What’s the Plan D?

Hi Folks I am sat here excitedly as I finally get to write a blog on one of my favourite subjects, the Rapid Sequence Induction (RSI) of a patient in ED. This also applies to any patient who is anaesthetised in an emergency, or out-with the anaesthetic room in a planned procedure. If I told you just how much interest I have in this subject you wouldn’t believe me so I have copied in a picture of my mate Katie who dressed up as me at a work party (circa 2015) and this was the top she made…

Dress up as you work hero they said….. thanks Katie!

My main interest for this subject come from my time in the military where I was privileged to be able to undertake an operational tour in Afghanistan on the Medical Emergency Response Team (MERT). MERT is a 4 person medical team (12 person wider team with the awesome aircrew and force protection), we would fly to the patient and treat them on the move towards to the trauma centre. The unique part of this team was being able to deliver meaningful interventions on the move due to the size of the helicopter.

This meant we could deliver team based interventions such as RSI, thoracostamies, blood product administration, IO access + advanced analgesia to name but a few. Due to risk associated with doing these interventions on the move and in somewhat noisy circumstances we practiced as a team every single day, and it made me realise how hard it is to replicate this in UK ED’s, where you may not work together as a team every day, nevertheless I feel it is just as risky from a noise and stress point of view. Doing things that should happen in an anaesthetic room or intensive care unit in our sometimes sub-optimal busy departments means we have to be prepared and get it right.

SO…. when I left the military in 2013 and started working in the NHS I set about developing an RSI assistant course for the nurses in my hospital. This was to ensure each patient receiving this treatment in the ED resus bay was safe, and also that the team were safe in this potentially dangerous situation.

This led to the implementation of a checklist, department training and simulation and a change in the culture whilst this procedure was done. Why is any of this important to you as an ED nurse? You have to be the one driving adherence to the guidelines and more often than not, pushing for use of the checklist (if your department has one….. if it doesn’t… please make this your challenge to implement- here is an example from the legends over at The Resus Room

I have used more in depth checklists in the pre-hospital environment as there is much more that can go wrong, mostly related with not having an ITU up the corridor, or a back up consultant etc etc. It depends how in depth you want it, perhaps you want a challenge response checklist so that everyone can hear the location of kit, the plans etc.

Another checklist that I really love is the one they use in Preston- special thanks to Kirstyfor sending the link to this and to the anaesthetic guys who designed it, its available on the internet so in true #foamedstyle use it if you think it’ll improve patient safety. Click herefor that one.

What is an RSI?

This is an anaesthetic delivered to a patient in an emergency where it is assumed that the patient has just had 8 pints of beer and a kebab (with extra chilli sauce), and we do things to ensure that stuff doesn’t end up on our shoes or the patients lungs- both would be a bad day at the office.


The only thing it is important to highlight is cricoid pressure or Sellicks Manoeuvre to give it the proper name, is in the process of change so you will come across clinicians who do not use this and others who will not perform an RSI without it. As an ED nurse you need know how to perform this properly as your first time to do it should ideally not be when you here ‘can anyone do cricoid’?

‘Trained Assistant’- that is the role of the ED nurse in this situation, and remember ODP’s are the experts at this and train for a long time to be able to do this inside out, so we are trying to learn the bare basics of a small part of their job and not just that- learning to sue these skills when it’s at its most sub-optimal. Something to think about when you next here someone talking of this as if its an everyday occurrence that doesn’t require awareness, training and heightened levels of alertness.

You will hear some people call it a rapid sequence intubation and others call it a rapid sequence induction, technically the only thing that is meant to be rapid is the time from drugs being on board to the tube being secured hence the choice of drugs is important. Check out this awesome blog by the guys at life in the FASTLANE herewhich explains the process in more depth.

RSI can be learned in chunks and I would suggest splitting your learning into the following sections.

The process/procedure

Follow the links above for some really good explanations and have a read of all of these maybe over the course of two days to really optimise your learning.

The Kit

You have to be familiar with your own kit but as a rough guide you are going to need to following and set up on a trolley in a sensible fashion.

The Drugs

Please ask your ED and Anaesthetic colleagues if there is a trust SOP on the preferred drugs of choice for an ED RSI, a lot of it comes down to the clinician performing the procedure, however a lot of places are emphasising the use of Ketamine as the primary sedative due to the hypotension caused by other induction agents such as propofol particularly in trauma patients.

Further, ensure you have the correct muscle relaxant as again more and more we are seeing Rocuronium being used as the first line muscle relaxant as oppose to suxamethonium as the original ‘wake the patient up’ if this doesn’t work isn’t really an option for our ED patients anaesthetised due their critical condition.

Roc vs Sux is all about length of duration, RSI’s were traditionally done using Sux so that if you didn’t get the tube in you could wake the patient up, this may be ok in an appendicitis going in theatre who could come back tomorrow, but not for the head injured patient with a GCS of 7 who is needs to go to CT ASAP. And if you give Sux and the tube goes in you will then also have to add in something longer acting such as Roc.  Here is an excellent article with self assessment on these two drugs.

Finally don’t forget about on going sedation before the RSI so that it’s ready, also emergency drugs and analgesia if required

The Aftercare

Everything needs to be documented fully, and placed in the patients notes, dont forget to ask the clinician how the intubation was in terms of difficulty, and encourage them to document this for future reference. This patient has just gone from being an ED patient to an ITU patient, but may not see an ITU nurse for some hours so its time to step up to the plate, follow the #betweenthelinesblogs herefor more education on how to do this well.

Learn all things Oxylog ventilator here

Final thoughts

This is a risky procedure in the ED but we can make it excellent, we should strive to make it excellent- for those of you who haven’t seen the Elaine Bromiley video please take 14 minutes from your day to watch it here. In this case, this happened during a planned procedure with a very very experienced team who worked together regularly. The loss of situational awareness can happen to anyone and at anytime regardless of seniority, what the assistant can do is to recognise this, bring the person back into awareness and keep the patient safe.

As someone who has taught the assistant procedure and course for a number of years, I actually intubated during an RSI for the first time in ED three days ago. I can tell you as soon as the room fell silent and I placed the laryngoscope into the mouth, my heart rate increased and I could have very easily lost focus. However I had the amazing ITU doctor J beside me, she asked me to describe what I saw, suggested improvements and even at one point moved my hair out of the way- these are things a good ‘assistant’ will do- these are the things YOU will do.

Go fourth and make all RSI’s in ED safe and efficient and please keep doing an amazing job- #EDlegends

References- As per the links in the blog

RCN Competency Framework L1 and L2

CD2.6- Emergency Airway and Ventilation Management

  • 6.1.2
  • 6.1.3
  • 6.1.4


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