An unanticipated difficult RSI can occur for a number of reasons:

  • Rapidly deteriorating patient/ haemodynamic instability – make attempts to optimise haemodynamic parameters prior to intubation and ensure team aware of, and plan for deterioration.
  • Uncooperative or combative patients – consider cause of agitation or aggression – can this be managed/treated prior to RSI? Is the use of delayed sequence intubation (DSI) required [Modified RSI where ketamine is used to provide a dissociative state, allowing pre-oxygenation to occur. RSI can then proceed in a safe controlled fashion.9
  • Structural airway problems (e.g. short neck, immobilised neck in trauma) – experienced airway operator (s) present? Use of video laryngoscope considered?
  • Full Stomach (increased risk of regurgitation, vomiting, aspiration), secretions, vomitus, blood present – tilting trolley in use? Suction and back up suction available, team briefed on plan for vomiting?
  • Difficult ventilation – ensure airway adjuncts available and sized pre-procedure (NPA, OPA, LMA), two-person BVM technique. Significant facial hair such as prominent beards can make mask ventilation challenging. Some suggested management steps include using a tegaderm/defibrillator pad over the entire mouth and hair with a hole cut in the middle for ventilation. Removal can be another solution (however care needs to be exercised around facial hair in cultural and religious circumstances and where possible consent should be obtained prior to its removal. Another suggested route would be to if first laryngoscopy attempt is unsuccessful to bypass NPA/OPA/ Mask ventilation and proceed directly to LMA prior to second attempt at laryngoscopy.10

Always ensure that the following medications are within reach:

Drug Use How to make up Final concentration Suggested initial dose
Atropine Bradycardia Neat from pre-filed syringe  






Neat into 2ml syringe 600mcg/ml 600mcg
Glycopyrronium Bradycardia Neat into 5ml syringe 200mcg/ml 200mcg
Metaraminol 10mg Hypotension 1 vial Add N Saline to make 20ml 0.5mg/ml 0.5mg
Ephedrine 30mg Hypotension 1 vial Add N Saline to make 10ml 3mg/ml 6-9mg
Sugamaddex 500mg/5ml Reversal of NMB Neat into 5ml syringe 100mg/ml 16mg/kg (immediate reversal)
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