Effective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival1 and the evidence shows us the benefits of this procedure when carried out with the appropriate training, education, robust competency framework and overarching clinical governance. It is a challenging procedure, and repeated attempts endotracheal intubation is associated with increased morbidity and mortality. It follows that this is a skill that should only be performed by appropriately trained and competent practitioners working in a properly structured prehospital system. This includes the mandatory use of standardised RSI checklists which have been proven to reduce cognitive load, eliminate individual practitioner variability, reduce error, and confirm availability of equipment, doses of drugs and failed intubation management plans.

Standards of practice and monitoring should be similar to those recommended for in-hospital anaesthesia.


Emergency anaesthesia is carried out to facilitate control of the airway and ventilation of critically ill patients. There are four broad indications for the procedure:

  • Failure of airway maintenance or protection
  • Failure of oxygenation or ventilation
  • Predicated clinical course/humanitarian reasons
  • To facilitate safe transportation
Patient Factors & Considerations

The decision to perform prehospital anaesthesia should be based on a thorough consideration of the RISKS vs BENEFITS to the individual patient. This should take into account:

  • Estimated transfer time to definitive care
  • Clinical indications for performing prehospital anaesthesia
  • Skill set available
  • Relevant patient comorbidities
  • Alternatives
Factors in favour of on-scene intubationFactors against on-scene intubation
  • Impaired airway maintenance and/or protection
  • Hypoxaemia or hypoventilation, OR hyperventilation in patients requiring neuroprotection
  • Fluctuating or deteriorating conscious level
  • Thermal injury to neck or airway
  • Penetrating neck injury
  • Long road or air transfer with risk for deterioration
  • Polytrauma patients requiring multiple interventions or procedures
  • Combativeness
  • High cervical lesion with diaphragmatic breathing
  • Patient morphology or pathology that may hinder successful intubation (e.g. laryngeal fracture)
  • Time critical surgical lesion (e.g. penetrating injury with associated shock)
  • Short distance to definitive care
  • Hostile environment
  • Unconducive team dynamics
Airway Assessment

Time pressures in the pre-hospital environment mean practitioners rarely have the luxury of performing a comprehensive airway assessment. Tools such as the Aintree six-step approach to potentially difficult airways highlight the following important questions to ask prior to setting up for an RSI/DSI:

  • How much time do I have?
  • What access to the airway is available?
  • How compromised is the airway?
  • What fascial planes are involved?
  • What management plan best fits the circumstances?
  • Could I make the situation worse? If so, how?

Additionally, cognitive aids such as the Airway Assessment chart displayed, take from The Vortex approach, provide a simple way of approaching an airway assessment.

Airway assessment for RSI
  • Always use the RSI checklist to facilitate set up and preparation
  • Establish bilateral IV/IO access
  • Establish monitoring (SpO2, ETCO2, NIBP – cycling every 3 minutes, ECG)
  • Assemble dump kit
  • Prepare pre-drawn RSI medication and doses
  • VAPORS assessment
  • Establish failed intubation plan and equipment
  • Optimise patient environment
  • Upright position if possible or 30 degree tilt
  • OOPS ("Oxygen On, Pull mandible forward, Sit upright if possible")
  • C-spine conisiderations
  • Check IV/IO access patent
  • Prehydration with fluid +/- blood
  • Optimise haemodynamics
  • Consider inotropic support

Preoxygenation is vital for safe prehospital anaesthesia and should proceed through the entire preparation phase. A variation to RSI is that of DSI or Delayed Sequence Induction, which is generally described as the process of pre-oxygenation with sedation in advance of paralysis.

The table below illustrates a guide for the most appropriate form of preoxygenation for different patient groups as per their risk category:

Table 1: Risk categorization of patients during preoxygenation

Risk Category

Based on pulse oximetry whilst receiving high flow oxygen

Preoxygenation Period

(3 minutes)

Onset of muscle relaxation

(~ 60 seconds)

Apnoeic period

(Variable duration dependent on airway difficulty, ideally <30 seconds)
Low risk
(SpO2 96-100%)
  • Non-rebreather mask on maximal flow rate
  • Non-rebreather mask plus
  • Nasal prongs at 15L/min
  • Nasal prongs at 15L/min
High risk
(SpO2 91-95%)
  • Non-rebreather mask OR
  • BVM with PEEP
  • Non-rebreather mask, CPAP OR
  • BVM with PEEP plus
  • Nasal prongs at 15L/min
  • Nasal prongs at 15L/min
(SpO2 <91%)
  • BVM with PEEP
  • BVM with PEEP plus
  • Nasal prongs at 15L/min
  • Nasal prongs at 15L/min
  • Consider fluid challenge (blood or crystalloid) and/or inoptropic support for haemodynamically compromised.
  • Fentanyl
    • 2-3mcg/kg IV / IO
    • Indicated in raised ICP and cardiovascular disease (e.g. great vessel rupture/dissection, aneurysmal disease, IHD)
    • Helps decreases catecholamine discharge secondary to intubation, thus decreasing risks associated with increases in blood pressure in patients with cardiovascular disease, aortic dissections etc.
  • Ketamine
    • 1-2mg/kg IV / IO
    • Indicated for any RSI.
    • Use cautiously with active cardiovascular injury (MI) or heart failure.
    • Ketamine exerts complex pharmacological actions including inhibition of biogenic amine uptake, binding to opioid receptors. Synergistic effect with opioids to produce desired sedation and analgesia.
    • Apnea is a rare side effect of ketamine.
  • Midazolam
    • 0.03 mg/kg
    • Indicated for patients with ketamine sensitivity or contraindications to same. (Thyroid replacement therapy or known allergy.)
    • Use cautiously due to vasodilator and respiratory depression. 
Prior to commencing RSI the standardised check list MUST be utilised as a final check
Paralysis and Induction

Pre-drawn RSI drugs in standardised concentrations have been introduced as a means of reducing drug related errors.

