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Don’t DSI…Rapid Sequence Airway

Darren Braude, MD Professor of EM, EMS and Anesthesiology

University of New Mexico @darrenbraude

[email protected]

R.S.I.D.S.I.R.S.A.

Concept Evolution

So what is R.S.A.?

Advantages

• Faster –Minimal interruption of ventilation – Get on with diagnostics and therapeutics – Get off scene

• High success rates • Minimal airway trauma

Disadvantages

• Some patients are poor EGD candidates – Upper airway obstruction –Morbid obesity – Severe lung disease

• Necessitates secondary procedure • Does not provide “definitive” airway

“The best is the enemy of the good”

Voltaire a long time ago

“The effort to avoid aspiration that may have already occurred or may never occur often leads to hypoxemic complications or

even death”Braude – Just Now

Our Data

• 55 Prehospital Patients –Many predicted difficult intubations and/or

performed in confined space aircraft • 93% success – Remainder required intubation

• 3/41 (7%) with evidence of aspiration – Lower than our ETI population

How I use RSA• Prehospital – On scene to keep scene times short – In-flight

• In-hospital – Patients with refractory hypoxemia likely

secondary to de-recruitment that are not good candidates for DSI or to facilitate endoscopic intubation via the EGD

American Journal of Respiratory and Critical Care MedicineVolume 175, Number 5 (2007), Page 521

100 miles/160 km

60 miles/100 km

Summary• RSA is an alternative to RSI for selected

situations, particularly for prehospital use and hypoxemic patients that are poor candidates for DSI

• RSA has not been subjected to RCTs

• SMACCDUB has been AWESOME!!