A couple of things on airway that may be of interest.
But Remember that Sux Sucks (Succinylcholine Contraindications)
Dr. Laurence Boss of Oxy's Log produced a great slide for when sux is and isn't safe to use. Of course I can't leave well enough alone, so I modified a bit (with permission) and here it is:
here is a fantastic review article on the subject for those of you who just can't get enough.
Update:
This in-press editorial is interesting and IMHO comes to false conclusions (Jacknin, G et al. Succinylcholine in an ED patient with unanticipated hyperkalemia: a case report and brief review of the relevant literature. Am J Emerg Med. 2016 Mar 8. PMID: 27021128)
Dash-1A
Then Bill Hinckley advanced the ideal of ED/Crit Care Airway Management:
DASH-1A (Definitive Airway Sine Hypoxemia on 1st Attempt)
Note: Bill uses the word Sans, but why support the French : )
This encompasses what we really want 1st pass success, but without the sat dropping below 90%. He posted the video below on Minh's site:
Then Yen Chow updated the concept:
George Kovacs has a similar goal:
How about a goal of 90s: a 90% 1st attempt success rate, with saturations over 90% and a SBP greater 90 mmHg within 90 seconds (blade in to + EtCO2).
- EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients - April 4, 2020
- EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer - March 31, 2020
- EMCrit Wee – Stop Kneejerk Intubation with the EMCrit Crew - March 30, 2020
Whoo Hoo, Dr Hinckley! I used to work with him and the amazing team in the ER in Cincinnati (2004-2007) prior to joining the AF. Way to represent UC, Dr Hinckley!! I miss you guys a TON!
PS: love the mention of Freakonomics!
Can’t believe it’s been five years, Shelley. Time flies. Great to hear from you.
Excellent Dr. Hinkely. I’m encouraged by the ” No Desat” emphasis that prevails throughout these pod casts.
Thanks, guys! Speaking of NO DESAT, I can’t believe I forgot to mention nasal apneic oxygenation as one of the keys to DASH-1A success. I’m a big proponent. One other thing I need to clarify: when I mentioned 83% as the success rate reported by NEAR, that was first attempt success (DA-1A), with or without hypoxia, not overall success as I made it sound in the video.
Bill, I think Ron Walls will forgive you
Don, Bill, nasal oxygenation as part of your DASH1A concept is a brilliant addition and needs to be specifically planned for because it is so new to current practice of Emergency intubation/airway management.
I mean its not even mentioned in Ron Walls bible yet! Prob in the next edition, right, Bill?
My point is that when I have introduced it into my own practice in the last 9 months, it takes some explanation and planning to your aircrew or retrieval team about what the heck you are doing and why you want to take an extra portable oxygen cylinder with you or place nasal cannula as well as face mask..or DOctor why the heck do you need to have nasal cannula on as well as that BiPAP mask going? You need to preplan taking the second oxygen source or making sure its available and dedicated.
And Don, absolutely we should record our experiences and publish findings
Dr. Hinckely…the very thing I sat down and discussed with my airmedical crew this afternoon as a training topic. Just no one has officially tried it here in a RSI setting as of yet. When we do I’ll post something back as how it went. But it’s my feeling that with Dr’s Levitan, Weingart and now yourself bringing this to the fore front that we will reap the benefits of your lengthy good experiences.
Don, I’ll look forward to hearing about how it goes for you and your team. Thanks!
A bit behind on my podcasts! Thanks for the erudite dissection of a relatively controversial issue. I agree that first pass success is not a measure that is particularly important. In our HEMS program, our goals generally are: 1. Oxygenation, 2. Ventilation, 3. Airway protection. The particular device and method to achieve these goals is not of great concern (a la Darren Braude). We must not give short shrift to ventilation however. Hypercapnea is likely as bad as hypoxia. In addition, we need to heed Dr. Dan Davis and Steve Aguilar with respect to our measure of hypoxia. The assumption that pulse ox reflects current oxygen status is generally incorrect. Pulse oximeter placement determines the latency of response which can be up to 120s. This is of critical importance if implementing a DASH-1A metric. The patient may not have been hypoxic during the intubation event, but two minutes later! Does this count as a DASH-1A success?
Mike Jasumback, MD
Mike, I thought exactly the same thing. I think the measure should be nadir saturation during the peri-intubation. If they are 66% 2 min after the tube is in, that is the sat that should be counted.
Totally agree, gentlemen. That’s exactly how I measure it. Sorry that I didn’t clarify that.