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Airway management advances in the prehospital setting

Delayed sequence intubation and lung protective ventilation have replaced rapid sequence intubation in modern airway management

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Rapid sequence intubation has quickly become a relic of the past. In Episode #14 of the MCHD Podcast, Dr. Jeff Jarvis joins the hosts to discuss the Williamson County EMS experience using an airway bundle checklist for delayed sequence intubation (DSI).

The concept of DSI centers around resuscitating and properly preparing patients for intubation prior to administering paralytic agents. This is vital, as paralytics can often lead to significant hemodynamic consequences.

The core of this process is the use of ketamine to allow proper positioning, setup and pre-oxygenation prior to paralysis. Adequate pulmonary nitrogen washout directly translates clinically to additional time available to intubate before oxygen desaturation occurs. The entire procedure must be stepwise and methodical, with an emphasis placed on PEEP use, apneic oxygenation and proper bag valve mask application.

Delayed sequence intubation with Dr. Jeff Jarvis

On Episode #35 of the MCHD Podcast, flight paramedic Brandon Means joins the hosts to further discuss the finer points of ventilator management in the EMS environment.

Lung protective ventilation using low tidal volumes based on height as opposed to weight is one of the key topics addressed. For those familiar with the complex ARDSNet tidal volume tables, listen closely for a quick and easy way to approximate lung protective volumes without multiple clunky charts and graphs. This allows EMS providers to start with a ventilator management strategy that will prevent downstream complications.

Please don’t ignore the episode if your service doesn’t have the luxury of mechanical ventilators, all of the concepts discussed translate to EMS patients transported with a BVM and supraglottic airway in place. These episodes will leave you prepared to intubate and ventilate like an up-to-date pro.

How to approximate lung protective volumes

Tackling the difficult airway

Finally, the MCHD medical directors take a scenario based, deep dive into the finer points of tackling the difficult airway.

The MCHD Paramedic Podcast was launched in early 2018 in an effort to provide easily consumable core-content EMS education and insights from prehospital care thought leaders. The Clinical Services Department of The Montgomery County Hospital District EMS service developed the podcast as a tool to better engage and disseminate continuing education to our MCHD medics as well as first responders and EMS professionals nationwide.

Dr. Casey Patrick is the assistant medical director for Montgomery County Hospital District EMS and is a practicing emergency physician in multiple community emergency departments across Greater Houston. His EMS educational focus is on innovative paramedic teaching via the MCHD Paramedic Podcast. Dr. Patrick’s prehospital clinical research involves the investigation of paramedic use of bolus dose intravenous nitroglycerin for acute pulmonary edema and the implementation of lung protective ventilation strategies for intubated EMS patients. Casey and his wife, Alyssa, work and live in Conroe, Texas, and Spokane, Washington. Together they have five children: Mia, Ainsley, Brock, Dean and Will.

Dr. Dickson graduated with honors from the University of Texas Health Science Center San Antonio in 2001 and completed emergency medicine training at Indiana University in 2004. He serves as the EMS medical director at Montgomery County Hospital District EMS and an assistant professor of emergency medicine at Baylor College of Medicine in Houston, Texas. His academic interests include systems of care in stroke and other time-sensitive emergencies, neurologic emergencies and education. He is board certified in emergency medicine in both the U.S. and Australasia, and has subspecialty board certification in EMS medicine. He has authored multiple professional articles and presented at regional, national and international conferences on emergency medicine and EMS topics.