Out-of-hospital rapid sequence intubation practices by emergency care practitioners in selected provinces of South Africa: a retrospective cross-sectional review

Rapid Sequence Intubation (RSI) is an advanced airway intervention performed by Emergency Care Practitioners (ECPs) in South Africa to secure a definitive airway for critically ill or injured patients in the out-of-hospital setting. Although RSI forms part of advanced out-of-hospital airway management practice in South Africa, limited evidence describes documented pharmacological practices, airway management strategies, procedural outcomes, and peri-intubation Adverse Events (AEs). This multicentre study described documented out-of-hospital RSI practices performed by ECPs in selected South African provinces. A descriptive cross-sectional retrospective record review was conducted using patient care records from participating public and private Emergency Medical Service (EMS) providers in Gauteng, KwaZulu-Natal, and the Western Cape provinces between January 2019 and April 2025. Patient care records documenting RSI performed by Health Professions Council of South Africa (HPCSA)-registered ECPs were reviewed using a predefined data extraction tool. Variables included patient characteristics, pharmacological agents administered, airway management practices, procedural outcomes, and documented AEs. Data were analysed using descriptive statistics, with exploratory analyses examining associations between selected pharmacological strategies and first-pass intubation success, and between multiple intubation attempts and documented AEs using Odds Ratios (ORs), 95% Confidence Intervals (CIs), and p-values. A total of 535,479 patient care records were received or screened, of which 354 met the eligibility criteria for analysis. Trauma accounted for 238/354 (67.2%) RSI cases. Ketamine was documented in 265/354 (74.9%) cases and rocuronium in 185/354 (52.3%). Pre-oxygenation was documented in 352/354 (99.4%) cases, end-tidal carbon dioxide monitoring in 296/354 (83.6%), and post-intubation sedation and/or analgesia was documented in 255/354 (72.0%). Overall procedural success was documented in 334/354 (94.4%), while first-pass intubation success was documented in 287/354 (81.1%). Documented AEs included emesis in 33/354 (9.3%), airway trauma in 26/354 (7.3%), cardiac arrest in 16/354 (4.5%), and oesophageal intubation in 8/354 (2.3%). Exploratory analyses showed no significant association between induction and neuromuscular blocking agent choice and first-pass success; however, multiple intubation attempts were associated with higher odds of any documented AEs (OR 2.20; 95% CI 1.17–4.14; p = 0.015). This retrospective review provides contemporary evidence describing documented out-of-hospital RSI practices among participating South African EMS providers. The findings demonstrate high documented procedural success and widespread use of ketamine and rocuronium, with no significant association between pharmacological strategy and first-pass success. In contrast, multiple intubation attempts were associated with higher odds of documented AEs, reinforcing the importance of first-pass success as a procedural quality indicator. Opportunities remain to strengthen airway monitoring, post-intubation management, documentation quality, and clinical governance. Not applicable.