OBJECTIVE: Rapid sequence intubation (RSI) is used to secure the airway of some patients with stroke. Recent observational studies suggest that RSI is associated with poorer survival, and that decreases in systolic blood pressure (BP) following RSI could be a cause of worse survival. The present study aims to find if decreased systolic BP after paramedic RSI is associated with poorer survival in stroke patients transported by ambulance. METHODS: The present study was a retrospective analysis of all stroke patients who received paramedic RSI attended by Ambulance Victoria, Australia. Logistic regression predicted the survival for strokes that had received RSI. The change in systolic BP during paramedic care was the main predictor. RESULTS: Of 43 831 patients with stroke, 882 (2%) received RSI. Almost 48% of RSI had a decline in systolic BP of more than 20% from baseline, and the decline in systolic BP after RSI was largest for intra-cerebral haemorrhage (-22.7 mmHg) compared to ischaemic strokes (-10.1 mmHg) or subarachnoid haemorrhage (-15.6 mmHg) (P = 0.001). Sixteen percent of the RSI group had an episode of hypotension anytime during the out-of-hospital care. For each 10 mmHg decrease in systolic BP with RSI for intra-cerebral haemorrhage an increase of 11% in the odds of survival is apparent (P = 0.04); for subarachnoid haemorrhage an increase of 17% (P = 0.02) and for ischaemic strokes a non-significant decrease of 7% (P = 0.26). CONCLUSIONS: Paramedic RSI-related decrease in systolic BP is associated with improved survival in those with intra-cerebral or subarachnoid haemorrhage but not ischaemic stroke.