1. RSI Check List Version 4 May 2012
Step Tick or Time
People
Anaesthetist: (Unless patient in ED and ED seniors able to manage) Called ____:____ Arrives _____:_____
ED Senior if patient in ED Called ____:____ Arrives _____:_____
XRay: Call in if not onsite. Called ____:____ Arrives _____:_____
Team leader / drug push _____________ Hands off if possible
List speaker / scribe _____________
Intubator _____________]Prepare air way equipment
Intubator’s assistant _____________]suction, pass tube, hold corner of mouth
Cricoid / External Laryngeal Manipulation _____________)
C-spine stabilisation if required _____________)assist with drug preparation
Monitoring, lines, fluids _____________)
Patient assessment
AMPLE Hx – if available
• Allergies/sensitivities esp to anaesthetics
• Medications
• Past medical, surgical and anaesthetic Hx
• Last ate or drank
• Events – what got the patient into this state
Airway assessment. Risk of difficult BVM or intubation
• Neck size and mobility (including potential c-spine injury)
• Thyromental distance
• Beard
• Mouth opening and jaw protrusion
• Dentition
• Tongue size/masses
• View of oropharynx / modified Mallampati (I: all of uvula; II: part of uvula; III: soft palate;
IV: hard palate only) ______________
• If in ED: Call anaesthetist if signs of difficult BVM or intubation
Obs
• Current Observations. Does technique need to be modified?
• O2 sat _______%
• RR _______
• HR _______
• BP ___/____
• GCS E ___/4 V ___/ 5 M ___/6 = ___/15
• Best Motor R ________ L ________
____:_____
• Pupils R ______mm Reactive ____ L ______mm Reactive ____
Ponder Is this the right thing to do now with the available resources?
Preparation
Drugs: Doses calculated, drawn up and labeled
• Pressor eg phenylephrine or ephidrine
• Anaesthetic eg propofol, ketamine, etomidate
• Muscle relaxant eg suxamethonium or rocuronium
• Sedative bolus + infusion eg propofol, midazolam, ketamine
• Analgesic bolus + infusion eg fentanyl
• Long acting muscle relaxant if not used for RSI eg rocuronium
2 oxygen sources + bag-valve-mask checked. Nasal prongs. 
Suction on and under pillow
ETT 
• Lubed stylet or bougie in ETT: Adult male: 8. Adult female: 7.5. Paeds: age/4 +4
• A smaller and larger ETT available
Monitoring x4 
 Audible oximetry
 BP set to go every 2 minutes
 ECG – check the trace to make sure you’re not missing something cardiac/tox
 Capnography tested and attached to ambubag
Airways: Oral and nasal airways sized but not opened
Bougie
IV line x 2, IV fluid running, take bloods if required
Laryngoscope x 2 tested
LMA of correct size but not opened
Surgical airway available but not opened (unless “double set up” deemed necessary)
Position patient: ear canal in horizontal line with sternal angle or reverse Trendelenburg
Preoxygenate: Ambubag, CPAP or BIPAP, or 15L via reservoir mask > 3 minutes if possible
• Check O2 supply and ambubag

2. • Consider high flow O2 via nasal cannula
• Time preoxygenation started
Put to sleep: Anaesthetic _________________________ Dose ______mg ____:_____
Paralyze _________________________ Dose ______mg ____:_____
Protection
C-spine if needed
Cricoid
Place tube
Type of laryngoscope
If difficulties: options ____:_____
• External laryngeal manipulation ____:_____
• Bougie ____:_____
• Different laryngoscope (type) ____:_____
• LMA (type)
• Surgical (type)
Tube type (circle): ETT LMA Surgical
Size _______ Depth _________ at Teeth/gums (Adults 24cm, Paeds 3 x ETT)
View Grade: __________ (I: complete glottis visible. II: anterior glottis not seen
III: epiglottis seen, but not glottis, 4: epiglottis not seen).
Placed by _____________________________ Attempt no: _____
Comments:________________________________________________________________________
Proof
End tidal CO2 ___________mmHg ____:_____
Fogging of tube
Auscultate
O2 sats ______% ____:_____
(Also check a BP now: _____/______) ____:_____
Secure tube
CXR: Call for XRay now. Take XRay once NG/OG tube in situ
Post intubation management
Drugs
• Sedative
o Bolus ________________ Dose ______mg ____:_____
o Infusion ________________ Rate ______mg/hr ____:_____
• Analgesic
o Bolus ________________ Dose ______mg ____:_____
o Infusion ________________ Rate ______mg/hr ____:_____
• Muscle relaxant
____:_____
o Bolus Rocuronium Dose ______mg
o Next dose due: Time ____:_____ (30-45 minutes later depending on initial dose)
Airway
• Suction ETT
• Insert NG or OG tube
• Check tube position
o Auscultate
o Tube length at teeth/gums _________cm
o Oximetry ________%
o End tidal CO2 _______mmHg ____:_____
o XRay Performed: _____:_____ Viewed: _____:_____
Breathing: Put on ventilator eg SIMV, TV 6ml/kg, F = 16, 5cm PEEP, 100% O2 ____:_____
Circulation
• HR ______ BP ____/_____ ____:_____
• Fluids and pressors as required
• Bloods eg VBG
• Urinary catheter
• Consider arterial line if time
D
• Check patient adequately sedated: Look for HR or BP or tearing
• Recheck pupils
• Head up 30º if no spinal injury suspected
• Consider mannitol if neurosurgery imminent
E: Thermoregulation as appropriate. Keep warm unless post VF arrest. Temp _____˚C
F: Inform family + gather history from them
G: BSL ______ mmol/L
H: Hx eg from old notes, family, GP. Document Hx and events in ED
I: Any further investigations needed: Bedside, lab, imaging
R: Refer
S: Secondary survey if not done
T: Tetanus, clean wounds, antibiotics if time.
T: Thank the team

3. T: Transfer
NB: In ED the intubator is responsible for photocopying this sheet and putting a copy in Dr Cresswell’s pigeon
hole.