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The RSI Kit Dump

Article regarding the principles and practice of the pre-hospital RSI kit dump

Pre-hospital team in RSI kit-dump with packaged patient, pre-oxygenation in progress

In the step Lara Hammond (KSS HEMS Paramedic) and Julian Wijesuriya (KSS HEMS Doctor) describe the principles and practice of setting up a standardised RSI kit dump for pre-hospital emergency anaesthesia and intubation.

Introduction

The ideal location for anaesthesia and airway management is the hospital anaesthetic room, which gives clinicians a safe, well-organised space to work. There are many essential components to the anaesthetic room setup that can easily be taken for granted. Pre-hospital scenes, by definition, do not offer such “luxuries” and present a number of additional challenges. It is incumbent on pre-hospital clinicians to create a safe space containing these essential components before undertaking pre-hospital emergency anaesthesia.

Image highlighting the ergonomics of the hospital anaesthetic room - as per article text Components of a hospital anaesthetic room

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Airway Matters

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The RSI Kit Dump Concept

Safe pre-hospital anaesthesia and intubation requires a standardised setup that can be deployed on scene, comprising the required personnel, equipment and environmental protection. This is colloquially termed “the RSI kit dump” and is established by the airway assistant. However, the term is somewhat of a misnomer, as unlike its fairly simplistic name, there is a lot more to the RSI kit dump than may initially be apparent.

Every pre-hospital scene is different and it takes experience and skill to assess the scene, mitigate hazards and utilise available resources in order to rapidly establish an RSI kit dump.

Schematic representation of the RSI kit dump setup - locaitons of kit and personnel

Schematic of a standardised RSI kit dump. Credit: KSS Standard Operating Procedures

The RSI kit dump ensures that essential airway equipment is immediately available and that back-up emergency rescue devices are close at hand. There is also some redundancy built into the setup – in case of failed oxygen supply, suction or airway equipment.

The patient should concurrently assessed, treated and packaged in a standardised way, as you learnt in a previous step. This ensures that they are clinically stabilised, appropriately monitored, physically secure and in an appropriate position prior to induction of anaesthesia.

Selecting and Optimising the RSI Kit Dump Location

Key factors to consider when selecting & creating a kit dump location include:

Hazards
Space & patient access
Light, weather & terrain
Noise
Vehicle access & egress
Patient privacy
On scene resources
Patient specific factors

Hazards

Safety is paramount and, as discussed in a previous activity, it is the responsibility of the team to identify and address any hazards prior to the kit dump setup.

Space & Patient Access

The chosen location should allow enough room to access the patient from 360 degrees, including adequate space for the patient, both crew members, and any additional colleagues that may be needed, for example to provide MILS or cricoid pressure. 360 degree access is essential for trauma patients who may require surgical procedures such as thoracostomy or thoracotomy immediately after intubation.

Terrain & Weather

The RSI kit dump area should be flat and, if possible, sheltered from weather. As both team members are likely to be kneeling, the terrain should ideally be dry and firm. If this is not possible, there may be time to put down blankets or head-blocks to improve stability. Shelter can be created by positioning bags to shield lightweight equipment from the wind, or by asking other emergency service colleagues to set up temporary structures or tarpaulin sheets to shield from the rain. Wind direction should also be considered where there is fire, smoke or noxious gases on scene or nearby.

Light

Light is a key consideration when selecting an RSI kit dump location and may influence the decision to use direct or video laryngoscopy. During the daytime it is typical to ensure that the sun is behind the intubator, so they are not looking directly into bright light. However if videolaryngoscopy (VL) is anticipated then additional shading from glare may be required. At night, lamp posts, external residential lights, vehicle lights or mobile lighting from other emergency services can be used to light the area. As with strong sunlight, if VL is used, it may be necessary to reposition lights (or the kit dump) in order to minimise glare on the screen.

Noise

If possible, an area selected should be away from noise or large crowds. In some cases it may be possible to control noise at critical times; strategies include: asking colleagues to turn off their vehicles, pausing the use of loud equipment (eg lifting or cutting equipment) or asking the police services to move large numbers of bystanders. This is especially important on scenes involving multiple patients or entrapped patients.

Vehicle access & egress

Forward planning is essential to avoid delays to definitive patient care; this includes considering how the patient will be conveyed to hospital. When selecting an RSI kit dump location it is helpful to ensure that there is easy access to the conveying aircraft or ambulance and that the vehicle itself has a clear egress route from scene. In many cases it may be necessary to move the vehicles rather than the kit dump to facilitate this.

