Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department. This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.

1. Re-
Sequencing
Intubation

2. 43 Male
Sat 80% on NRB
Rales up to clavicles
In severe distress
Rips off the NRB and tries to get out of his
stretcher
Pt keeps shouting he can’t breathe

3. The
Laryngoscope as a
Murder Weapon

4. How to stop killing
our friggin’
patients when
intubating

5. DASH-1A
Bill Hinckley, MD

6. Definitive
Airway

7. Sine
Hypoxemia

8. 1st
Attempt

9. Crash

10. Paradigm Shift

12. 43 Male
Sat 80% on NRB
Rales up to clavicles
In severe distress
Rips off the NRB and tries to get out of his
stretcher
Pt keeps shouting he can’t breathe

13. Low Sat and the
Pt won’t tolerate the mask

16. RSI

17. Modified
RSI

19. Pulse Ox
Lag

20. From George Kovacs

21. DSI

22. Delayed
Sequence
Intubation

23. Denitrogenation
Preoxygenation
Positioning
Gastric Emptying
Team Briefing

24. Delayed Sequence Intubation
(DSI)

25. DSI is not
CPAP
Preoxygenation

26. DSI ApOx
Vent as
Bag
CPAP
Preox

27. How should we apply
CPAP for
PREOX?

28. CPAP Devices

29. Add a
Nasal Cannula
Journal of Clinical Anesthesia (2010) 22, 164–168

30. Mapleson

34. Nasal Cannula
+
BVM
+
PEEP Valve

35. Nasal Cannula (15)
+
BVM (15)
+
PEEP Valve (15)

36. Sometimes we
use it for other
reasons…

37. Where is the evidence
for DSI?

39. 62 Patients

46. No complications
2 patients avoided
intubation

47. A Dirty
Little Secret
about DSI

48. Where is MORE
evidence?
Strayer RJ.Am J Emerg Med. 2008 Nov;26(9):985-1028.

49. What if something
goes wrong?

50. DSI
becomes
RSI

51. A Dirty
Little Secret
about DSI

52. Emesis

53. Altered
Mental
Status?

54. What if the pt is
hypertensive or
tachycardic?

55. Can’t I do this with
other meds?

56. Standard RSI
Induction Agents?

59. DSI is just procedural
sedation
The procedure is
preoxygenation

60. emcrit.org/preox
emcrit.org/dsi

61. To Review

63. Don’t be forced
into a
CRASH
Intubation

64. DSI
keeps you
in control

65. Most
Vulnerable
Moment

66. The
Laryngoscope as a
Murder Weapon