It’s high time for the STEM airway workshop and we are going RSI BASE jumping!
BASE. How low can you go?
BASE jumping is the most dangerous of the extreme sports. It is about forty times more dangerous than plain old parachute jumping. Hands up who would like to have a go. Now take a look at this vid.
Hands up again who wants to have a go. In this case the BASE jumper had a relatively soft landing and survived. Albeit with a broken pelvis, vertebrae and legs.
The mortality from BASE jumping is around 0.04%.
The peri-intubation cardiac arrest rate (defined as cardiac arrest within 10 minutes of administration of RSI drugs), in the ED population, is around 2.5%. About 1% cannot be resuscitated. Which makes RSI about 25 times deadlier than BASE jumping.
Hands up who wants to have a go at RSI. It is a FOREST of hands going up! Funny thing isn’t it, risk perception. But then, you’re not on the end of the blue cigar.
Yes sir I like to bougie
In ED of course there are plenty of situations in which we encounter death. In ALS week we learned that 93% of Out of Hospital Cardiac Arrests (OHCAs) don’t make it. But with RSI, the stakes are different. When ALS succeeds, we convert a dead patient into a live one. When RSI fails, we convert a live patient into a dead one.
Which is why RSI should not be taken lightly, in any circumstances.
So this Wednesday, we’ll be taking a global look at RSI, and what we can do to make it safer: preparation, communication, teamwork, technique, and fallbacks. It’s a lot more complex than just shoving a tube through a hole.
Until then, here are five key questions:
1. What is first-look intubation?
click here to reveal the answer
- It’s the precept that you should not look away from the larynx until you get the tube in.
- It’s tied to the concept that your first attempt at intubation should be the best – and only – attempt.
- The rationale behind these rules is that emergency airways are much more difficult than those encountered in a routine anaesthetic list. Emergency patients aren’t starved, often have cardiorespiratory compromise, and their airway access may be complicated by C-spine immobilisation and/or bleeding into the oropharynx. We can ill afford to fail the first attempt at intubation. Having a second go… and a third go… and a fourth… leads to desaturation, an increased risk of aspiration and the onset of the “airway death spiral”.
- To optimise chances of success first time, use a technique that will work with an unexpected Grade 3/4 airway: think videolaryngoscope (my preference). VL is killing DL.
- If you use a bougie, place its tip at the corner of the mouth before you go in so you don’t have to look away to find it. There’s a neat single-handed technique called the D-grip.
2. What is the ramp position?
HELP! I need somebody. 3. What is the silo technique? Silo airway. Use it to launch an RSI. 4. What is apnoeic oxygenation? 5. What is delayed sequence intubation? DSI. Use when RSI = Really Stupid Idea click here to reveal the answer
click here to reveal the answer
click here to reveal the answer
click here to reveal the answer
