You prepare to intubate the patient using a rapid sequence induction protocol: etomidate, succinylcholine, 8-0 endotracheal tube.
Or do you?
This Paucis Verbis card discusses the delayed sequence intubation (DSI) protocol made famous by Dr. Scott Weingart (EMCrit blog). Thanks to Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob Bryant (Intermountain Medical Center in Utah) for designing this helpful card. Rob has even implemented a DSI protocol in his ED.
The card breaks down the reasoning and steps behind DSI. Anecdotally, ketamine has often calmed patients down enough during the preoxygenation phase to enhance oxygenation/ventilation so much so that intubation is not required.
Feel free to download this card and print on a 4'' x 6'' index card.
See other Paucis Verbis cards.
References
Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. PubMed PMID: 22050948. Link to free PDF
I am going to go out on a limb here and state that DSI should not be done. Every expert in airway management, at least in the US, has come out against this.
ReplyDeleteok, at least MANY experts (Ron Walls being one of them) have come out against it. I am definitely not sold on it, so I guess what I am saying is...be careful!
ReplyDeleteIs there any literature against DSI?
ReplyDeleteA few points:
ReplyDelete1. The opinion of one "expert" (ie Ron Walls) smells of pride, dogma, and anecdote...all are much greater limits to good patient care and progress in clinical practice than some ketamine or DSI
2. In my opinion (yes, I see the irony), the reported incidence of laryngospasm is greatly over-reported (must less than the 0.3% often quoted)...too many times I have seen a large dose of ketamine pushed too quickly with the expected transient apnea misinterpreted as laryngospasm by clinicians inexperienced with ketamine. I would say that largyngospasm should not be a concern for a doc who would prefer RSI to DSI anyway, as NMB will fix any larngospasm and NMB is what the skeptic is recommending anyway (I hope).
HH
Excellent comments, everyone. I think with any new changes in technique or protocols, one should be cautious before implementing as standard of care.
ReplyDeleteFrom the PHARM Podcast with Scott and Minh Le Cong (http://prehospitalmed.com/2012/06/20/pharm-podcast-23-mr-emcrit-and-the-dsi-chronicles/) mentions how the "old guards of airway management" were initially skeptical of the DSI approach.
Concerns include:
- ketamine adverse effects
- "hybrid" protocols based on DSI causing complications
- aspiration, loss of airway reflexes
As for literature for/against DSI, there actually aren't any studies either way! Just anecdotal reports. That being said, I've done this about 3 times. Two eventually got intubated but had great much-needed preoxygenation period. One just got better with BiPAP.
Someone SHOULD do a DSI study.
The lack of evidence is suboptimal but the patient population for DSI is a very sick group with few other options and isn't perfectly amenable to study. What else would we do for the patient who we cannot preoxygenate? now the "standard" is give RSI meds, bag patient up, and if that doesn't work then too bad!
ReplyDeleteOur case series of ~2 dozen patients with safe DSIs will be presented at the Society for Airway Management meeting later this month, and hopefully a formal paper (with more patients) after.
Looking forward to seeing the case series publication.
DeleteAgree that anti DSI might be eminence based rather than evidence based, but also agree there is a paucity of evidence. Surprised that Walls would be stongly against - his concept of reserve changed my airway med giving life! (And DSI fits neatly into that paradigm) Perhaps there is a fear that some pts. in dire need of a tube will have delayed care and worse outcomes.
ReplyDeleteI think this is just the nature of things when trying to change established standards of care in Medicine. RSI is such an ingrained foundation in our training, that it's often hard to think beyond it. With more time (and formal evidence), I'm sure DSI will be an accepted approach.
Delete