Delayed Sequence Induction

So we're going to talk today about is delayed sequence induction. And what this is, is a way for us to kind of re evaluate and re look at our patients that need intubation and try to do better in every single day and optimize their first pass success rate. So we should really think about this as procedural sedation with the end point being oxygenation. This is very similar to what happens in the emergency room. You bring a patient in that has a shoulder dislocation and we give a medication of knives, ketamine and we put that shoulder back in place. That's our end goal. And this is, this is what we're going to be using for patients that come in that may have, may be a little bit encephalopathic. Maybe someone that has, you know, they're not really willing to wear a non rebreather mask and we're not able to get that oxygen up to a level that we want them to be at so we can have a successful intubation and, and not have any of the complications associated with these kind of peri. Intubation issues. So what we're doing is giving a medication that allows us to pre oxygenate them well and get them into a place where we can have first pass success when we do actually intubate them in the future. So let's review the protocol. The first point that we're gonna go talk about is preparation. So all of our patients, we need to have all of our tools available to us. They need to be really at arm's length. So we're gonna put the patient on a cardiac monitor, we're gonna watch their heart rate, watch their blood pressure, put them on SpO2 monitoring to get their oxygen saturation, put them on end tidal CO2 and you know, watch their respiration rate. These are all really important for any patient that's gonna be, you're seeing on a regular basis. In particular for these patients that we're gonna be maintaining their airway. We need to really watch these very vigilantly to watch for any changes. And also for post intubation, in particular for the respiration rate, we want to kind of match that to what they had prior to their intubation so that we don't have any issues with their metabolic changes in the future. The next part of the protocol is going to be premedication. We have a couple options that we can use. Ketamine is the one that we're probably going to be using the most frequently. And when that's contraindicated, we're going to be using etomidate. For adults, the dose for ketamine is going to be 200 milligrams, utilizing a 60 drop set, set and run wide open. For pediatrics, it's going to be 2mg per kg, also utilizing a 60 drop set and run wide open. And if there's a contraindication, in particular for pregnancy, we're going to be using etomidate 30mg or 0.3mgk. The reason we're going to be using ketamine more frequently is for really a few different reasons. Probably the most important reason is its safety profile. It allows us to maintain airway reflexes. And it also has a very first pass medication. That means it's able to be. You can see the effects of it very quickly. And it also kind of augments the cardiac output, so it allows that to be pushed around into the system very fast so that we can see those effects optimally as well. Ketamine also has a very good safety profile in that it's cardiac protective and allows us to maintain good perfusion pressures. The next part of the protocol is going to be positioning. It's a really important part of the protocol in that it allows us to optimize our first pass success. One of the ways that we do this is aligning the airway, and this is making all the passageways optimized for positioning the tube into the trachea itself. This is done by aligning the ear to the sternal notch in a similar fashion like this, using an inline stabilization when there is a need or concern for spinal cord injury, and also elevating the stretcher 15 to 30 degrees. The reason we do this is to help with any atelectric changes that may occur, especially if the patient is obese and you have all that pressure pushing on the chest. It helps us to improve their tidal volumes as well. Pre oxygenation is the next important part to this protocol. The thing that we're really trying to achieve here is an SpO2 reading of greater than 93%. We achieve this in a few different ways. First is going to be applying a nasal cannula at 15 liters per minute. This is going to be applied to the face and then using a BVM over that, the prong to the nasal cannula. You're going to be attaching a peep valve to the exhalation port there, initially tightening that to 10cm of water as needed. That can be moved up to 15. If you're not achieving that goal and the important thing to remember here is that you do not need to squeeze the bag. This is cpap. This is allowing oxygenation to occur in an apneic way. And it's really important to get to that 93% marker. The problem is if we don't get to that level, there is a quick drop for oxygen saturation. SpO2 readings that you normally see on a monitor may be about 30 seconds behind what's actually happening in the body, especially in people that are critically ill, that that time frame is actually much higher. So what you need to do is get that SpO2 reading up to an optimal level. And in our draft version, this is 93%. And once we get to that level, then we can move on to the next step. An important thing to remember is that if you're unable to achieve our goal of SpO2 reading of 93% or more for three minutes, then we need to abort and apply a supraglottic airway. The next step in the protocol is perfusion. This is probably one of the biggest indicators of mortality and morbidity that we see in patients in the peri intubation phase. When we're intubating a patient, we're moving them from a negative to a positive pressure system. So the patient's ability to have good preload is dramatically decreased. So what we want to do is maintain a systolic blood pressure of 90 or above. And if we can't achieve that, start augmenting it as follows. We start off with 1 liter of normal saline and if that is, if we're and after assessing for scent, breath sounds and capillary refill, if we're not achieving that goal, we can move on to push dose epinephrine, which is found also in the protocol. Also, we should not forget that in the setting of trauma, if the patient has indications for whole blood, we can also use that to help us. Our goal, if we're unable to correct the hypotension, we should abort the procedure and insert a supraglottic airway and expedite air transport to the nearest receiving facility. For a delayed sequence induction. The next step is going to be paralysis. In our case, we're going to be using rocuronium 100 milligrams, that's given as a one time dose. There are indications for this, including.

Apneic patients and status epilepticus. Patients that have significant trismus and you're unable to intubate them without the paralytic itself and also at the discretion of our EMS captains and flight crew. There are some contraindications. A newest addition is asthma, which we are not going to be giving this medication for. Also contraindications include major facial trauma and patients that have previous hypersensitivity reactions to this in the past. The next step is going to be proceeding with the intubation itself. Two tips should be made and if not, if we're unable to intubate the patient at that point we should insert a supraglottic airway and continue to the receiving facility in an expedited fashion. Proof of placement is the next step of this protocol. End tidal CO2 is mandatory in all these patients. It needs to be used continuously and upon transfer of care. We require that there are at least three box like capnographic waveforms noted and that we evaluate the patient to make sure that there is auscultatable sounds in the lung fields and that we had proof of placement when we inserted the tube during the initial laryngoscopy itself. Post intubation management this is mandatory for all patients that are receiving an induction procedure, including endotracheal intubation or a supraglottic airway. This could be given by ketamine infusion, Versed and or fentanyl. Not all three medications need to be given. If we're using ketamine, that can be given together with fentanyl and ketamine could also be given with Versed, but fentanyl cannot be given by itself. Now to speak about the difficult airway, nothing much has changed in the protocol since the previous draft. If you're unable to intubate the patient and unable to augment their ventilation and oxygenation with an mpa, an OPA or supraglottic airway, then know that there are certain interventions available. In particular, needle crike can be given to pediatric patients less than 12 years of age and a surgical crike for greater than 13 years of age. Thank you for your time and I hope you enjoyed this training video and more to come.