scott weingart - emergent intubation resequenced
TRANSCRIPT
Re-Sequencing Intubation
43 MaleSat 80% on NRBRales up to claviclesIn severe distressRips off the NRB and tries to get out of his stretcherPt keeps shouting he can’t breathe
TheLaryngoscope as a
Murder Weapon
How to stop killingour friggin’
patients when intubating
DASH-1A
Bill Hinckley, MD
DefinitiveAirway
SineHypoxemia
1st
Attempt
Crash
Paradigm Shift
43 MaleSat 80% on NRBRales up to claviclesIn severe distressRips off the NRB and tries to get out of his stretcherPt keeps shouting he can’t breathe
Low Sat and thePt won’t tolerate the mask
RSI
Modified
RSI
Pulse OxLag
From George Kovacs
DSI
DelayedSequenceIntubation
DenitrogenationPreoxygenation
PositioningGastric Emptying
Team Briefing
Delayed Sequence Intubation
(DSI)
DSI is not
CPAPPreoxygenation
DSI ApOx
Vent as Bag
CPAPPreox
How should we apply CPAP forPREOX?
CPAP Devices
Add aNasal Cannula
Journal of Clinical Anesthesia (2010) 22, 164–168
Mapleson
Nasal Cannula+
BVM+
PEEP Valve
Nasal Cannula (15)+
BVM (15)+
PEEP Valve (15)
Sometimes weuse it for other
reasons…
Where is the evidence for DSI?
62 Patients
No complications
2 patients avoided intubation
A DirtyLittle Secretabout DSI
Where is MOREevidence?
Strayer RJ.Am J Emerg Med. 2008 Nov;26(9):985-1028.
What if somethinggoes wrong?
DSIbecomesRSI
A DirtyLittle Secretabout DSI
Emesis
AlteredMentalStatus?
What if the pt is hypertensive or
tachycardic?
Can’t I do this with other meds?
Standard RSIInduction Agents?
DSI is just procedural sedation
The procedure is preoxygenation
emcrit.org/preoxemcrit.org/dsi
To Review
Don’t be forcedinto a
CRASHIntubation
DSIkeeps youin control
MostVulnerable
Moment
TheLaryngoscope as a MurderWeapon