When to Choose RSI Versus DSI
Clinical Triggers, Red Flags, and Contraindications
Airway control demands decisive action when oxygenation fails despite escalating basic maneuvers. Teams identify red flags like inhalation burns, severe head injury, and exhausting work of breathing. Clinicians avoid drug-assisted attempts when shock deepens or preoxygenation remains impossible. Leaders match technique to physiology while following medical direction and agency protocols. For a full program overview, explore our Paramedic classes at Ricky Rescue.
Preoxygenation Strategies and the DSI Workflow
Crews start with upright positioning, a sealed non-rebreather, and nasal cannula apneic oxygenation. Providers escalate quickly to BVM with PEEP when saturations stall despite strong coaching. Agitation that blocks preoxygenation calls for dissociation while preserving respiratory drive. Ketamine enables calm preoxygenation and smoother preparation for controlled drug-assisted intubation. Teams complete readiness checks, verify numbers, and then proceed with confidence.
Medication Strategy: Analgesia, Induction, and Paralysis
Choosing Agents and Field Dosing Ranges
Pain fuels tachycardia and distress, so clinicians treat pain before sedation. Ketamine suits unstable states, while etomidate offers neutral hemodynamics for many adults. Rocuronium grants longer working time, while succinylcholine allows rapid offset when appropriate. Teams tailor choices to comorbidities, protocols, and anticipated airway difficulty. Clear announcements and cross-checks reduce error and strengthen team situational awareness.
Hemodynamic Preparation and Push-Dose Vasopressor Readiness
Smart preparation prevents peri-intubation collapse during high-risk airways in the field. Crews prime fluids, draw labeled push-dose pressors, and stage adjunct medications. Head-up positioning, cautious PEEP, and gentle ventilation protect venous return. Clinicians reassess after each step and adjust based on blood pressure responses. Educational bundles hard-wire these habits into every advanced airway attempt.
First-Pass Success Tactics at the Head
Team Roles, Read-Back Checklist, and Backup Plans
Roles stay explicit: laryngoscopist, airway assistant, monitor lead, and logistics support. The team rehearses a brief read-back covering blade, tube size, and plan B. Assistants prepare suction, external manipulation, and bougie delivery on cue. A fourth person watches time, saturation trends, and rescue device readiness. Everyone commits to short, timed attempts anchored in an oxygenation-first mindset.
Video Versus Direct Laryngoscopy and Bougie-First Technique
Video laryngoscopy promotes shared visualization, coaching, and efficient corrective feedback. Blood or glare still favors direct laryngoscopy as a dependable backup option. Bougie-first technique improves first-pass success across difficult emergency intubations. Positioning strategies, including ramping, open the view and shorten attempt times. Short attempts with reoxygenation cycles elevate safety and overall success rates.
Confirmation and Tube Security
Waveform Capnography, Failure Patterns, and Troubleshooting
Continuous waveform capnography confirms tube placement with reliable specificity during transport. Crews expect a persistent square waveform during ventilation with coordinated chest rise. Disappearing waveforms or sudden hypoxemia demand immediate troubleshooting and rapid reassessment. Arrest physiology can lower values without negating correct placement entirely. Leaders integrate clinical exam while prioritizing waveform capnography for confirmation.
Depth Marking, Fixation, and Early Physiologic Checks
Clinicians record depth at the teeth and inflate the cuff securely. Teams listen axillary and epigastric while observing symmetric chest rise. Crews recheck depth after every move, lift, or device change. Ongoing surveillance of pressures, saturation, and ETCO₂ catches early deterioration. Strong fixation prevents migration, selective mainstem, and unrecognized dislodgement during movement.
Post-Intubation Analgesia and Sedation
Analgesia-First Sequence and Sedation Targets
Patients remember pain during paralysis, so crews treat pain first. Clinicians titrate fentanyl or alternative agents while monitoring hemodynamics carefully. Sedatives follow to maintain comfort, amnesia, and ventilator synchrony during transport. Teams document targets, doses, and times to maintain continuity across handoffs. Programs teach structured bundles that pair analgesia and sedation thoughtfully.
Preventing Awareness, Dyssynchrony, and Emergence Agitation
Awareness prevention requires uninterrupted sedation throughout any period of paralysis. Crews tune trigger sensitivity, inspiratory time, and flow to improve synchrony. Teams treat dyssynchrony with analgesia and sedation before repeating paralysis. Short-acting sedatives demand planned redosing during longer transports. Clear handoffs communicate goals so receiving teams continue dosing without gaps.
