![]() ![]() I cannot possibly cover the entire debate here. RSI medications are one of the most hotly debated topics in emergency medicine. P: Pharmacology (induction agent, paralytic, ongoing sedation, vasopressors).A: Airway equipment (laryngoscope, multiple blades, multiple sizes of ETT, stylet and backup options, syringe, bougie).If you don’t have a printed checklist, the SOAP-ME mnemonic is often taught as a way to remember the essential equipment: The EMCrit RSI checklist is excellent and covers the entire intubation procedure, not just the equipment. There are many other checklist options, a number of which can be found in the links at the bottom of this post. My favourite checklist has a visual layout of the equipment, so that you can actually see what you have and what you are missing, such as this one from my friend Casey Parker at Broome Docs. Jaber (2010) showed how a simple checklist for endotracheal intubation used in four critical care departments could decrease complications by 50%. I like physical checklists a lot, because when I have a critically ill patient in front of me, I don’t want to be using my limited brain cells to try to remember what equipment I need. ![]() (Leeuwenburg 2015 Cook 2011 Frerk 2015) Check equipment (use a checklist) This is not because I think that mark will actually help with the procedure, but because I hope it will help me and my team overcome the significant cognitive hurdle associated with performing a surgical airways. When potentially difficult anatomy or pathology is identified, but I still think that rapid sequence induction is preferable to awake intubation, I will mark the cricothyroid membrane with a marker. (Apfelbaum 2013) If the patient is unstable, or rapidly evolving, you will often have to make your best attempt, with a planned early transition to a surgical airway. When the anatomy or pathology predicts a particularly difficult airway, ask: does this patient need a tube right now? If the patient is stable, call for extra help and consider using alternative techniques to RSI, such as awake intubation or planned, awake, urgent tracheostomy. This systematic assessment is supplemented by the most powerful tool at our disposal in emergency medicine: gestalt. E: Evaluate 3-3-2 rule (mouth opening at least 3 fingers, distance from tip of chin to hyoid bone at least 3 fingers, distance from hyoid bone to thyroid cartilage at least 2 fingers).I like the LEMONS assessment: (Braude 2009) However, using a systematic approach for the assessment of airway anatomy is a good way to remind yourself that RSI is not the ideal approach for all patients. (Levitan 2004 Soyuncu 2009) I approach every single airway with the mindset that it will be potentially difficult to pass the tube. We probably aren’t as good at prediction as we would like to think, and parts of the classic anesthesia exam aren’t feasible in the emergency setting, but I am not going to get into that debate. Consider the anatomy of the patientĪ lot has been written about predicting the anatomically difficult airway. After appropriate resuscitation and pre-oxygenation, we can start with the procedure of intubation. However, he remains unconscious and you think it is now time to proceed with intubation… My approachĪs was discussed in the last post, before starting with RSI it is important to consider if the patient is physiologically ready for intubation. His vital signs are now a heart rate of 105, a blood pressure of 122/77, a respiratory rate of 16, and an oxygen saturation of 100% with a non-rebreather set at flush rate and nasal prongs at 15 L/min. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him. ![]() His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. A 55 year old man was found unconscious in the bathroom by his family. ![]()
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