This post might become a regular under the banner “What I learned from Scott Weingart this week!” Scott runs the EMCrit blog and if you haven’t seen it – do yourself a favour and download his podcasts from Itunes – he is a great teacher, and pitches his education in a practical / pragmatic fashion that is well suited to rural GP Anaesthetic / ED types.
I got in contact with Scott a few weeks back to give my 5 cents on “pre-oxygenation”, basically I (and a lot of Anaesthetists) was taught to think of it as “denitrogenation” of the lungs – aiming to get the ET O2 up to 80 – 90% prior to RSI. This is true, however as Scott has pointed out in his video response – this is missing a few crucial steps. You cannot directly translate what we do in OT back to the crashing ED patient.
Check out Scott’s video and demonstration of pre-oxygenation on himself.
Then check out Scott’s “DSI: delayed sequence intubation” concept – this is basically how to preoxygenate a sick patient, and hopefully avoid them crashing on induction. The link then links to another video demonstrating the technique.
This is me learning a better way, it does break a few of the “Anaesthetic Commandments”.
Would love to hear your comments
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Great blog and also great to have a rural/remote point of view. I am a ACRRM with almost exclusive expereince in rural and remote australia. Particular the Isa and mining communities in central Qld. I think the problem with all of these RSI rules so to speak is that they come from the anesthetic world. Commonly fasted patients, pre-screened, sats normalised, predicted difficult airways etc.
Where is the ED airway rule all of the above is not present. I do believe that we need to rethink the RSI paradigm be it DSI or even rsa a RFDS doc I know does the following:
Standard RSI placement of proseal single use drop a ng tube suck the gastric content up this ensures that the patient is adequately pre-oxygenated then proceeding to traditional intubation. This is conceptually great as we have ensured the patient is pre-oxygenated not on the code brown end of the disassociation curve and that we have ensured that we can oxygenate if we cant get a ETT in! Would love your comments on this
Hi Ray. Interesting technique. I have to say, I am not too comfortable with an LMA in a resus / trauma case up front. I completely accept that it is great if you are not prepared to tube or the right skills are not present, however in my practice it is unusual not to be able to get the ETT down either clean or with a bougie. (Probably < 5% of cases) If you can get the tube down quick, then I reckon this is the best option. THe LMA / proseal is a good plan B and has saved my bacon a few times, and has a place as plan A when the patient arrives on your bed before you have had a chance to do any prep / get the team together - this still happens to me a bit! I teach this to my JMOs / nurses who might get stuck at 3 am, waiting for one of the senior MOs to arrive. I have yet to have a chance to use the DSI that Scott and Emcrit descibes - but I think that this is a good option in the sick / trauma patient where you have a few minutes to get it together and recruit all the lung you can before dumping in your drugs. Thanks for reading, keep the comments coming! Casey