Tag Archive for: RSI

The ENDAO Trial: Is Apneic Oxygenation a Futile Intervention in ED RSI?

21 Aug
August 21, 2017

Background: One of the most feared complications associated with rapid sequence intubation (RSI) is hypoxemia ultimately leading to cardiac arrest.  The FELLOW Trial, a recent randomized controlled trial demonstrated no difference in hypoxemia rates between patients that received apneic oxygenation and those that did not (i.e. “usual practice”) in the ICU.  What many forget about this trial is 1/3 of the patients were pre-oxygenated with a bag valve mask and another 1/3 of the patients with a BIPAP device, meaning that 2/3rds of these patients were not truly apneic during the period that induction medications were pushed up to laryngoscopy.  Currently, there is a lack of high quality research on the use of apneic oxygenation in the ED setting.  Many still use the intervention as it is cheap, easy to do, with no increase in patient harm, but there are still naysayers that do not feel the intervention is warranted in standard RSI practice. Read more →

Etomidate vs Ketamine in Trauma RSI

16 Mar
March 16, 2017

Background: Etomidate and ketamine are both routinely used as induction agents during rapid sequence intubation (RSI) in trauma patients. It is well established that etomidate transiently suppresses the adrenal gland through inhibition of the 11-beta hydroxylase enzyme. Though adrenal suppression in theory can cause deleterious outcomes, there is no high-quality evidence demonstrating a change in patient centered outcomes with it’s use in comparison to alternate agents. Ketamine has long been an alternative induction agent to etomidate but historical concerns, though disproven in more recent literature, limited it’s use due to concerns over increasing intracranial pressure. Read more →

Succinylcholine vs Rocuronium for RSI in Traumatic Brain Injury

21 Apr
April 21, 2016

Succinylcholine vs Rocuronium v2Background: Airway management is a critical part of the management of patients presenting with traumatic brain injury (TBI). Emergency Physicians (EPs) have no ability to change the primary injury once it has occurred and so our focus is on preventing secondary brain injury. Hypoxemia and hypercarbia are major contributors to morbidity and mortality and management must focus on preventing them. Patients with TBI and depressed mental status frequently require definitive airway management in order to avoid these secondary insults. Rapid sequence intubation (RSI) with serial administration of a neuromuscular blocking agent (NMBA) and an induction agent is common practice. The most commonly used NMBAs are the depolarizing agent succinylcholine and the non-depolarizing agent rocuronium. There are strong proponents arguing for the dominance of one agent over the other based on qualities of the drugs but scant data investigating the question has led to clinical equipoise. Read more →

REBELCast Bootcamp Edition

15 Jun
June 15, 2015

REBELCast Bootcamp EditionWelcome back to a special edition, or should I say “bootcamp edition” of REBELCast. We have started to do something new by inviting guests onto the show to discuss papers in the literature they find interesting. This month I had the pleasure of working with Steve Carroll, an emergency room physician in my neck of the woods, down in San Antonio, TX. Today, Steve and I are going to specifically discuss how to manage the hypoxic and agitated patient, and the topic we are discussing:

Delayed Sequence Intubation (DSI) of the Hypoxic and Agitated Patient

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