Patient Privacy

While patient and team safety is the primary consideration, patient privacy is also important and should be maximised if the environment allows. Prehospital teams arriving by air can attract large amounts of interest from the public, equally patients may present in areas of high foot traffic, such as parks or busy pedestrian areas. The police can help by setting up a cordon and controlling large crowds. Emergency vehicles can be used to shield the area from sight and other emergency service colleagues can hold up tarpaulin sheets or blankets to provide privacy for the patient.

Extreme Conditions

There may be instances where the challenges of the environment outweigh the benefit of having 360 degree access to the patient. These can include severe weather, such as torrential rain or significant levels of surface water, or scene safety factors such as contamination or the presence of hostile bystanders. In such cases, consideration may be given to conducting an RSI inside an ambulance or aircraft, inside a property or relocating away from the scene. These situations require pre-emptive training, careful consideration of the balance of risks and agreement within the team.

Practicalities & Setup

Airway Equipment Sheet

Essential airway equipment should be immediately available and prepared on a clean waterproof sheet. This equipment typically includes:

RSI checklist and drug aide memoire
Laryngoscope with chosen blade
Appropriate ET tube with KY gel, 10ml syringe and tube tie
Bougie or stylet
Circuit including: inline ETCO2 monitoring, HME filter and catheter mount
Temperature probe
In-line suction
Pre-drawn anaesthetic drugs

Equipment should be taken out of its packaging, checked and kept clean. In addition, secondary equipment such as supraglottic airway devices, surgical airway equipment and alternative laryngoscope blades should be prepared or close to hand if not laid out.

Immediately-required airway equipment laid out on clean plastic sheet The airway equipment sheet (drugs not shown)

Additional Equipment

In addition, the following equipment is required:

Two oxygen cylinders (confirmed full and with master valves open)
Primary and backup suction units
Emergency drugs
Bag-valve-mask (BVM)
Patient monitor

Some of this equipment may be with the patient and does not need to be duplicated. The figure below shows an overview of a prepared RSI kit dump prior to the patient’s arrival.

View of kit dump setup from behind - showing bags, equipment and drugs arranged in a standardised way Overview of the RSI kit dump

Objective

The ultimate goal is to achieve a safe, appropriately lit area that is flat, protected from the elements and allows full access to the patient. All the essential components of the hospital anaesthetic room should be present and organised in a standardised manner. In this setup the doctor and paramedic are side by side and at same level ensuring good communication, a shared overview, and in close contact for handling airway equipment.

Complete RSI kit dump with patient and essential personnel

Team Dynamics

Initial Assessment

Two person pre-hospital teams should work together during initial patient assessment and management, with the general guideline to remain together “until the scoop is clipped” or in some cases until the patient is fully packaged. This ensures both team members have a shared understanding of the patient’s condition and can jointly plan further patient management.

At an appropriate time, the airway assistant will move away from the patient and their colleague and start setting up the RSI kit dump. Prior to this there should usually be a short discussion within the team regarding drug regimens and dosages, blade type and ETT sizes.

Communication & Situational Awareness

Ideally when setting up the kit dump, the airway assistant should remain in visual and verbal contact with their colleague who has remained with the patient. This enables them to assist if there are any changes in the patient’s condition and ensures both team members maintain situational awareness. This is an additional consideration when selecting the RSI kit dump location.

There may be instances where this is not possible, for example when a patient is inside a property and the RSI is planned to take place outside. In such cases, the airway assistant could peel away as extrication starts, in order to minimise the time they are out of contact or intermittently regroup with their colleague if appropriate.

Standardisation & Safety

Having standard operating procedures (SOPs) and rehearsal ensure that individual team members have a consistent approach to scene and patient management and the RSI kit dump process. This allows colleagues who have not worked together before to work safely and efficiently together, but also ensures that the process causes minimal cognitive loading. When dealing with chaotic scenes or complex patients, these practices can provide a feeling of familiarity, stability and control and this allows teams to regroup and restore bandwidth. Similar principles apply to the conduct of anaesthesia and difficult or failed airway drills.

Summary

The RSI kit dump represents the pre-hospital re-creation of the hospital anaesthetic room. The process optimises patient and team safety, ensures that vital equipment is available and that personnel have the space to work. Having a standardised process reduces cognitive loading and brings structure to chaotic scenes. Overall, the RSI kit dump is one of the cornerstones of safe pre-hospital anaesthesia and intubation.