  • Fentanyl: 500mcg in 20ml (25mcg/ml)
    • Induction dose of 1-3mcg/kg
  • Ketamine: 200mg/20ml (10mg/ml)
    • Induction dose of 1-2mg/kg
  • Rocuronium: 200mg in 20ml (10mg/ml)
    • Induction dose of 1.2-2mg/kg
Passing the tube / Proof of placement
  • Consider BURP/bimanual laryngoscopy to facilitate passing the tube
  • Maintain sight of tube passing through cords and position appropriately
  • Confirm placement by visualization, auscultation, etCO2 (6 non diminishing wave forms)
Post Intubation management
  • Use of RSI post intubation checklist
  • Note position of ETT at teeth
  • Secure tube (consider tape in head injured/children)
  • Secure all lines/equipment
  • Appropriate sedation and paralysis
  • Establish appropriate ventilator settings for patient condition
  • Check VBG to titrate settings to clinical condition
  • Use of Pre-scene departure checklist for packaging and final checks

Table of initial ventilator settings and tips for titrating

Parameter Normal lungs ARDS/ALI Asthma/COPD Metabolic Acidosis Head Injury Severe obesity
Aim Lung protective strategyRecruitment, shunt retention, avoid atelectic trauma, achieve adequate oxygenationOxygenation, adequate exhalation avoiding breath stacking and volutraumaEnsure adequate respiratory rate to maintain and even improve compensation for metabolic acidosisAvoid reduced venous return by avoiding high intrathoracic pressuresAvoid atelectasis and shunting due to obesity
Position 20-30 degree head up unless hypotensive and reduced cerebral perfusion a concern
VT (mL/kg) 86monitor5-88-106-88-10
Respiratory rate 1414148-1020-301614
I:E Ratio 1:22:12-4:11:4-1:51:1-1:21:21:1-1:2
Pinsp (cmH2O) --25-30----
PEEP (cmH2O) 510-1510-15
  • Asthma: 0
  • COPD: 5
FiO2 Start at 100% and rapidly titrate down, ideally achieving FiO2 0.4. Avoid significant hyperoxia. Aim for oxygen saturations > 95%; pO2 >80. Aim Pplat <30.
Other Adjust parameters to ensure O2 and CO2 within normal limitsWatch pressures; may need to lower Vt and accept higher CO2. Titrate FiO2 and PEEPMinimise derecruitmentMinimise derecruitment, i.e. minimise suctioning and disconnection. Consider recruitment manoeuvresWatch for breath stacking and volutramua or barotrauma. Consider permissive hypercapnia. pH >7.15. May need to accept higher peak pressures in asthmatics. Aim Pplat <30Avoid high PEEP if possible. Aim PCO2 35-40. Tape rather than tie ETT to avoid impeding jugular vein flow.Minimise decruitment, i.e. minimise suctioning and disconnections
Additional Information

Christine M. Groth, Nicole M. Acquisto, Tina Khadem. Current practices and safety of medication use during rapid sequence intubation,Journal of Critical Care,Volume 45,2018,Pages 65-70,ISSN 0883-9441,https://doi.org/10.1016/j.jcrc.2018.01.017.

Brandon G. Santoni, Ph.D. ; Bradley J. Hindman, M.D. ; Christian M. Puttlitz, Ph.D. ; Julie B. Weeks, M.P.T. ; Nathaniel Johnson, B.S. ; Mazen A. Maktabi, M.D. ; Michael M. Todd, M.D.Manual In-line Stabilization Increases Pressures Applied by the Laryngoscope Blade during Direct Laryngoscopy and Orotracheal Intubation. Anesthesiology January 2009, Vol. 110, 24–31.https://doi.org/10.1097/ALN.0b013e318190b556

Jeffrey L. Jarvis, MD. 2016. Using DSI to Prevent RSI from Becoming RSD (Rapidly Sequenced Death). Williamson County EMS. http://txemsa.com/using-dsi-to-prevent-rsi-from-becoming-rsd

Manoach, Seth & Paladino, Lorenzo. (2007). Manual In-Line Stabilization for Acute Airway Management of Suspected Cervical Spine Injury: Historical Review and Current Questions. Annals of emergency medicine. 50. 236-45. 10.1016/j.annemergmed.2007.01.009.

Robitaille A, Williams SR, Tremblay MH, Guilbert F, Thériault M, Drolet P. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg. 2008 Mar;106(3):935-41, table of contents. doi: 10.1213/ane.0b013e318161769e. PMID: 18292443.


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