Indications

Patients requiring RSI with controlled tube placement below the vocal cords for example in:
- Trauma with:
  - Suspected or confirmed tracheal disruption
  - Risk of false passage or worsening tracheal tear

Contra-Indications

Situations where awake intubation is indicated (e.g. suspected or known difficult airway in a cooperative patient)
No suspicion of tracheal injury (no added benefit over standard RSI)
RSI not required (e.g. fasted and negligible risk of aspiration)

Prepare for RSI
- Preoxygenate, optimise patient position, ensure team and equipment readiness
Perform rapid induction and paralysis
- Administer RSI drugs
- Avoid positive‑pressure ventilation unless required to prevent or correct significant hypoxaemia
- Maintain manual in‑line stabilisation if indicated
Perform laryngoscopy
- Suction airway if needed
- Identify laryngeal inlet and vocal cords
- Insert ETT to laryngeal inlet, but do not advance distal tip beyond the vocal cords
Introduce the flexiscope through the ETT into the trachea
- Confirm endotracheal location by identification of tracheal rings, trachealis muscle, and carina
- Inspect trachea for trauma (e.g. tracheal ring disruption or false passage)
- Advance bronchoscope to the carina for definitive confirmation
Railroad ETT over scope
- Ensure bevel orientation avoids mucosal injury during advancement into the trachea
  - Once past the vocal cords rotate the ETT back if anterior tracheal injury is suspected to decrease the risk of the ETT hanging up on, and extending, a tracheal tear
- Once ETT positioned, remove flexiscope while stabilising the ETT
Confirm placement
- bronchoscope view (and secondary confirmation with VL view)
- sustained ET $CO X_{2}$ waveform
Secure the ETT