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almost all of my emergency airways to a ket- amine/rocuronium combination, because the last thing you want while doing a cri- cothyroidotomy is the patient reaching up and grabbing your hand because everything wore off. The rest of the potential things that can go wrong mostly center around the effects of the medications involved. Narcotics, benzos and (especially) propofol can give you hypotension. Succinylcholine can shift potassium out of the cells, causing lethal arrhythmias. Rocuronium can outlast your sedation, leaving you with an awake, paralyzed patient. People coming out of ket- amine can develop frightening emergence reactions. There is also some concern that etomidate can increase mortality in septic patients, although some studies show no difference. Above all, don't forget sedation and pain control! Vecuronium isn't a seda- tive, even though it will keep your patient from pulling at lines and tubes. Gene: By using a controlled approach, being prepared and having practiced using a pit-crew procedure, you can successfully paralyze and intubate your patient in an orderly fashion. Now let's turn back the clock and assume your crew was prepared for RSI/DSI. After recovering from the initial shock of realizing RSI has to be done, you imple- ment the plan you've practiced with your team many times. You grab your RSI/DSI kit while the IV starter gets the line. Esti- mating your patient's weight at 80 kg, you draw up 200 mg of ketamine while your partner secures the IV. Your airway assis- tant suctions the airway and applies the pulse oximeter. You push the ketamine, and in 30 seconds your patient is relaxed and breathing easily. Your airway assistant applies a NRB at 15 lpm and a nasal cannula at 15 lpm from the other regulator in your ambulance. You prepare your laryngoscope and tubes, draw up 100 mg of succinylcho- line and push it. Your airway assistant reports a sat of 99%. You take over and open the airway and take a look. There is some blood in the airway, so you suction and look again. Your patient has a short, thick neck, so you don't see the cords and you know it's going to be a difficult intu- bation, but since you have preoxygenated your patient adequately, you know you have plenty of time to accomplish it—far more than 30 seconds. After applying bimanual laryngeal manipulation (BLM), you ask your airway assistant to put her fingers on yours to maintain the view you've achieved. You insert your bougie, feel it bumping along the tracheal rings, advance it until it stops at 27 cm, and thread your 8.0 ET tube over it into place. You have already checked the cuff, and the syringe is still attached, so you inf late the cuff and ventilate. You see chest rise, hear good breath sounds bilaterally and attach the EtCO 2 monitor sensor. You see 40 torr of CO 2 registering with a nice, f lat plateau in the waveform. You secure your tube and retake vital signs. Now you push your long- term sedatives and paralytic. The rest of your transport is routine. Jason, Kelly and Gene: RSI/DSI does not have to be a panic situation. Through plan- ning, preparation and practice, you can master this essential technique and, when the time comes, complete the procedure in a calm and orderly manner. REFERENCES 1. Bernard SA, Nguyen V, Cameron P, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg, 2010 Dec; 252(6): 959–65. 2. Benumof J, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology, 1997 Oct; 87(4): 979–82. 3. Levitan R. No Desat! Emergency Physicians Monthly, www. epmonthly.com/archives/features/no-desat-/. 4. Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med, 2006 Jun; 47: 548–55. PEOPLE COMING OUT OF KETAMINE CAN DEVELOP FRIGHTENING EMERGENCE REACTIONS. ADVERTISER INDEX EMSWORLD.com | OCTOBER 2015 55 Request Free Information at www.emsworld.com/e-inquiry COMPANY PAGE INQ # Ambu, Inc. 41 29 Bound Tree Medical, LLC 5 12 Columbia Southern University 31 26 CompX Security Products 25 20 ECCU/Emergency Cardiovascular Care 17 Emergency Medical Products 53 32 Emergency Products and Research 30 25 EMS Store 19 EMS World EXPO 52 COMPANY PAGE INQ # FireHouse World Expo & Conference 11 General Devices 60 34 ImageTrend Inc. 23 19 iSimulate USA 13 16 Junkin Safety Appliance Co. 26 22 Knox Company 50 31 Lenoir Community College 9 14 Mangar International 10 15 MedaPoint 29 24 Mercedes-Benz USA 3 11 COMPANY PAGE INQ # Mercury Medical 43 30 Minto Research and Development 37 28 Nasco 22 18 Physio-Control Inc. 2 10 S&S; Medical Products 15 17 Silent Partner Technologies 26 21 Simulaids Inc 35 27 Stryker EMS 59 33 U-Cap-It 27 23 ZOLL 7 13