RSI and then they die
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- čas přidán 23. 07. 2024
- When patients come in critically ill, we have lots of excuses. They were sick before we got to them. The outcomes are easy to rationalize. However, the truth of the matter is, they were alive before we decided to intubate, and now they are dead. Although I believe we have been improving since I started practicing emergency medicine, statistics tell us that peri-intubation cardiac arrest is still a common occurrence in emergency medicine and critical care. This talk considers the 5 high risk scenarios for “RSI and then they die” and what we can do to prevent that outcome.
The check list I use for predicting peri-intubation collapse is:
What is the patient’s oxygen?
What is their blood pressure (and shock index)?
What is their respiratory rare (ie, could this be metabolic acidosis)?
Could this patient have RV failure?
Is there bronchospasm?
That check list will help you identify almost all patients who are high risk for peri-intubation arrest. Before every intubation, just remember to pause and ask:
Is this patient ready for intubation?
Is RSI the best approach?
Because we were trained on the ABC model, airway always feels like a priority, but remember it is often a better idea to resuscitate before you intubate.
More resources:
The FIrst10EM airway series:
first10em.com/airway-optimizi...
first10em.com/airway-is-the-p...
first10em.com/intubation/
first10em.com/cricothyroidotomy/
first10em.com/post-intubation/
Pulmonary hypertension and right ventricular failure:
first10em.com/pulmonaryhtn/
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Resuscitation: resus.first10em.com/
Evidence based medicine: ebm.first10em.com/
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Timestamps:
00:00 Intro
01:35 Start of talk
04:16 Key points
05:50 Case 1 (Oxygen)
20:40 Case 1 continued (Hypotension)
32:09 Case 2 (Metabolic acidosis)
36:14 Case 3 (RV failure)
42:44 Case 4 (Bronchospasm)
45:43 Conclusion
Hashtags:
#resuscitation #emergencymedicine
First10EM is devoted to free, open access medical education, aimed at medical professionals. The website does not provide specific medical advice. I may be a physician, but I am not your physician. If you are a medical professional, the information should be used like any other you encounter: think critically, consider other sources of information, and ensure that you understand how the information presented here fits with your own skills, work environment, and resources. Full disclaimer: first10em.com/disclaimer/
I have never accepted money from any drug or device company. I have no financial conflicts of interest in any information I present.
Thank you for watching! 🙂
I read the title of this video and got a bit concerned ... I have just been diagnosed with repetitive strain injury.
Welp, son, looks like we gotta put yah down! lol.
4:19 As an anesthesiologist I am very much looking forward for what’s coming next in this video. I feel it’s something I’ll most likely agree with.
After watching it all, I could confirm my hypothesis. Great work!
as someone who works in health insurance and an abnormal interest in autopsies, i am too... its great to see when medical experts can learn from mistakes rather than hide them for fear of malpractice
Excellent lecture. I think this would also be extremely good for those of us on the pre-hospital side of EM. Addressing these risk factors in the field would probably greatly improve pt outcomes
One important cause of hyooxia in the 'peri-intubation' period is aggravated ventilation perfusion mismatch due to hypotension (reduction in cardiac output) from positive pressure ventilation, sedative medications, and patients already in shock. Have a low threshold to give phenylephrine/ ephedrine/ mephentermine if there is downtrend in MAP, without actual hypotension. Do not ever try to give any BP lowering agent in hypoxic patient (+/- hypeecarbia). The hypertension is due to reflex sympathetic activation. This will settle / get replaced by hypotension soon after intubation.
such a useful video. please keep making more vdeos like this one .
As always a great review on the subject.
Instead of the expensive NIV-masks I would suggest the technique advocated by Scott Weingart using a standard BVM mask that is equipped with a ring with 4 hooks (the rings are sold separately as well if your masks come without them) in combination with cheap reusable mask straps.
You can now provide CPAP hands-free if you add some corrugated tubing in combination with the BVM+PEEP valve+NC+ ETCO2 setup or you can provide either CPAP or BPAP if you hook the patient up to a standard ventilator set to NIV mode (which all but the most basic of ventilators have these days).
