Don’t DSI…Rapid
Sequence Airway
Darren Braude, MD
Professor of EM, EMS and Anesthesiology
University of New Mexico
@darrenbraude
dbraude@salud.unm.edu

R.S.I.
D.S.I.
R.S.A.

Concept Evolution

So what is R.S.A.?

Advantages
• Faster
– Minimal interruption of ventilation
– Get on with diagnostics and therapeutics
– Get off scene
• High success rates
• Minimal airway trauma

Disadvantages
• Some patients are poor EGD candidates
– Upper airway obstruction
– Morbid obesity
– Severe lung disease
• Necessitates secondary procedure
• Does not provide “definitive” airway

“The best is the enemy of the
good”
Voltaire a long time ago

“The effort to avoid aspiration
that may have already occurred
or may never occur often leads
to hypoxemic complications or
even death”
Braude – Just Now

Our Data
• 55 Prehospital Patients
– Many predicted difficult intubations and/or
performed in confined space aircraft
• 93% success
– Remainder required intubation
• 3/41 (7%) with evidence of aspiration
– Lower than our ETI population

How I use RSA
• Prehospital
– On scene to keep scene times short
– In-flight
• In-hospital
– Patients with refractory hypoxemia likely
secondary to de-recruitment that are not good
candidates for DSI or to facilitate endoscopic
intubation via the EGD

American Journal of Respiratory and Critical Care Medicine
Volume 175, Number 5 (2007), Page 521

100 miles/160 km
60 miles/100 km

Summary
• RSA is an alternative to RSI for selected
situations, particularly for prehospital use
and hypoxemic patients that are poor
candidates for DSI
• RSA has not been subjected to RCTs
• SMACCDUB has been AWESOME!!