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Hot Topics in RSI – Guidelines from The Society of Critical Care Medicine

October 18, 2023

Written by Seth Walsh-Blackmore

Spoon Feed
Positioning, preoxygenation, medication selection, and other questions surrounding emergent rapid sequence intubation (RSI) are addressed by an expert panel.

Some pre-intubation contemplation
RSI is the norm for intubation outside the operating room, but there are substantial variations in provider approach. A Society of Critical Care Medicine panel seeks to provide evidence-based guidelines for 10 important practice considerations as summarized in the table:

From cited article

Inclined position:  A meta-analysis and two RCTs did not favor inclined positioning in their outcomes, but three observational studies did. There is established physiologic rationale why it would improve oxygenation and reduce aspiration with no additional resources. The existing data are likely muddled by heterogeneity in populations, providers, experience, and what defines an incline.

Preoxygenation:  Multiple RCTs and observational studies (some on JF 1, 2, 3) consistently support high-flow preoxygenation to reduce desaturation events vs. facemask/standard cannula. An RCT of patients with severe hypoxia (PaO2/FiO2 < 150) favored CPAP/BiPAP over high-flow, as did two observational studies. The evidence for recommending premedication of agitated patients to facilitate preoxygenation is essentially one ED observational study using ketamine, though a recent RCT adds more support.


  • In five observational studies, using a NMBA before intubation (along with the induction agent) consistently improved first-pass success and decreased aspiration vs. a hypnotic agent alone. Succinylcholine is recommended (unless contraindicated) over rocuronium.
  • Sedative hypnotics are recommended, regardless of hypotension, based on one observational ED study (which showed no difference in a composite outcome of 10 events ranging from lip trauma to death that did not report individual event rates).
  • The challenge to etomidate’s hemodynamic superiority is from plentiful but heterogeneous data, primarily comparing etomidate to ketamine +/- adjunct medications like fentanyl . A Cochrane review found no difference, with observational studies for and against. A post hoc of the INTUBE RCT was not included in the review but found greater odds of cardiovascular collapse with propofol.
  • Multiple RCTs comparing etomidate with or without various corticosteroid protocols (given concern for adrenal suppression) found no difference in mortality.
  • Peri-intubation vasopressor data show some improvement in various endpoints (BP, HR), but heterogeneous medications/dosing and confounding by bundled protocols (i.e fluids, multiple meds) preclude a standard use recommendation. The PREPARE II trial, which was not included in the review, found no benefit with a pre-intubation fluid bolus.

Decompression: NGT decompression before induction is recommended if a full stomach is confirmed via ultrasound or history, but no evidence is cited.

How will this change my practice?
A majority of this aligns with the standards of my institution and personal practice. Inclined positioning is something I should do more. It’s a simple adjunct with little downside other than my comfort level, which I feel empowered to improve.

Another Spoonful
Although the authors did not cover the choice of VL vs DL, Sam Parnell recently covered the DEVICE RCT.

Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med. 2023 Oct 1;51(10):1411-1430. doi: 10.1097/CCM.0000000000006000. Epub 2023 Sep 14.

What are your thoughts?