'Delayed Sequence' approach to intubation - What do you guys think?

[firemedic12]

Delayed Sequence Intubation has recently become a popular topic of conversation among the EMS junkies at my firehouse.

We have standing protocols for RSI that work fairly well, but I am a fan of avoiding field intubation whenever possible. I think that this is an interesting approach which may lead to improved patient outcomes in many cases.

Here's an overview article. There is a bunch of literature out there regarding the topic.

http://emcrit.org/wp-content/uploads/preox-deox-dsi-in-the-ed.pdf

What do you guys think? I'm curious to see if other systems are looking into this research as well.

---

Members don't see this ad.

 

[tdog60tf]

Another advantage of DSI is that frequently, after the

sedative agent is administered and the patient is placed

on non-invasive ventilation, the respiratory parameters

improve so dramatically that intubation can be avoided.

We then allow the sedative to wear off and reassess the

patient's mental status and work of breathing. If we deem

that intubation is still necessary at this point, we can

proceed with standard RSI as the patient has already

been appropriately preoxygenated

I'd like to see numbers on this......even pts placed on CPAP sometimes require intubation. Not sure how your fixing the pathology causing the hypoxia so quickly by giving a sedative and ventilating.

The article even states this:

A physiologic shunt is caused by

areas of alveoli that are blocked from conducting

oxygen, but still have intact blood vessels surrounding

them. This perfusion without any ventilation leads to a

direct mixing of deoxygenated venous blood into the

arterial blood. Causes of shunt include pneumonia,

atelectasis, pulmonary edema, mucus plugging, and

adult respiratory distress syndrome. No matter how

high the fiO


2, these areas will never have an improved

oxygenation because inhaled gas never reaches the

blood. The only way to improve oxygenation in these

areas of the lungs is to fix the shunt.

Pneumonia, Pulmonary Edema etc...don't go away because your preoxygenating.....therefore preventing intubation??


Secondly, this to me is a waste of time in the field. Get em to definitive care or tube em then fix the underlying pathology.

 

[turkeyjerky]

I think this is a great approach to preoxygenation in the ED, however I don't really think it's a prehospital intervention. If you're talking about giving the patient some anxiolysis in order to tolerate NIV on the way in, then I'm all for it. But actually planning out a full DSI? Seems like the focus in that case should be on transport. Obviously this depends on your transport times.

Pneumonia, Pulmonary Edema etc...don't go away because your preoxygenating.....therefore preventing intubation??


Secondly, this to me is a waste of time in the field. Get em to definitive care or tube em then fix the underlying pathology.

I think you need to review your indications for intubation/mechanical ventilation. Pneumonia, pulmonary edema etc, are not indications for ETT placement. Failure to oxygenate, however, is. And that most certainly can be corrected via CPAP or NIV.

 

[firemedic12]

If you're talking about giving the patient some anxiolysis in order to tolerate NIV on the way in, then I'm all for it.

That would definitely be my interpretation of the pre-hospital approach to DSI. I like the idea of administering our sedative, proceeding to NIV pre-oxygenation, and then reevaulating to possibly avoid the tube altogether.

The real selling point for me would be a faster transport time. I agree that formally setting up a full DSI would be inappropriate for pre-hospital settings. As you pointed out, our focus should be on transport.

Obviously there will always be circumstances in which RSI is indicated, but I think that having a protocol for an approach dealing with some variation of DSI could be very useful.

Pneumonia, pulmonary edema etc, are not indications for ETT placement. Failure to oxygenate, however, is. And that most certainly can be corrected via CPAP or NIV.