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PHARM Podcast 11 – Rapid Sequence Airway with Dr Darren Braude

Hi folks, today I interview Dr Darren Braude, an emergency physician in New Mexico and the man most associated with the novel concept of the Rapid Sequence Airway

Dr. Braude’s Credentials:

Darren Braude, MD, EMT-P, FACEP
Medical Director, PHI Air Medical of NM
Attending Physician, Adult and Pediatric ED
Associate Professor of Emergency Medicine University of New Mexico School of Medicine
Author, Rapid Sequence Intubation & Rapid Sequence Airway
EM-News Columnist, “The Emergency Airway”
Co-Director, Airway911 Training Program
Co-Director, National Procedural Sedation Course

Today’s Discussion:

Did I just mispell RSI? What on earth is RSA and why would I need it?

I ask Darren to explain the concept of a Rapid Sequence Airway and what patients would benefit from it over RSI. I have performed RSA a few times and it is a resilient technique. The SGA goes in much quicker than most laryngoscopies, you connect your capnography up and ventilate away. If you got a SGA with a gastric drain channel and port then even better. Check out the YouTube video demo below!

James DuCanto mentioned this concept of using SGAs into emergency airway management in a much more comprehensive hybrid strategy on PHARM Podcast 010. A hybrid strategy combines optical enhanced technologies with supraglottic airways using RSI drugs. It offers advantages such as continuous ventilation during passage of a bougie into the trachea. It offers visual confirmation of correct tracheal placement and not just blind passage of a bougie through a SGA.

So the RSA concept is the first step in this new hybrid strategy. Pushing RSI drugs and dropping in a SGA then maximising oxygenation and improving ventilation.

Big thankyou to Darren for recording his thoughts and opinion on the RSA and explaining how you can become operationally resilient in your emergency airway management.

Links of Interest:

Airway 911

YouTube video demonstration of RSA

Case report of RSA in trauma patient

Case report of RSA in cardiogenic shock patient

RCT simulation model of RSA vs RSI

Stay safe and enjoy the podcast!
Minh

Now on to the Podcast


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10 Comments Post a comment
  1. Hi Minh & Darren,

    Thanks for the podcast. Makes a lot of sense. I’ve often wondered about ventilating critical care patients who do NOT have glottic or lung compliance issues with an SGA; particularly patients who are short term intubated for investigation of their presentation.

    The YouTube video shows the doc administering the rocuronium PRIOR to the etomidate. Is this because of the relatively longer onset time for Roc? I don’t use etomidate, so I’m not very familiar with its timing.

    Thanks

    Matthew

    May 18, 2012
    • Hi Matt!
      I was just having an email debate with an ICU colleague of mine about this last night!
      This timing issue of giving Roc first for RSI is well demonstrated in a Youtube video by Dr Sachetti here http://www.youtube.com/watch?v=kTd7km_jnKw

      Yes the concept is that it takes Roc longer to work,so you give it before your sedative..which is the usual revers of traditional RSI with sux.

      To be honest in clinical practice at the 1mg/kg dosing, it does not appear to matter. When you dose roc at 0.3-0.6mg/kg for RSI it probably does matter somewhat the timing but if you are experienced laryngoscopist you will probably manage anyway even if the roc is only just starting to work when you start your laryngosocopy. In effect you are tubing mainly with the benefit of the sedative initially with paralysis just starting to take action.

      Sux is useful in this regard as it has a clear indication of when to begin your laryngoscopy.

      May 19, 2012
      • What’s the advantage of pushing in the Roc before the sedative other than timing? You’re going to sedate your patient at some point (unless you’re feeling particularly unpleasant) and most sedatives will hang around long enough to cover the onset of the NMB. The only aspect I can think of is that you can witness the patinet weakening as the Roc hits home and you know they’ll be ready for intubating.

        If your patient is totally delerious, this might not matter, but I could imagine the sensation fo rapidly progressive weakness before the sedation hits being quite unpleasant. Add in some sepsis or cardiogenic shock and the slower perfusion time might lead to a patient who is slower than anticipated to be sedated. I’m just not sure that there is a great deal of gain with NMB first, sedative second.

        I work in a hospital that is still very Sux/RSI-centred. Have you switched entirely to Roc, or is there still a place for Sux in your kit?

