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Kelly: The key to success in a successf ul resuscitation, like any complex EMS call, is scene choreography. The pit crew approach gives us a ready- made template to work out the intricate ballet of resuscitation. In the pit crew approach to CPR, each rescuer has a desig- nated position and task. That position and task may vary among agencies and with dif- ferent crew configurations, but the point is that each res- cuer has a role and place—no fumbling over each other and duplication of efforts. That same approach can work for other time- sensitive and intricate procedures, such as RSI/DSI. Gene: Preparation requires that you set up your equipment for easy access, so you don't have to dig through different bags to find all the items you'll need. Most services keep drugs in one place and the airway kit in another. This requires the operator to open at least two bags or more to find the tools that will be needed and assemble them. Instead, prepare an RSI/DSI kit to be used only for this procedure. It should be set up in a special way: First, pick a container that will allow you to place items in order of use. An airway "roll" may work, or a tool box. Whatever you use, configure it to make things easy to find and have everything that will be needed for the RSI in it. Put your sedative in the first location. If you are using etomidate, tape a syringe to the vial and place it first in the kit. Next have your laryngoscope and blades. Then tubes, with syringes next to them, bougie and sty- let, then your paralytic vial with syringe, long term-sedation vials with syringes, and if you use succinylcholine, your long-term paralytic with syringe. Have everything in the order you'll need it. Practice means exactly that. As a wise person once said, "Amateurs practice till they get it right; professionals practice till they can't get it wrong." When we are deal- ing with human lives, that should be our mantra. Unfortunately too few crews ever practice these procedures together. The time to perfect your techniques is before they're needed. Every lead medic should practice the RSI/DSI procedures with all his partners until it is second nature. Kelly: The purpose of preoxygenation is to establish a buffer to give us time to perform endotracheal intubation before desaturation occurs. For most, an oxygen mask applied for three minutes or so, or eight vital-capac- ity breaths via a BVM immediately before an intubation attempt, will do the job. This preoxygenation technique promotes max- imum alveolar oxygenation and nitrogen washout, and in healthy, nonobese adults without significant pulmonary pathology, establishes a buffer of up to eight minutes before saturation falls below the critical 90% threshold. Even those with significant pul- monary pathology will still have a buffer of up to four minutes, giving us minutes to secure a tube, and not the arbitrary 30 seconds promoted by NREMT. 2 In 2010 Dr. Richard Levitan described his technique of apneic oxygenation in Emergency Physicians Monthly. 3 Simply put, add a nasal cannula at 15 lpm to your usual preoxygenation technique and keep it in place until an advanced airway is secured. The nasal cannula will allow you to reach oxygen delivery levels unobtainable with the BVM or nonrebreather alone, and it will provide a pressure gradient that will keep the alveolar capillaries suffused with oxygen for as long as you'll need to secure an airway. In studies, researchers were able to maintain apneic patients' oxygen saturation at 98% for up to 100 minutes. That certainly dispels the fear of a crash intubation while the pulse oximeter alarm beeps urgently in your ear, doesn't it? All you need do is assign one team member—who can even be a BLS provider—the role of positioning the airway and beginning preoxygenation while you sedate the patient and prepare your equipment, and you have effectively performed DSI in the same time frame as it takes to perform RSI. And one last thing: We're talking about proper airway positioning, not what passes for a sniffing position with most provid- ers. Keep the patient's head elevated so the external auditory meatus is aligned with the sternal notch. The facial plane should be parallel with the ceiling and not tilted back. Jason: Getting the sedative on board early makes preoxygenating a patient much easier. Of course, how much bang for your buck you get out of that time between seda- tive and paralytic depends on your medi- cations. Benzodiazepines and narcotics (usually midazolam and fentanyl) depress the respiratory drive—exactly what you don't want. Some people are also relatively resistant to those classes of medications, which might require you to give escalat- ing doses to achieve adequate sedation. In general, these medications shouldn't be used as your sole induction agents. (Having said that, the combination is useful to maintain sedation. It is also excellent for pain control, should your patient be an RSI candidate due to trauma.) Etomidate has always been really popu- lar for RSI because it's a reliable medication that rarely changes a patient's hemodynamics and generally leaves respiratory drive intact. Unfortunately, if you give it more than a min- ute in advance of the paralytic, you're going to have to give another dose to ensure you're not Preparation requires that you set up your equipment for easy access. EMSWORLD.com | OCTOBER 2015 51