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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.



Now on to the Podcast

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

5 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.


    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:
      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


    June 26, 2012

Trackbacks & Pingbacks

  1. DSI (Delayed Sequence Intubation): Una tecnica utile!!
  2. Delayed Sequence Intubation (DSI) or Rapid Sequence Intubation (RSI)–An Outstanding EMCrit Podcast From Dr. Scott Weingart | Tom Wade MD

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