Performing Rapid Sequence Intubation safely in the ED.
RSI in the ED is a dangerous undertaking. Focus on these 4 areas to improve safety:
ED vs Anaesthesia
Higher complication rate in ED, with higher case fatality rate when complications develop.
Incidence of death or brain damage from an airway event 38x higher in ED, and 58x higher in ICU, compared with anaesthesia.
Anaesthesia 1:150,000, ED 1:4000, ICU 1:2600
More can be found here (EMCrit) and here (NAP4)
Read Tim Leeuwenburg evidence-based talk here
Other checklist links available here
We don’t have evidence that doing a risk assessment in beneficial, but we have evidence that not doing it is harmful (NAP4)
Levitan’s ear-to-sternal notch positioning
Find out about ramping here and here (EMUpdates)
See also the PreOx, ReOx paper by Weingart & Levitan
Preoxygenation, Reoxygenation and Deoxygenation – EMCrit
Covers Pre-oxygenation with CPAP in the hypoxic patient – watch the 2 videos
Preoxygenation and Prevention of Desaturation During Emergency Airway Management article by Scott Weingart and Rich Levitan – a must read
RebelEM – a nice summary and explanation of the above paper
http://lifeinthefastlane.com/ccc/preoxygenation/ – LITFL’s overview
The problem with the BVM for pre-oxygenation – Nick Crimes
NO DESAT! – Rich Levitan
PulmCrit – an in-depth discussion by Josh Farkas, including the THRIVE study
http://lifeinthefastlane.com/ccc/apnoeic-oxygenation/ – LITFL’s overview
Apnoeic oxygen relies on an open airway, so we have to maintain a jaw thrust.
NCs buy you more time, in normal, obese and hypoxic patients.
High-flow NC would be even better, but are complicated because getting a BVM seal over them is not possible
Failed Airway Plans
Failing to plan for failure increases risk (NAP4)
Vortex available here and other difficult airway plans available here (LITFL)
Find out more about the post-intubation package from EMCrit and download the checklist here
Protective lung ventilation is the current standard of care for mechanical ventilation, and includes low tidal volumes (4-8 mL/kg predicted/ideal body weight, not actual body weight) as well as low pressures. It reduces mortality both in patients with ARDS and those without. Find out more on LITFL.