I took a break from unpacking my new apartment and walked the 3 blocks to the Supreme Court building to see the ACA ruling:

Supreme Court just before the ruling

best sign I saw

just after the ruling

me & SCOTUS & ACA & some random guy walking past

There seems to be some persistent confusion/conflation of DSI, NIV for preoxygenation, and awake intubation. I don't intend to get into all of the individual details here, and some others have some other good posts/discussion on some of the differences (see Minh's concise post on DSI vs NIV for preox; and Minh & EMCrit on DSI podcast cover all of these throughout), but I think a single place to discuss the 3 very different ketamine-enhanced airway maneuvers that Scott Weingart talks about might help.

First:
Preoxygenation is necessary for safe intubation, particularly with paralysis (i.e. RSI). Oxygen can be delivered by any method; the most common for preox is a non-rebreather mask. Some patients shunt and need PEEP so Scott Weingart advocates NIV (aka CPAP) for preox in some patients.

This gives us #1:

NIV for preoxygenation
Indication: patient pending intubation, with shunt
Drugs: RSI meds AFTER preoxygenation
Goal: delivery of oxygen with PEEP

Next:
What is DSI? Whereas RSI is the simultaneous dosing of sedative + paralytic AFTER adequate preoxygenation, some patients cannot comply with preoxygenation for whatever reason, usually delirium. The idea of DSI is to sedate the patient while keeping them breathing and protecting their airway so that you can preoxygenate them, then paralyze them for intubation. Confusion because this was also propagated by Weingart. You can use any oxygen delivery method that works (NRB, NIV, nasal prongs, BMV, tent, blowby) to get the oxygen in.

DSI - delayed sequence intubation
Indication: delirious, hypoxic patient
Drugs: sedative*, preoxygenation, then paralytic
Goal: procedural sedation for preoxygenation

What's the difference? NIV is a type of oxygen delivery; it's about pushing the little O2 molecules around. DSI is about the meds you give to get the patient tolerating any oxygen delivery method.

Weingart has done some podcasts on awake intubation, and both people who might follow me have heard me talk about DSI & awake intubation, but they are completely different.

and lastly:
Awake intubation is for patients you think may be difficult to intubate. It is not about oxygen delivery. It is about the short-necked, prognathic, microcephalic, obese, bearded, C5-C6-fixated, irradiated-thyroid, laryngeal tumored, trauma patient who is satting perfectly but you may not be able to find the cords in time if you paralyze him, even with a heat-seeking bougie and magical Glidescope. Ketamine is a good choice because it makes the patient happy while still breathing and protecting their airway (but the patient still tolerates the laryngoscope because you topicalized them with lidocaine).

Awake intubation
Indication: predicted difficult airway
Drugs: sedative and topical lidocaine
Goal: keep patient breathing while you intubate

Review:

• RSI = preox then sedative + paralytic (no bagging)
• NIV for preox is about delivering O2 and PEEP in any patient you may be intubating
• DSI is procedural sedation for the procedure of preoxygenation for the delirious, hypoxic patient
• Awake intubation is for predicted difficult airways

*you want to preserve respiratory drive and airway reflexes, so options may be limited to ketamine, dexmedetomidine, and maybe droperidol. I know that 2 of those are really "dissociatives" and not sedatives but I like the parallelism with RSI

There seems to be some persistent confusion/conflation of DSI, NIV for preoxygenation, and awake intubation. I don't intend to get into all of the individual details here, and some others have some other good posts/discussion on some of the differences (see Minh's concise post on DSI vs NIV for preox; and Minh & EMCrit on DSI podcast cover all of these throughout), but I think a single place to discuss the 3 very different ketamine-enhanced airway maneuvers that Scott Weingart talks about might help.

First:
Preoxygenation is necessary for safe intubation, particularly with paralysis (i.e. RSI). Oxygen can be delivered by any method; the most common for preox is a non-rebreather mask. Some patients shunt and need PEEP so Scott Weingart advocates NIV (aka CPAP) for preox in some patients.

