So...

Delayed Sequence I...

Metadata

• Author: @emcrit on Twitter
• Full Title: So...
  Delayed Sequence I...
• Category: #tweets
• URL: https://twitter.com/emcrit/status/1547709257260228608

Highlights

• So...
  Delayed Sequence Intubation (DSI):
  It was conceptualized >10 years ago and has evolved quite a bit since then...
  Hopefully this thread may disambiguate some of the misunderstandings and add some gasoline to the fire. https://t.co/8XoCamPZrG (View Tweet)
• First, as to the name--It seems a bit too heavy lifting for any three word name to explain a concept without knowing what it is beforehand, which seems to be the expectation of many posters during this discussion. (View Tweet)
• DSI is intended for the same group of patients RSI is meant for, namely, unfasted, emergent patients requiring intubation. Patients for whom standard induction is contra-indicated. DSI is indeed performed expediently, just like RSI, with one key difference (View Tweet)
• In DSI, there is a deliberate pause between the administration of the induction agent and the paralytic. Well how is that any different than standard induction? Because the "induction" agent is one that preserves spont. breathing and airway reflexes. (View Tweet)
• So we insert a pause (or in other words, we insert a DELAY into the sequence of RSI)--if you don't like that title, I challenge you to come up with three words that express it better. It is not that ED folks have a different frame of ref to understand it. (View Tweet)
• It is that ED folks know what it is and what it means. Many anesthesiologists do as well and they have no problem understanding what DSI refers to. If you have never heard the technique, then no--you will not understand it from the 3-word title (View Tweet)
• Now, why not Nick's "facilitated cooperation?" Well aside from the well aimed comments on that being akin to waterboarding, it misses many of the other uses of DSI. (View Tweet)
• Originally, it was studied [https://t.co/1vwPJ1kTkv] in patients who would not let you preox, position, or do necessary procedures in the peri-intubation. But it has evolved since then... (View Tweet)
• Hemodynamic DSI allows you to give a low dose of induction agent and actually check that the patient is completely dissociated prior to changing their respiratory physiology. This guarantees that you are not paralyzing an aware pt and gives you the lowest possible induction dose. (View Tweet)
• If they drop their pressure after the ketamine, resuscitate more before paralyzing. But wait, there's more... (View Tweet)
• If you need to do an "awake" intubation, but the patient is not giving the time for a full prep, administer the ketamine. I still like to give a 4% lidocaine spray, and then take a look with video laryng or bronch. If the intubation is easy (many awakes are) then paralyze (View Tweet)
• If you have a morbidly obese patient that you want to RSI, there is a real danger of inadequate induction to ensure lack of awareness. Use DSI to guarantee they are induced (dissociated) prior to paralyzing. (View Tweet)
• So facilitated cooperation really doesn't cut it to describe the uses of DSI. (View Tweet)
• So hate the name if you like, but once you know the technique, I think you will have no problem understanding what those 3 words actually refer to (just like every other name for techniques in medicine, i.e. TAP Blocks etc.) But don't hate the technique. (View Tweet)
• It is now in most of the International Airway Guidelines, many of the textbooks. Try it--you may like it. More info at:
  https://t.co/Rdldos8DZp (View Tweet)
• @KristinJBoyle @SpontVentGA @NicholasChrimes @CasDamian @expensivecare @garrettsbarry @UniversalAirway (View Tweet)