Initial Ventilator Setup in the Truck
Lung-Protective Starting Points and ETCO₂ Targets
Portable ventilators support safe, repeatable ventilation across varied prehospital environments. Teams start with lung-protective volumes and then individualize based on pathology. Clinicians target physiologic ETCO₂ ranges while monitoring pressures and patient response. Field programs emphasize sedation and analgesia alongside mechanical ventilation. Agencies align device-specific settings with protocol and medical direction.
| Phenotype | Tidal Volume | Rate | PEEP | ETCO₂ Goal | Notes |
|---|---|---|---|---|---|
| Normal lungs | 6–8 mL/kg PBW | 10–14 | 5 cm H₂O | 35–45 mmHg | Reassess pressures and synchrony frequently during transport. |
| Obstructive | 6–8 mL/kg PBW | 8–10 | 5 cm H₂O | 40–50 mmHg | Prolong expiratory time and watch closely for air trapping. |
| Pneumonia/ARDS | 6 mL/kg PBW | 14–18 | 8–10 cm H₂O | 35–45 mmHg | Use the lowest driving pressure that achieves adequate ventilation. |
Troubleshooting Desaturation, Hypotension, and Auto-PEEP
Sudden desaturation prompts suction checks, circuit inspection, and position changes. Crews confirm depth, verify waveform, and examine the chest for complications. Hypotension after intubation responds to smaller volumes and lower rates. Clinicians reduce PEEP when preload collapses and support with pressors when needed. Expiratory flow that never reaches baseline suggests auto-PEEP requiring prompt adjustment.
Rescue Pathways and the Failed-Airway Algorithm
Supraglottic Rescue and Oxygenation-First Mindset
When attempts fail, teams pivot early to a supraglottic device. Crews confirm placement with waveform capnography and stabilize oxygenation confidently. Providers avoid lengthy attempts that erode saturation and jeopardize safety. Effective rescue preserves life while definitive management proceeds at the destination. Protocols define clear thresholds for transition and transport priorities.
Decompression in Peri-Arrest When Ventilation Fails
Stiff ventilation, crashing saturation, and falling pressure suggest tension physiology. Clinicians decompress at approved sites while another provider maintains oxygenation. Crews re-evaluate ventilator parameters and assess chest rise after each intervention. Teams document side, equipment, and response for quality review. Frequent simulations keep the skill crisp, timely, and safe.
Documentation, ePCR Pearls, and QA/CQI Signals
RSI Package Documentation and Timestamps That Matter
Strong documentation begins with indication, plan, and preoxygenation duration. Crews record devices, saturation trends, and hemodynamics before induction. Teams capture attempts, adjuncts, final technique, depth, and confirmation evidence. Ventilator settings and ETCO₂ values appear alongside transport times. Programs use these data to refine training and update protocols.
Post-Intubation Reassessments and Vent Checks That Count
Crews reassess comfort, synchrony, and hemodynamics at planned intervals. Teams verify tube security and cuff integrity whenever the stretcher moves. Clinicians chart ETCO₂ trends after any ventilator change during transport. Leaders hand off with concise medication times and current ventilator settings. Receiving teams confirm equipment, continue sedation goals, and reassess immediately.
Field Scenarios That Teach the Nuance
Agitated Hypoxemic Pneumonia Requiring DSI and Controlled VL
A patient fights the mask while saturations linger in the low eighties. Providers coach positioning while escalating PEEP through a well-sealed BVM. Dissociative ketamine allows calm preoxygenation and structured preparation for intubation. The team completes a single controlled video laryngoscopy attempt using a bougie. Post-placement care includes capnography confirmation and lung-protective ventilation throughout transport.
Hypotensive Trauma Requiring Ketamine, Gentle Ventilation, and Backup Pressors
A trauma patient presents with weak pulses and a drifting mental status. Clinicians select ketamine for induction and prepare push-dose epinephrine thoughtfully. The crew limits tidal volumes, moderates PEEP, and protects preload during transport. Sedation and analgesia follow promptly to maintain comfort and synchrony. Documentation includes ventilator settings, medication times, and response trends.
FAQs
Do I choose RSI or DSI when agitation blocks preoxygenation?
DSI fits cases where agitation prevents effective preoxygenation despite coaching and positioning. Ketamine preserves respiratory drive while enabling calm preoxygenation and safer preparation. Teams then proceed to full drug-assisted intubation once numbers stabilize. Structured checklists guide timing, roles, and readiness before laryngoscopy. Programs emphasize oxygenation as the primary outcome during difficult airways.
What confirms my tube in the field when conditions complicate assessment?
Continuous waveform capnography provides reliable confirmation during prehospital care. Crews integrate symmetric chest rise and axillary sounds as supportive checks. Disappearing waveforms trigger immediate troubleshooting and rapid reassessment of placement. Arrest physiology can lower values without proving esophageal placement alone. Teams keep oxygenation stable while resolving the cause of waveform changes.
How do I prevent awareness during paralysis on transport vents?
Teams maintain analgesia and sedation throughout every minute of paralysis. Clinicians titrate to comfort and synchrony while tracking hemodynamics closely. Providers adjust ventilator settings before repeating paralysis for dyssynchrony. Handoffs include explicit targets, redosing timelines, and recent responses. Receiving teams continue the plan to protect comfort and safety.
What ETCO₂ range should I target after placement during routine transport?
Most adult transports aim for physiologic ETCO₂ in the mid-thirties to mid-forties. Teams individualize settings for head injury or significant metabolic derangements. Clinicians avoid unnecessary hyperventilation and document reasons for any deviation. Trends matter more than single snapshots during bumpy transport conditions. Medical direction approves final targets for local protocols and devices.
Keep Moving Forward
Airway excellence grows from repetition, coaching, and transparent review within your program. Crews drill checklists, practice bougie workflows, and time short attempts intentionally. Leaders track metrics, share lessons, and update protocols with purpose. Candidates ready to enroll can review prerequisites and timelines on our Application Process page. Graduates carry these habits into every shift and protect patients with confidence.