        As an aside, the physician in the YouTube video you suggested in your previous reply advocates cricoid pressure (and BURP) as “essential”, which Richard Levitan tells us was never really a useful technique. Who to believe ?!?

        Thanks again

        May 21, 2012
  2. How’d Darren escape the infamous Minh Le Cong surprise prehospital nightmare case scenario?

    Just kidding. I’m wondering with Darren’s vast experience with the use of EGDs over prolonged periods whether he finds he can typically maintain adequate analgesia / sedation in these patients (with tennis ball-sized cuffs inflated in their throats) without paralysis beyond the initial dose of roc that he uses for the RSA?

    Thanks for another great discussion, gentlemen!

    May 19, 2012
  3. Yeah we were short on time so I did not pose Darren ,the prehospital scenario of a bus crash of Jehovah’s Witnesses with haemophilia

    I have had no issue with sedation of a ventilated patient with a LMA in place during aeromedical transport. We do this all the time in elective anaesthesia and its little different in prehospital setting. You have to be careful as we talk about during the podcast, with air in the LMA cuff expanding during air transport. Have a manometer and check cuff pressure and clinically for any significant leak.
    For a King LT, I have no experience of that in the aeromedical setting so defer to Darren or yourself Bill on that one!

    May 19, 2012
  4. Minh-

    Great talk, of course!

    Darren Braude’s work is of course outstanding- however, I’m concerned about RSA for preoxygenation, because you are paralyzingly a patient who is not adequately preoxygenation. This leaves a very narrow margin for anything to go wrong. Thoughts?

    Also, with regards to whether or not to admin roc before etomidate, the concern for me would be if something went wrong with the IV- you give roc, IV falls out, now a paralyzed patient without sedative. However, it the reverse happened, you have an induced patient w/o optimized intubating conditions (roc/tube/apology is probably preferable!).

    May 20, 2012
    • Seth,you make a good point but in my experience its less of a gamble than traditional RSI
      I have taught a flight nurse to do this under my supervision during a flight. I pushed drugs and she dropped the LMA Supreme in and we were ventilating within ten seconds…in someone who had no recordable SaO2 prior to RSA. In other words RSA is a useful technique for rapid control . DSI is another option as you and Scott have been able to describe. you could combine both concepts

      May 20, 2012
  5. Thanks Mathew for the questions.
    I still use Sux but more and more have been using Roc. One ICU colleague I work with almost entirely uses a fixed 25mg dose of Roc for his adult intubations now..weird eh as its not the oft quoted 1mg/kg dosing we read about in the research for RSI and Roc. When I use Roc I give the larger dose. it works almost a quick as Sux but last a heck of a lot longer.That is ok with me for most situations but I still use Sux when I dont want them paralysed for an hour ..like status epilepticus. My colleague argues at the lower dose it wears off in about twenty minutes or so and sees thats ok for even the status epilepticus patient post intubation. I guess what this all means is that RSI is not a science but an art. You got to choose your RSI for the patient..its not cookbook recipe stuff.
    As for this whole timing issue of giving the Roc first..I dont do that in practice as it confuses my assistants. I give my sedative then the roc and know that the patient will be asleep first before onset of paralysis. If I want to paralyse the patient as quick as possible I would still use sux. Listen to my podcast with JimDucanto and he says the same thing.

    About cricoid pressure and BURP, I agree with Levitan mostly but in my view there is still a role in high risk aspiration cases and in fact video laryngoscopy has changed the playing field. Now your assistant can see if they are putting on excessive pressure and adjust accordingly.with practice they can move the larynx to improve the view without any guess work.
    To be honest I dont normall request cricoid pressure but if its a case of a UGIT bleeder or bowel obstruction and you ultrasound their stomach and its full of pizza and beer, I would not only drop a NGT and suck out as much as I could, I would ask for cricoid pressure as well. If its someone with facial trauma and bleeding into their airway , same thing I would apply cricoid pressure initially. You can always take it off if you are having trouble visualising the larynx but the principle of protecting the airway is appropriate and cricoid pressure applied appropriately will help. VL makes this much more successful nowadays. Blind cricoid pressure needs to be practiced and applied carefully by an assistant..I often volunteer to do it myself when assisting another intubator. If I did not have an assistant experienced in cricoid pressure I would err on side of not using it at all.

    May 21, 2012

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  1. Supraglottic Airway Device Use as a Primary Airway During Rapid Sequence Intubation | PHARM
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