I would advise great caution against using the dedicated NIV machines for this as some models require special masks where the exhalation port is fitted into the mask itself. But since you were planning to intubate the patient anyway why not use the regular ventilator from the getgo for simplicity and to avoid wasting masks and tubing.
You can also use the mask in combination with the vent (not set to NIV but to AC mode now) for oxygenation and ventilation during the apneic period and for reoxygenation if your first attempt at intubation would fail.
This has also been advocated for by Scott Weingart and Jim DuCanto in these videos:
“RSA to RSI by Jim DuCanto” and “initial output” (misspelled “inital”) and “Vent as a Better BVM” on the EmCrit CZcams Channel.
Very helpful, thank you!
Thanks for the video, made a lot of sense to a layperson. Awake intubation with lidocaine sounds like a nightmare as physician and patient :/
I was a pediatric CCRN and PALS certified for 32 years working in the ICU at a level 1 trauma center and internationally recognized transplant center. Although I've been retired for 3 years it was nice to get the old brain working again.
Much of the content here is valid in the pediatric setting also. (I wouldn't like to see the result of a sustained peep of 20 on an infant 😄😄😄).
THANK YOU for mentioning methemoglobinemia. That was one of my inservices that I presented every year.
As relates to the PHTN patient. If an NG was already in place a dose of Viagra 15 minutes prior to intubation might possibly be prudent.
Thanks
Yeah - I will probably have to do a full video on the management of pulmonary hypertension at some point. I may not have been explicit enough, but ongoing management of the underlying condition is key when considering intubation.
dont have a clue how i ended up here im not even close to the medical field but its interesting to learn about this
Absolutely fascinating.
In advanced airway management, rapid sequence induction (RSI) is a special rapid process for endotracheal intubation that is used where the patient is at high risk.
So how does this RSI pertain to day trading indicators? Can you cover the MACD next? Thank you
One thing that is needed is BVM with capno built in. That extra step of locating, ipening and attaching the capno takes forever when the adrenaline is flowing. It only takes 5 to 10 seconds if you are organized, but add adrenaline, low light, and a chaotic situation the time to add capno at the beginning seems prhibative.
Key is to make it a departmental standard that all BVMs are set up for capnography at the beginning of all shifts.
Any topics regarding STEMI or cardiac?
I have covered a lot of cardiology on First10EM.com - first10em.com/first10em-cases/cardiology/ - and will definitely plan on turning some into videos.
did some lack of this knowledge produce unnecessary covid deaths due to early intubation or intubation + midalozam ?
Anesthesiologist retired for 25 years. Very little time in ER. Wow a lot has changed in the interim.
Thanks for the update in my thinking and analysis about RSI.
Are these mistakes what caused or contributed to the demise of many patients starting in in early 2020?
Or were there structural or anatomical changes in the blood alveolar interface caused by the infection?
Or has it been determined that initially unrecognized micro-pulmonary emboli were the major source of high incidence of post-intubation morbidity? Please, point me the right direction with some videos or valid papers about other significant aggravating factors.Thanks.
You can start by defining the term "RSI". Believe it or not everybody does not know.
If you don't know what RSI is, I don't think you're the target audience...
This is like commenting on an Apple unveiling complaining that Apple didn't define "CPU" or "AI"
I am an MD graduate and I did not know what RSI stands for. Had to look it up. I did my med school in europe
Repetitive Strain Injury and then they die? Really?
Rapid sequence intubation
why would you intubate someone whos breathing already?! and give any kinds of medication without diagnosing anything?
you know, pure oxygen is poison and corrosive right?
What’s RSI
Resuscitation Sequence Intubation as opposed to Rapid Sequence Induction. The latter is not what he's talking about. But both go by abbr RSI. They are very different. The first is much more considered. The latter is used in an emergency, but has risks.k
Repetitive Strain Injury.
In this case he is talking about rapid sequence intubation
@@GVWOLF11 no, he's taking about Resuscitation Sequence Intubation. Didn't you watch the video? That's very different to Rapid Sequence Intubation. He explained it very clearly.