This gives us #1:

NIV for preoxygenation
Indication: patient pending intubation, with shunt
Drugs: RSI meds AFTER preoxygenation
Goal: delivery of oxygen with PEEP

Next:
What is DSI? Whereas RSI is the simultaneous dosing of sedative + paralytic AFTER adequate preoxygenation, some patients cannot comply with preoxygenation for whatever reason, usually delirium. The idea of DSI is to sedate the patient while keeping them breathing and protecting their airway so that you can preoxygenate them, then paralyze them for intubation. Confusion because this was also propagated by Weingart. You can use any oxygen delivery method that works (NRB, NIV, nasal prongs, BMV, tent, blowby) to get the oxygen in.

DSI - delayed sequence intubation
Indication: delirious, hypoxic patient
Drugs: sedative*, preoxygenation, then paralytic
Goal: procedural sedation for preoxygenation

What's the difference? NIV is a type of oxygen delivery; it's about pushing the little O2 molecules around. DSI is about the meds you give to get the patient tolerating any oxygen delivery method.

Weingart has done some podcasts on awake intubation, and both people who might follow me have heard me talk about DSI & awake intubation, but they are completely different.

and lastly:
Awake intubation is for patients you think may be difficult to intubate. It is not about oxygen delivery. It is about the short-necked, prognathic, microcephalic, obese, bearded, C5-C6-fixated, irradiated-thyroid, laryngeal tumored, trauma patient who is satting perfectly but you may not be able to find the cords in time if you paralyze him, even with a heat-seeking bougie and magical Glidescope. Ketamine is a good choice because it makes the patient happy while still breathing and protecting their airway (but the patient still tolerates the laryngoscope because you topicalized them with lidocaine).

Awake intubation
Indication: predicted difficult airway
Drugs: sedative and topical lidocaine
Goal: keep patient breathing while you intubate

Review:

• RSI = preox then sedative + paralytic (no bagging)
• NIV for preox is about delivering O2 and PEEP in any patient you may be intubating
• DSI is procedural sedation for the procedure of preoxygenation for the delirious, hypoxic patient
• Awake intubation is for predicted difficult airways

*you want to preserve respiratory drive and airway reflexes, so options may be limited to ketamine, dexmedetomidine, and maybe droperidol. I know that 2 of those are really "dissociatives" and not sedatives but I like the parallelism with RSI

"All medical records of pediatric patients admitted to the Center between 1989 and 1999 with scald burns from various types of soup were retrospectively reviewed and divided into the Noodle Soup group, and the Other Soup group."

Shalom A, Bryant A, Smith-Meek M, Parsons LR, Munster A. Noodles stay hotter longer. J Burn Care Res. 2007 May-Jun;28(3):474-7.

"All medical records of pediatric patients admitted to the Center between 1989 and 1999 with scald burns from various types of soup were retrospectively reviewed and divided into the Noodle Soup group, and the Other Soup group."

Shalom A, Bryant A, Smith-Meek M, Parsons LR, Munster A. Noodles stay hotter longer. J Burn Care Res. 2007 May-Jun;28(3):474-7.

Screencast of my senior talk on DSI & case series preliminary data

Hosted by Minh Le Cong at PHARM (available free on iTunes)



Special thanks, of course, to Scott Weingart

Screencast of my senior talk on DSI & case series preliminary data

Hosted by Minh Le Cong at PHARM (available free on iTunes)



Special thanks, of course, to Scott Weingart

As a followup to Matt's award-winning screencast on the terribleness of femoral lines, check out these 2 great discussions/cross-promotional campaigns:

As a followup to Matt's award-winning screencast on the terribleness of femoral lines, check out these 2 great discussions/cross-promotional campaigns:

Screencast of my talk from Illinois College of Emergency Physician's NEXT Great Speaker Series.

Basically the reasons are:

• they get infected.  JAMA. CCM.
• there are guidelines (good guidelines) against doing them
• there are some terrible insertion complications
• the anatomy is highly variable
• there are other, better options

Screencast of my talk from Illinois College of Emergency Physician's NEXT Great Speaker Series.

Basically the reasons are:

• they get infected.  JAMA. CCM.
• there are guidelines (good guidelines) against doing them
• there are some terrible insertion complications
• the anatomy is highly variable
• there are other, better options

Facebook EM Grand Rounds
TEE in Cardiac Arrest
from the great Dr. Rob Arntfield, MD, FRCPC, RDMS



see also the inaugural FBEMGR with Scott Weingart

Facebook EM Grand Rounds
TEE in Cardiac Arrest
from the great Dr. Rob Arntfield, MD, FRCPC, RDMS



see also the inaugural FBEMGR with Scott Weingart

The ultimate* Minh Le Cong's Own the Airway In Audio series is a follow-up interview with me on awake intubation in the ED. Hosted at LITFL.

