EMCrit Podcast 40 – Delayed Sequence Intubation (DSI)

This is the DSI Podcast. If you want all of the great DSI information, please come to the EMCrit Delayed Sequence Intubation (DSI) Page



You finished the 'cast,
Now get CME credit

Already an EMCrit CME Subscriber?
Click Here to Get CME Credit for the Episode

Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!


Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 5 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.


  1. Sebastian says

    Nice article !! I only suggest to include a note saying that ketamine should be avoided in agitation do to TBI or stroke, because it enhance oxygen consumption in the brain and increase damage.
    Greetings !!

    • Nico says

      I’d suggest you read this piece…
      Myth: Ketamine should not be used as an induction
      agent for intubation in patients with head injury
      Yevgeny Filanovsky, MD;* Philip Miller, MD;† Jesse Kao, MD‡
      CJEM 2010;12(2):154-7

      Here is the conclusion:
      Based on its pharmacological properties, ketamine
      appears to be the perfect agent for the induction of
      head-injured patients for intubation. The evidence for
      neuroprotection in humans remains inconclusive at
      this time. However, more recent prospective data
      examining ketamine usage as a sedative agent in
      patients treated with mechanical ventilation suggests
      that there is no association with increased ICP in head
      Despite limited evidence specific to its use as an
      induction agent, we feel that additional consideration
      must be paid to the possible usage of ketamine for RSI
      in patients with head injury, especially when alternative
      agents that do not cause hypotension are unavailable.

  2. Matt L. Wong says

    Great ideas and a great article. I love your work.

    However, check the URL in the JEM article you provide for the video demonstration. Should it still be “blog.emcrit.org/misc/preox” or simply “emcrit.org/misc/preox”? I can’t access the former.

      • emcrit says


        this could be made to work with many sedative agents, but I can’t recommend any of them, b/c the potential to screw-up is much higher. It doesn’t mean you could not do this with propofol, etomidate, or versed; it just means it is tougher and riskier. The other problem is that the sedative dose for the preox will not be the same as the induction dose for the intubation with these other agents.

  3. Scott Gallagher says

    I like your approach with Ketamine. I think that it is conceptually similar to the rapid sequence airway (RSA) approach advocated on the UNM airway site as a bridge to intubation(http://hsc.unm.edu/emermed/Airway911/Videos/RSA_Preoxygenation.html).

    However, the RSA technique differs in that they take away protective reflexes in order to place an NG-loaded LMA Supreme to facilitate preoxygenation prior to ETT attempt of a suspected difficult airway.

    Interesting small case series using Precedex for awake, difficult intubation:
    Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. Abdelmalak B – J Clin Anesth – 01-AUG-2007; 19(5): 370-3

    • emcrit says

      Darren Braude’s RSA technique is another great way to go and I have used it a bunch. Great dexmedetomidine reference, Scott.

    • says

      my concern about RSA is that you are paralyzing a patient who is not optimally preoxygenated — the margin for something going wrong is pretty tight!

  4. David Marr says

    What about pain management with the DSi sequence. At what point would you give your first dose of Fentanyl, and would you use the same dose as with a true RSI like 3mcg/kg?

    • emcrit says

      Ketamine is a potent analgesic, no additional pain control should be necessary. If you are using demedetomidine, I sometimes will add a little fentanyl.

  5. paul says

    looking forward to giving this a whirl on my next appropriate patient.
    am limited by not having dex at my shop (or droperidol. hahaha)

  6. says

    Great work as always Scott – waiting for the next blue, agitated patient to come in. For those of us without easy access to droperidol – is there much difference between droperidol and haloperidol in practice?

    • emcrit says

      my experience, and i think the literature bears this out, is that haldol is slower and less sedating. you might not get them compliant enough with the haldol to stave off the crash tube.


  7. Doug says

    Scott: Can you comment on the use of Ketamine and DSI in the Excited Delirium patient (specifically PCP, Cocaine, Bath Salt toxicity). Handcuffed, profusely diaphoretic, tachycardic, highly agitated and uncooperative. Thanks.

      • Doug says

        Thanks. I used Midazolam IM, got patient transferred to bed, NRB mask, IV access, RSI with Propofol/Roc. Went pretty smooth but no DSI. I am sure guy was hypoxic, not sure if hyper or hypo-carbic.

  8. Javier Benitez says

    Happy 4th

    I’m going through the literature of DSI now. My patient is agitated, acidotic, tachypneic, and hypoxic is DSI ideal for this patient?