4:11 I have a question. What causes a person to die? Is it lack of oxygen to the brain? I know you need to find and treat the initial problem but if the patient doesn’t get O2 to the brain then they are going to die or decline before you can even treat to main problem. Where is she hemorrhaging from?…..the stomach? The Lungs?….the esophagus? How do you keep them alive long enough to find out?An SAT of 91 is very low but not fatal so why was that the first concern? She could have been bleeding internally for who knows how long. What was her blood pressure. If she doesn’t have enough blood then no amount of oxygen is going to help.
Just an observation from someone who has no medical knowledge. Well, not entirely true but close enough. Perhaps she should have been triaged better. Rather than wait for ct results someone with common sense could have been saving her life! Or isn’t time a factor in trauma medicine! Why did she need to crash before getting attention? It seems to me someone drop the ball long before she was intubated. Yes, I know hindsight is 20/20 but come on! Use more than test results…look at a patient’s appearance, pallor, age, frailty. Or he’ll, just talk to them but Medicine is also common sense. I think this lady was lost due to lack of that! Likely her coughing spasm caused a pulmonary rupture and that’s where all the blood was coming from….and I know you know what to do to treat that!
I sure as hell wouldn’t have had this woman sitting up in a chair, I’d have had her in a bed with her back at 45 degrees and her legs at least elevated above her heart.❤️ It’s not the RSI it’s the timing!
Look up anaerobic and aerobic respiration. It reveals chemical process set in motion when respiration is inadequate or missing .....
@@firehorse_44alpha-omega Already familiar with that but I’m going to revue/read up on it again….things change and it’s be years since I was a military medic. I was in a recon unit so my trauma medical training was a bit more extensive than a normal medic. A recon team can be away from any medical assistant so we had extra training and permission to use medication not normally available to a regular combat medics.
I appreciate your advice.
As for intubation, that was always a difficult decision. Remember, the people I treated were always in excellent health so I was not dealing with geriatrics or people with multiple or chronic illnesses. It was always the mechanism of the injury that was important to understand for diagnosing treatment.
PS., It must be difficult inserting a bougie tube when there so much blood obstructing your view.
PEEP does not recruit alveoli.....that would be driving pressure.....however ,PEEP would keep recruited alveoli open
I'd love to see some physiologic papers, if you have any, because my understanding is PEEP alone will recruit. Clinically, PEEP definitely recruits.. consider the impact of CPAP alone in CHF. But you will also see the same in pneumonia. I've have many patients with infiltrates started on CPAP temporarily with significant increases in oxygen saturations. So clinically speaking, PEEP improves VQ mismatch, or 'recruits', unless we are using these words differently.
BSRT for 9 years, PEEP recruits. When we do recruitment maneuvers, we don't increase driving pressure, we increase PEEP. Peep does add to driving pressure though, keep that in mind when management for stubbornly airway pressures.
Don't talk about shit you don't understand.
First learn what recruitment means. Peep by its very definition exists to recruit alveoli.
Peep, mainly, will just keep open sacs open.
You stated that LMA can be used for 30mins to an hour which is an *apparent* contradiction to the conventional wisdom that a pt will aspirate when given a paralytic if they have not fasted prior to induction.
I say apparent because I am absolutely not an expert and I am aware that conventional wisdom is often proved entirely wrong by new research and evidence.
I do have an entire video planned about the entire concept of fasting, although not resuscitation focused. Paralytics definitely do not cause aspiration in patients who have not fasted. LMAs can definitely be used safely (when properly monitored) in resusctation settings.
@@First10EM Looking forward to that video.
It interesting that “the pt is at the most risk of aspiration after the administration if a paralytic” was drilled into our heads (caveat: paramedic school isn’t medical school).
Making me go on another Pubmed all nighter again 😂
Jargon laden.
As one of my teachers once said (about triaging in the field):
"When they stop breathing, you can just as well start compressions because that hearth is going to stop anyway if it ain't already"
Also perfectly applies here though:
Freeing an airway is great, but it is just a part of the solution and not a solution in itself in 99% of cases.
Apparently your “teacher” is ignorant of the existence of the bag valve mask and the entire subject of airway management….
Be a Hippocrat 🙏
This is not meant for us.
bye bye
Maybe they didn't need to be Alive to begin with
Yup, stupid sums up ....
That comment is sick.
More snob crap.
Wow, if it saved your life maybe you would type something more relevant.
Wow
What do you mean by snob?