Episode IV: Awake Intubation In Audio II

the original:
Episode II: Awake Intubation In Audio

*i.e. final

The ultimate* Minh Le Cong's Own the Airway In Audio series is a follow-up interview with me on awake intubation in the ED. Hosted at LITFL.

Episode IV: Awake Intubation In Audio II

the original:
Episode II: Awake Intubation In Audio

*i.e. final

It's clear from both evidence and experience that NIV (aka NIPPV, CPAP, BiPAP, etc.) is very helpful for many if not most (or all) of the acutely ill, dyspneic patients on a range of outcomes: symptom improvement, oxygenation, potential avoidable intubation, or preoxygenation for intubation.

However, many patients are initially resistant to NIV for a variety of reasons including:

• hypoxic delirium
• delirium from the disease process itself
• hypercarbia
• sensation of drowning, i.e. the worst sensation in the world

1) Set the mood

EM 101. Speak calmly & slowly like this seemingly crazy situation is absolutely routine for you.* Be nice to the patient. Reassure the patient that you know how terrible they feel right now, and that things will get better soon.

2) Explain that the patient is in charge

Explain nicely that while it first it may seem that the machine is blowing air in their face, after the machine figures out how they breathe, the patient drives the machine.

3) Mask only first

Put the NIV mask on the patient prior to hooking it up to the vent. If you have a friend, simultaneous symmetrical strap-tightening can help get the fit right the first time. No matter how low the settings, the vent ends up blowing some air all over the place, and that's just not comfortable. Ask any dog how that feels.

4) 0/0

Set the pressure to 0/0 and FiO2 100%. While the vent will still blow a little at first, it will really just provide fresh, clean oxygen when the patient breathes.

5) Deep breath: take the wheel

Calmly tell the patient to take some big breathes. The vent will catch on to the patient's respirations.

6) 0/2

Just a little PEEP to acclimate the patient to positive pressure...

7) ...slowly dial up

2 cm H2O of PS or PEEP at a time until at a reasonable starting pressure (e.g. 10/5 aka 15/5). I use about 10-15 seconds between dial-ups.

8) Smooth talk the patient

Some patients still need some gentle reassurance, even after a few minutes or intermittently thereafter. Sell it. Lay a gentle hand on their shoulder. Encourage them. Play some smooth jazz PRN.

*Pharamacologic Threshold*

I have a pretty high threshold to medicate patients to get them to tolerate NIV. All of these meds can cause respiratory and/or cognitive depression, and/or vomiting into a mask that forces air into their lungs. 

If you are giving meds you need to be fully prepped to give an ET tube. 

And, few patients need meds if you really lay on the smooth talk. 

9) Consider a SMALL dose of fentanyl

Something like 12.5-25 mcg. Be gentle. Fentanyl targets air hunger and can make NIV tolerable.

10) PSA

The end of the algorithm is essentially step 1 of DSI -- ketamine or dexmedetomidine to preserve respiratory drive and airway reflexes. Like NIV in any patient, there are 2 parallel paths: potentially stave off intubation while providing ideal preoxygenation if intubation in necessary.

The caveat is that in CO2 retainers, FiO2 should be "low" to target an SpO2 around 90-92% to avoid loss of respiratory drive.** If you decide that the patient requires glottic plastic supplementation, ratchet up the FiO2 ASAP to 100% to preoxygenate & denitrogenate.

*because it is
**not sure I totally buy that pathophysiology, but it looks bad if your COPD patient crumps with a sat of 100%, and it might be true.

my Top Six blogs, podcasts, websites, and iPhone apps at SAEM 2012 by Scott Joing of HQMedEd


(note the flattering screenshot)

in no particular order*:

blogs: Resus.me & EM Lit of Note

podcast: Emergency Medical Abstracts (subscription; free with resident EMRA membership)

websites:
EMCrit - beyond the podcast (free; CME available for small fee)
Life in the Fast Lane

iPhone apps:
eyeChart
Metronome

also linked by Life in the Fast Lane

*Behind the Curtain: iPhone apps were done last so there could be only 1 edit to show the apps