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