007 and p=0.004, respectively)


Group A number (%) Group NA number (%) Group M number (%)
Arryhythmia 2 (3.9) 2 (2.4) 3 (4.0)
Hypoxaemia 7 (13.7) 18 (22.0) 22 (28.6)
Hypotension 8 (15.7) 16 (19.5) 13 (16.9)
Complicated RSIs 17 (33.3) 28 (34.2) 37 (49.3)
Total in group 51 82 75

Table: Complication rates of RSI performed by each physician group. There is no difference between the complication rates between the groups. X2 analysis p = 0.232.

What does this mean for us?

These results suggest that complications rates from emergency RSI are similar between anaesthetists and non-anaesthetists. Prior training in a formal anaesthesia post did not significantly affect complication rates, although there were more episodes of hypoxia when intubation was attempted by non-anaesthetists.

It is important to note that in this paper intubating teams comprised junior (SHO) doctors who received two weeks training in emergency airway management prior to the study period. These trainees were then supervised throughout the study until such time they were deemed competent and thus capable of independent practice. Whether this training and close supervision is provided to all clinicians undertaking RSI is unknown and may impact the generalisability of these results to other institutions.

The authors point out that “training programmes for non-anaesthetists should be defined and standardised to optimise the safe and timely securing of the airway in emergency situations rather than debating which specialists should do it”

Kerslake, 2015.

The last paper we discuss is a very large prospective observational study of tracheal intubation in a UK ED. It is the largest study of its kind in the UK to date with data collected over 12 years between 1999 and 2011.

It’s fair to say that in this Edinburgh ED, joint working with the anaesthetics and critical care departments is likely to have contributed to the extremely high rates of RSI performed by EPs (a whopping 78%). Of the 3738 intubations included, 2749 (74%) were RSIs, 361 (10%) were other drug combinations, and 628 (17%) received no drugs.   Compare these results with those North American studies discussed by Kovac above and you’ll see they aren’t hugely dissimilar.

The authors of this study found that tracheal intubation was successful in nearly all patients (99.6%) with a first time success rate of 85%; 98% of patients were successfully intubated with two or fewer attempts. Failed intubation was extremely rare (n=14); only five patients (0.13%) had a surgical airway performed.

Complications rates were extremely low (8%) and were directly related to the number of attempts made; 7% in one attempt, 15% in two attempts, and 32% in three attempts (p < 0.001). If we compare these results to the Reid article we can see that Kerslake reports far fewer complications (8% versus 33% for non-anaesthetists). The types of complications encountered (hypotension and hypoxaemia) however, were similar.

Overall, Kerslake provided excellent and encouraging data to support ED RSI performed by non-anaesthetists with extremely high success rate and low failure and complications rates. Such results are likely to have been achieved through the adoption of excellent collaborative ways of working between emergency physicians and their anaesthetic and critical care colleagues.

So putting this all together what have I taken away from these papers?

To summarise it neatly the above papers demonstrate that RSI involving NMBA is the preferred modality for securing the airway. When performed by non-anaesthetists outside the operating room RSI has high success rates and low complication and failure rates. These results are encouraging for EPs developing and maintaining skills in airway management.

It is clear from the two UK papers that practice differs and as such so do success and complication rates. A common theme across each of the papers is that of education, training, and maintenance of skills. Until departments achieve collaborative ways of working, and training programmes including ACCS and CME initiatives such as ATLS unify their approach to education, results will remain varied.

Thanks for reading.

James Rudge

References & Further Reading

Kovacs, George, et al. A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance. Annals of emergency medicine 36.4 (2000): 301-309.

C Reid; The who, where and what of rapid sequence intubation: prospective observational study of emergency RSI outsode the operating theatre. Emerg Med J 2004; 21:296-301

Kerslake, Dean, et al. “Tracheal intubation in an urban emergency department in Scotland: A prospective, observational study of 3738 intubations.” Resuscitation (2015).

Scottish Intensive Care Society: RSI

Difficult Airway Society Guidelines

RCOA Anaesthesia in the Emergency Department Guidelines; Chapter 6.1

John Hinds on RSI at RCEM 2015 Belfast

St Emlyns blog post on Kerslake paper

AAGBI Pre-hospital Anaesthesia Guideline


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6 thoughts on “RSI in the ED; should EM be taking the lead?

  1. Tom says:

    So you do 6 months of anaesthetics at st2. How does one not lose those skills in the following 4 years of training whilst rotating through non RSI EDs?

    Should SPRs only rotate through EDs that perform RSI? Or should they do a further 6 months of airway training as a Reg? What should RCEM do, and what will you do in your own ED, to fix this training gap?

  2. sl says:

    Currently in the UK we spend 12 months in ITU and anaesthetics combined.

    There will obviously a skill level attrition rate, the bigger question is where we want EM to be in 10 years time, whether the familiarity with the ED and it’s processes puts us into a position to help patients by more frequently performing RSIs and then how we ensure that the skill are acquired and then kept up to the appropriate level.

  3. says:

    this is the way forward, we have been faar to late implementing this. at the end our job starts with a…

  4. Sam says:

    Did the online survey showing the draw of EM-led RSI equalling that of a MTC ever get published? I’d like to cite it if so! Many thanks,

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