By Philip Neuwirth, BS, MICP, CCEMTP, FP-C

The most important step in a timed, sequenced, orchestrated event is preparation.  I submit to you, Rapid Sequence Intubation (RSI) is not rapid; it is a purposeful, verbalized, timed, sequenced event.

That is not the way I was trained. I was taught RSI was a rapid emergency procedure. Throw your partner the drugs, select a 7.5 ETT, grab your laryngoscope and hope your partner was keeping up. Confirm your partner pushed the drugs, slide the laryngoscope past the incisors, and pray you have visualization. Tube placement was confirmed by auscultation, and the tube was secured with twill tape. If you had no visualization, you would say out loud, “wow, really anterior” and begin manipulating the trachea with one hand, while holding the scope in the other. Multiple attempts, switching partners and finally settling for a BVM that no one used correctly. This may be an exaggeration, but probably not too far off. There was no verbalization, preparation, positioning or backup plan. Frightening, right?

RSI has always been the most important and most dangerous procedure we perform. However, over the years we have learned many new techniques. First, we learned the most important step in this procedure is preparation and pre-oxygenation. The person intubating must evaluate the patient for a potentially difficult airway. Then, check patients hemodynamics; select their initial equipment and backup equipment; prepare a backup plan; check and set-up equipment; assign roles and responsibilities; verbalize their airway plan. The person administering the drugs needs time to draw up the meds and confirm dosages. BLS and ground ALS must be briefed in their role when assisting.

Why should we verbalize an airway plan?

  1. You want everyone (assistance) to know who is taking responsibility for this patient and confirm everyone is on the same page.
  2. Assigns roles and responsibilities to BLS/ALS assistance.
  3. It prepares assistance for a difficult airway and what to expect if you have a failed airway (there is no surprises and prepares them for that possibility).
  4. And most importantly, it makes you responsible to everyone else (e.g. stop me (grab my hand) if patients O2 sat drops below 93% or HR drops below 60)

Example of a Verbalized Airway Plan: 

We are going to pre-medicate our patient with 100 mcg of Fentanyl, and induce the patient with 200 mg of Ketamine. Then we will paralyze our patient with 150 mg of succinylcholine. My first & second attempt to intubate patient I will use a video laryngoscope maintaining an O2 sat >93%. If at any time my sat drops below 92%, I want -name- to stop me and I will ventilate patient slowly with a BVM. If after three unsuccessful attempts to intubate, I will place a supraglottic airway. If unable to oxygenate and ventilate the patient, I will place a QuickTrach to secure a definite airway. Once the airway is placed, I will ask -name- to confirm placement by auscultation. Then note patients ETCO2 waveform and numeric by printing an EKG strip. Once the tube is confirmed, I will ask -name- to help secure the tube and my partner will administer post intubation medications.


The RSI checklist I attached below includes a “Time-Out” as a reminder just before the procedure begins. Check:

  • Heart Rate
  • Blood Pressure
  • Blood Sugar
  • Acidosis (Salicylates, DKA) If RSI is necessary, maintain patients ventilatory rate
  • Medical Alert ID’s
  • Anticipated problems:
  • Any questions or concerns?
  • Is patient positioned optimized?

If a patient remains / becomes hypotensive after intubation, remember this pneumonic “Ah Sh!t.”

  • A: Acid / Anaphylaxis
  • H: Heart / Tamponade
  • S: Stacked Breaths / Auto peep
  • H: Hypovolemia
  • !: Induction Agent
  • T: Tension Pneumothorax

The RSI checklist was designed to be a laminated trifold; “Preparation” would be the front cover,” Medications” on the inside cover and “Procedure” on the back cover. This checklist was not intended to be comprehensive; check with your local protocols and make any necessary changes before using.  RSI Checklist v2.6

The views and opinions expressed are my own, based on my experiences in the field of critical care medicine and do not represent those institutions with whom I am affiliated.


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