    Thanks in advance


  9. Josh Farkas says


    Brilliant podcast, thanks.

    I am especially interested in the subset of patients who get ketamine or precedex and then improve and don’t require intubation. There seem to be a subset of patients with asthma or COPD who get into a vicious spiral of (anxiety ==> hyperventilation ==> autoPEEP & gas trapping ==> ineffective ventilation ==> anxiety, etc). I’ve had a lot of success with precedex gtt + BiPAP in this situation to help them slow down their respiratory rate enough to ventilate effectively (and avoid intubation). It needs to be done on carefully selected patients with extreme vigilance but so far I’ve gotten lucky. Any thoughts on this?


    • says

      Those are exactly the pts that avoid intubation. Dexmedetomidine works nicely for DSI as well. The advantage of ketamine is its intrinsic bronchodilation.

      • Leon says

        Scott/Minh or anyone else,

        You ever had a really hypoxic, precarious patient such as the one described by Josh Farkas who also had a particularly difficult looking airway? Did you ever in those cases think about trying video laryngoscopy with the ketamine on board while the patient is breathing thereby avoiding the paralyctic altogether? Gentle peak with the glidescope for example?

  10. MichaelMD says

    I had a patient the other night come in with flash pulmonary edema, but also febrile from a nursing home. Wasn’t sure if it was his CHF or ARDS, but he looked awful. Despite CPAP of 5 by prehospital care, his sat on arrival was 89%.

    Now in the past, prior to following your practice suggestions, I would have just tubed him then and there. Just said screw it, CPAP isn’t working, he’s still hypoxic and tachypneic and barely responsive.

    But I didn’t because I’m smarter than that thanks to your podcast! I put him on BIPAP instead, bumped his expiratory pressure up a bit, got his sat about 96%, left him there for a few minutes, then did passive oxygenation by nasal cannula. It took the resident about 45 seconds to get the tube, but the patient never desat’d below 95%. It would have been a really different story had we started with a pulse ox of 89%. What could have been a crash airway disaster went as smooth of an RSI as you could get.

    I didn’t have to use ketamine, so technically not DSI, but the concepts the same, using NIV positive pressure ventilation to preoxygenation.

    Thanks again for all you do!

  11. Mike says

    Hi Scott – thanks for all your work with the website very useful stuff. Recently I used DSI to successfully intubate a non resolving post-ictal patient (sidenote – I am a critical care flight Paramedic not a Physician). Worked great in a patient that was trending towards the airway death spiral 500+ statute miles from the closest hospital.

  12. Scott Gallagher says

    I love the DSI concept. However, because there is very little negative discussion of the concept I would like to share that I had a case recently in a child.

    I administered Ketamine to a 2 year child with bleeding profusely after eschar sloughed from T&A procedure. Child had borderline sats and was placed on nasal cannula oxygen, NRB and administered Ketamine. Shortly after Ketamine administration patient vomited copious amounts of swallowed blood obscuring the airway and making for a difficult intubation

    Is there some inherent risk in the ‘delay’ portion of DSI of losing the airway to stomach contents? Is the RSI concept not based upon this risk of vomiting during airway manipulation?

    • says

      not in adults, which is the only area I have ever advocated DSI. Adults have never had a case of periprocedural vomiting in the literature from ketamine. Kids definitely have.

      RSI is based on no positive pressure ventilation to avoid vomiting. DSI also avoids this. Kids can definitely vomit from ketamine during the procedure. While there has one been one case of Peds DSI in the literature, I do not treat children and can’t advocate the practice in a cohort I know very little about. Thanks for sharing the case.

  13. Ali Eskandar says

    Thank you scott for your lecture I learned alot !!!
    I need to ask you did you have the chance to publish your case series ?
    I would like to bring DSI topic to ecommunity chest network for further discussion if possible ….

  14. says

    A singular advantage to DSI would seem to be the patient keeps breathing thereby lowering the intubaters stress level and improving his chances for success.

    Also, since the patient is still breathing, the auditory cue of moving air, from your target, trachea, is preserved.

    Has anyone intubated through blood and whatever using sound as a guide?

    Jim Jones

    • says

      if I translate the ? correctly; it is not a ? of DSI. The ? is does keeping a patient on nasal CPAP increase intubation ease/success. AFAIK nobody has looked at this.


  1. […] podcast on delayed sequence intubation would have to be one of his best yet. Scott presents his concept of how to maintain oxygenation in […]

Speak Your Mind (Along with your name, job, and affiliation)