Skip to content

PHARM Podcast 23 – Mr EmCrit and the DSI chronicles

Scott and DSI

Tonight folks, all the way from NYC, Mt Sinai Hospital, the one, the only, Mr EmCrit aka Dr Scott Weingart, the Man from Upstairs, bringing it Downstairs

He needs no introduction. Here is what to expect over the next 49 minutes of our interview!

Scott tell us…

1. Your definition of DSI and the concept according to you

2. Is this new or is this just rebranded preoxygenation? Is this just premedication for RSI that is what was always taught? If not, why not?

3. How do you select patients for DSI?

4. Absolute contradindications for DSI?

5. RSA safer than DSI?

6. Awake intubation safer than DSI?

7. Good experiences with DSI? What about those cases that did not require intubation..thoughts on them?

8. Bad experiences with DSI?

Incredible, right? Now to show your appreciation go sign up to his EMCrit CME site

Check out the Airway World CME site with Dr Ron Walls, that Scott cites.

 

Minh

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

4 Comments Post a comment
  1. Sean Marshall #

    Thanks for the great podcast Minh and Scott,
    Although I was initially luke warm on DSI I’m starting to buy in.

    I have a couple questions:
    @Scott: do you have a reference for the esophageal opening pressure you quoted. I went looking for that info last week but found a wide variety of quotes. A Bipap pressure max of 15 in the ED would be very limiting in my practice as an RT, my comfort level at the moment is around 20 cmH2O and have not experienced an increased instance of vomiting at this level. Although your intent and rationale is received loud and clear, I would look toward evidence to suggest safe upper pressures.

    I love the idea of a preintubation difficult physiology assessment to accompany your difficult airway assessment. You stated hypotension, oxygenation and ventilation. The first 2 are obvious but am not sure of your meaning for ventilation. My best guess is a metabolic acidosis situation where you have previously described how you avoid interrupting ventilation for long in these pt’s. Otherwise I don’t see how ventilation derangements affect your approach to intubation. I might also suggest that ICP might be a factor that influences intubation procedures for some patients.

    Cheers,
    Sean

    June 22, 2012
    • Br J Anaes 1987;59:315
      Br J Anaesth 1987;59:315 and Acta Anaes Scand 1961;5:107

      yes, ventilation physiology relates to the patient with metabolic acidosis being compensated for with resp alkalosis. To a lesser extent brain injury patients with increased ICP also fit this category.

      On the airway world lecture next week, I will push for another diff airway algorithm acronym to add to LEMON, and the ones for diff SGA and difficult cric.

      That is the assessment for difficult physiology and it is simple:
      H-Hypotension
      O-Oxygenation
      P-pH and Ventilation

      June 22, 2012
  2. Rollcagemedic aka Dr MAthew MacPartlin sent in this email:
    Hi Minh & Scott,

    Great podcast on DSI. The physiology I have no problem with, but I have a bit of a concern with the implications of the introduction of the “4 hour rule” for disposition in Australian EDs. I’d be worried that DSI might be used to improve SpO2 and “avoid” intubation as a time saver with the expectation that the patient is going to the ICU anyway. Then you risk a patient’s disease severity being initially underestimated, particularly by junior staff who are taking care of these patients after hours, and maybe a delayed appropriate intubation with consequences. Or, worse, a patient who deteriorates in transit to the ICU, outside a safe environment.

    I think Scott’s points are worth emphasising:

    1) Clinical decisions are made for clinical reasons, not administrative convenience

    2) If you are doing DSI for a sick patient, the point is to improve the intubation outcome parameters. So unless you have a good reason, you should still be intubating, as the improvement in SpO2 just means that the patient is DSI responsive; not that the underlying condition has been treated! We already know that delayed appropriate invasive ventilation leads to worse outcomes.

    3) If you really, really, really think that the patient may now not need invasive ventilation, this patient is now not a less sick patient, needing less care. They need even closer monitoring and early identification of failure of NIPPV.

    Otherwise, great concept when applied as originally described.

    Thanks guys

    Matthew

    June 26, 2012

Trackbacks & Pingbacks

  1. DSI (Delayed Sequence Intubation): Una tecnica utile!!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

The Collective

A Hive Mind for Prehospital and Retrieval Med

Bits & Bumps

Obstetrics and Gynaecology FOAM

FOAMcast

Why FOAM it alone?

Prehospital and retrieval medicine blog

DrGDH

Or "How I'm Learning to Stop Worrying and Love Emergency Medicine"

rain0021

A great WordPress.com site

Genevieve's anthology

Writings to amuse, teach, inspire and entertain.

Prehospital and retrieval medicine blog

Monash Anaesthesia

Prehospital and retrieval medicine blog

Keeweedoc

A topnotch WordPress.com site

BoringEM

Bringing the boring to emergency medicine

resusNautics

Navigating resuscitation

Doctor's bag

by Dr Edwin Kruys

Prehospital and retrieval medicine blog

Prehospital and retrieval medicine blog

ETM Course

Emergency Trauma Management Course

The Doctor's Dilemma

Modern Medical Musings from Dr Marlene Pearce

Sim and Choppers

A blog combining medical education, simulation and helicopter retrieval medicine

GreenGP

Reflections of a Rural GP

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

Rural Doctors Net

useful resources for rural clinicians

expensivecare

Searching for the big picture in intensive care

Nomadic GP

Adventures of a Rural Locum

AmboFOAM

Free Open Access Medical Education for Paramedics

the short coat

Prehospital and retrieval medicine blog

BoringEM

Bringing the Boring to EM

When your shift turns to shit? Keep moving, keep caring!

Kangaroo Island doctor blogging about Rural Medicine in Australia

thebluntdissection

pulling apart cases from the ED...

Little Medic

Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.

MEDEST

Prehospital Emergency Medicine

ruralflyingdoc

Just another WordPress.com site

MDaware.org

Prehospital and retrieval medicine blog

Intensive Care Network

Prehospital and retrieval medicine blog

Broome Docs

Rural Generalist Doctors Education

Resus M.E!

Prehospital and retrieval medicine blog

EMCrit Blog - Emergency Department Critical Care

Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation

St Emlyns

Meducation in Virchester #FOAMed

Emergency medicine and critical care medical education blog

RFDS Australia - Queensland Section The STAR Program

Specialised Training in Aeromedical Retrieval

Follow

Get every new post delivered to your Inbox.

Join 7,629 other followers

%d bloggers like this: