1. SDACEP March 6, 2015 Abigail Polzin, MD Sanford USD Medical Center Emergency Medicine

2. Define Delayed Sequence Intubation Discuss the Published Literature Case Review and Video Review of DSI Applications in Community EDs

3. Hot Topic in EM Scott Weingart of EM Crit

4. Expertise in airway management RSI Difficult Airways Expertise in Sedation Local Anesthesia Anxiolysis Procedural Sedation

5. Combined administration of sedative and paralytic for rapid endotracheal intubation. On room air patients will have 45-60 seconds before desaturation. Studies as far back as the 1960’s found that providing pre- oxygenation with high FiO2 can increase this time. Preoxygenation is recommended for every ED intubation.

6. Non-rebreather set at 15L/min + (+/- nasal cannula in addition) 8 Vital Capacity Breaths or 3 minutes of pre-oxygenation Goal is oxygenation of 100% Adding positive pressure (BiPAP, CPAP, PEEP Valves) can increase oxygenation and decrease desaturations during intubation. Weingart, Preoxygenation and Prevention of Desaturation…

7. Co-Morbidities that can impact preoxygenation Obesity CHF COPD Anemia Volume Depletion Increased Metabolic Demand (trauma, sepsis, agitation, AMS) Impossible to predict the amount of time before desaturation, especially in our ED patient population.

9. “A procedural sedation, where the procedure is pre- oxygenation”

12. Patient A patient requiring emergent intubation but resistant to pre- intubation preparations because of altered mental status. Dissociation Administer a dissociative dose of Ketamine by slow IV-Push; administer additional doses as needed. Preoxygenate Use NRB Mask + Nasal Cannula. If Sats <95% use NIPPV. Paralyze Administer Succinylcholine or Rocuronium. Apneic Oxygenation Perform apneic oxygenation with nasal cannula. Intubate Use difficult airway techniques as indicated

13. Patient A patient requiring emergent intubation but resistant to pre-intubation preparations because of altered mental status. Good lungs but agitated/altered Trauma patient Ingestions Sepsis Bad lungs COPD CHF Pulmonary Edema Bad lungs AND agitated/altered

14. Dissociation Administer a dissociative dose of Ketamine by slow IV-Push; administer additional doses as needed. Why is ketamine ideal for this? Keeps the patient breathing Keeps airway reflexes intact 1 mg/kg (less than our typical dose for procedural sedation) Repeat as needed (0.5 mg/kg) until dissociation achieved Other medications? Propofol, Etomidate, Dexmetatomodine, Droperidol

15. Classified as a dissociative anesthetic that has potent analgesic and sedative effects Unlike most sedative agents – a typical dose response curve is not observed (once dissociated, giving larger doses likely won’t increase level of sedation) Can be given via the IV or IM route IV - onset ~30 seconds IM - onset ~3-4 minutes

16. Complications/side effects Respiratory depression when given via RAPID push Emergence reactions Post sedation emesis Excessive salivary secretions Laryngospasm Arrythmias Contraindications Allergy to ketamine Elevated ICP or TBI patients (historical contraindication) January 2015 Annals of Emergency Medicine “According to the available literature, the use of ketamine in critically ill patients does not appear to adversely affect patient outcomes.” Cautions Severe coronary artery disease

17. Preoxygenation Use NRB Mask + Nasal Cannula. If Sats <95% use NIPPV. Now patient will be able to tolerate mask, nasal cannula. DSI ≠ NIPPV for preoxygenation

18. Paralyze Administer Rocuronium or Succynilcholine Apneic Oxygenation Passive oxygenation following paralysis with nasal cannula Intubation Using difficult airway resources as needed

19. 62 Patients “Self controlled” Primary outcome – best saturation without DSI compared to post-DSI SpO2. PNA, Asthma, Pulmonary Edema Oxygenation Failure Ventilatory Failure Airway Protection

20. Eligible N=64 Patients Received DSI N= 62 Patients NRB Preoxygenation N=23 Patients Intubated N=23 Patients NIPPV Preoxygenation N=39 Patients Intubated N=37 Patients Admitted on NIPPV N=2 Patients Excluded 2 Patients (could not record post-DSI SpO2)

21. 31% couldn’t tolerate NRB 60% couldn’t tolerate NIPPV

24. Not RCT Selection bias Missed patients Small study

25. In the study, 2 patients had such improvement in oxygenation and air movement that they did not require intubation following ketamine administration.

26. 44 y/o F with PMH Fibromyalgia, Obesity, presented to OSH on 2/3/15 with cough, pharyngitis. No PMH other than +tobacco/marijuana use. Started on Z-pack, discharged home. Returned to OSH on 2/4/15 in AM. CXR was obtained, worsening respiratory complaints, pleuritic R side chest pain. Admitted and started on antibiotics. +Blood cultures with gram+ cocci in chains. 17:15 called to arrange transfer. Has had worsening respiratory distress for >2 hours. O2 sats in 80’s on NRB. Advised to start BiPAP – pt was unable to tolerate. Transported by ground EMS.

28. Vital Signs 20:25 124/53 HR 105 T 97.3 83% on 15L Pt arrived in ED. Agitated, leaning forward, diaphoretic, NRB on. Able to speak 1-2 words. Still awake but altered.

29. Constitutional: Obese, diaphoretic, severe distress HENT: Head: Normocephalic and atraumatic. Mallampati 4 Eyes: EOM are normal. Pupils are equal, round, and reactive to light. Neck: Normal range of motion. Cardiovascular: Tachycardic with 2+ peripheral pulses. No significant edema. Pulmonary/Chest: Patient in severe respiratory distress. She has increased work of breathing. She has diffuse inspiratory rales in all lung fields and overall diminished. Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is no tenderness. Neurological: Waxing and waning alertness. Moving all extremities Skin: No rash noted. Diaphoretic

30. How long will you have to RSI her before she desats? Will she be an easy or a difficult airway? Even with video laryngoscopy this airway is likely to be difficult, and 1 attempt taking longer than 15 seconds is likely to result in hypoxia. You are starting behind the 8 Ball.

31. Patient weight = 124 kg (estimated at the time) 100 mg Ketamine given BiPAP placed for 10 minutes – O2 sats improved to 100%. Pt did require repeat Ketamine to total of 200 mg. Following this further sedation with etomidate (pt was waking) and paralysis with succinylcholine. Intubation took 1 attempt and 15 seconds. Hypoxia to 73%. Positive pressure ventilation slowly improved oxygenation to 90%.

33. Hospital Course Intubated until 2/13/15 Required PS 23, prone positioning, low tidal volumes Antibiotics course AKI requiring dialysis Severe deconditioning and generalized weakness Anticipated discharge to a skilled nursing facility

34. What if DSI hadn’t been performed? Oxygen-Hemoglobin dissociation curve Anticipate even worse hypoxia and inability to ventilate Where’s the data? Preoxygenation, Reoxygenation, and Delayed Sequence Intubation in the ED

35. “I’ve tried BiPAP but I’m claustrophobic” The 95 year old DNR with pneumonia Agitated trauma patients Smaller facilities where intubation is not always available/comfortable Pre-hospital care?

36. Delayed sequence intubation is a viable alternative to RSI in patients who are not able to pre-oxygenate well. It is a utilization of 2 key skills in Emergency Medicine (airway management and conscious sedation) Currently there is a small amount of published data available.

37. Husband and Colleagues Sanford USD Medical Center Joel VanHuekelom, Pharm D Misty Brendan Patient from the case for giving her consent that her story and video be shared for learning purposes

39. Weingart, Scott. "Preoxygenation, Reoxygenation, and Delayed Sequence Intubation in the Emergency Department." The Journal of Emergency Medicine 40.6 (2010): 661-67. Print. Weingart, Scott, and Richard Levitan. "Preoxygenation and Prevention of Desaturation During Emergency Airway Management." Annals of Emergency Medicine 59.3 (2012): 165-75. Print. Weingart, Scott, and Seth Trueger. “Delayed Sequence Intubation: A Prospective Observational Study.” Annals of Emergency Medicine October 22, 2014. Online. Baillard, Cristophe. “Noninvasive Ventilation Improves Preoxygenation before Intubation of Hypoxic Patients.”American Journal of Respiratory and Critical Care Medicine 174 (2006): 171-177. Print. Weingart, Scott, and Darren Braude. "Airway Corner - Delayed Sequence Intubation." Interview. Audio blog post. EM:RAP. N.p., June 2014. Web. 4 Feb. 2015.. Cohen, Lindsay. “The Effect of Ketamine on Intracranial and Cerebral Perfusion Pressure and Health Outcomes: A Systematic Review.” Annals of Emergency Medicine 65.1(2015): 43-51. Print. “Podcast UPDATE on Delayed Sequence Intubation (DSI).” EMCrit. N.p., 17 Nov. 2014. Web. 01 Mar. 2015.