R.S.I. stands for Rapid Sequence Intubation. Sometimes it stands for Rapid Sequence Induction. What is really being talked about here, is the administration of powerful paralytic drugs like succinylcholine. The benefit is that it is easier to perform endotracheal intubation on a paralyzed patient.
The problem is that once these drugs are administered, the patient is no longer able to breath on their own. You must breath for them. If after you paralyze them, you cannot secure their airway, they could die. If you fail to ventilate them properly, they will die. This is a pretty big risk to take if you ask me.
Is it is a good idea for Paramedics to make patients stop breathing? How did this technique first become popular? I think a real bad case of “rotor envy” brought this idea into widespread acceptance. Many Paramedics want more than anything to be Flight Medics. That is where this technique was first used. Just because it is “cool” and used on helicopters, does not automatically make it a good idea for ground transport units.
For Helicopter use, it does make some sense. Imagine you are at 1,000 feet with a Head Injury becoming combative and dangerously agitated. The patient may have a compromised airway, and hold the potential to bring the whole aircraft down. For this situation, I can appreciate the risk-benefit analysis of using paralytic drugs.
But for ground use I just do not see how the benefits outweigh the risks. The true goal of airway management is to Ventilate, not merely intubate. You can ventilate just fine without an ET Tube in place, if you are good at Basic Life Support. If you are not good at BLS, you should probably not become a Medic just yet. If you do not have good basic ventilation skills, you sure as heck better not make anybody stop breathing. Is it smart to increase patient risk to compensate for lousy BLS Skills? I sure don’t think so.
When I teach Nasal Intubation Techniques I always remind students that if it is very difficult to nasally intubate, you are probably doing the procedure on someone who does not need it. If the patient can protect their airway from you, they can protect their own airway, right? Patients that really need a nasal tube will practically help you put it in. Those unable to protect their airway can be intubated orally. Those that fall somewhere in the gray zone, can be properly ventilated until definitive care can be reached.
I cannot think of one single occasion in my almost 30 year EMS career, where so-called RSI would have made a difference. Those few patients I have been unable to intubate in the field (two), I was able to ventilate very well until ED arrival. Not one person has ever expired in my care for lack of this technique. So why do we need it?
I don’t think we do, and teaching Paramedics to make patients stop breathing is just a Really Stupid Idea.
UPDATE 2015 from Red Flags in Prehospital Airway Management by Henry E. Wang, MD – Controversies in Emergency Airway Management presented at NAEMSP Med Director Meeting Jan 5 2015
RSI for TBI Davis, J Trauma 2003 • Multicenter implementation of prehospital Rapid Sequence Intubation • 209 pts compared with 627 historical controls • RSI associated with increased death – OR: 1.6 [1.1-2.2] Conclusion: Prehospital RSI Does Not Save Lives (and May Harm)