DSI(delayed sequence intubation) and king ketamine !

Рет қаралды 90,732

Күн бұрын

Пікірлер: 74

@ashishkorg8170 Ай бұрын

Ketamine ---increases SVR ,Cardiac afterload,HR.in most patients. Ketamine decreases BP in the patients on the verge of shock ,those with depleting stores of noradrenaline in their pre and post synaptic terminals. So beware..It is not for all comers..especially congestive card failure. Good demonstration of coordination,clear messages ,closed loop communications,mutual respect ,leadership skills ,role playing....Excellent..

@dr.vikasjangra3359 3 жыл бұрын

How easily and nicely that was done, nicely explained too. Thanks doc

@alexpuxty9922 7 жыл бұрын

Thanks for trying to add to the knowledge of induction techniques at our disposal. I have a few comments/suggestions: 1. This man was not really that combatitive. He allowed a high flow oxygen mask to be applied as well as full monitoring. 2. Your sequence is (partial) pre oxygenation with a high flow mask, followed by induction agent, bagging the patient, muscle relaxant then intubation. This is essentially a standard anaesthetic sequence given hundreds of thousands of times a day across the world. 3. Given 1, you did not need to use ketamine specifically and while it is a good trauma induction agent or one for limited resources, it does have issues with increased secretions (as in your video, which may have made intubation harder) and emergence delirium. Not great if the patient is already confused. I have used ketamine for combatitive patients but usually when they are psychotic, a danger to themselves and others and are attacking staff etc. 4. Suxamethonium was not the ideal muscle relaxant in a non RSI die to side effects. 5. The person bagging the patient was ineffectual. As already commented, the patient was clearly still breathing and the bagging was not with inspiration effort and also too vigorous, making insufflation of the stomach, and regurgitation and aspiration more likely. You can also hear the airway pressure relief valve going off as he bagged, suggesting the oxygen was not going into the patient. 5. Once the intubation was tricky, a bougie was used. The assistant should not let go of it. This is because as your incubator advanced the tube the bougie also went further distally and this an cause trauma and indeed perforation of the airways. I wish you all well but am not convinced about this video as a 'how to'

@fahad1448 7 жыл бұрын

thank you alex for a comprehensive feedback,appreciate it,will definitely work on ur suggestions and try improving . Anyways my thoughts to your queries= 1-combatititve is a relative term,he ws not actually allowing a mask and ws shouting in hindi to remove the mask as heard in the video 2-i started following the sequence after listening to one of scott weingarts talks to change the er sequence,so not really aware of the anaesthetic standards 3-well,ketamines role is controversial,some say its nt a good trauma induction agent as it raises icp while newer studies disagree,but one thing is fr sure is that it doesnt drop the blood pressure post intubation rapidly and maintains it and i actually would use its re emergence side effect to our advantage requiring lower sedation post intubation. 4-agreed rocuronium is ideal but suxamethonium wsnt contraindicated too 5-i totally agree and im gonna make sure he understands and we get it right

@sandhiller49 4 жыл бұрын

Ketamine is a GREAT medication if used properly in appropriate situations, used it tons as flight RN, but usually in conjunction with other meds

@nicholasdaniel3567 3 жыл бұрын

Good work with ur explanation very simple n easy to understand.

@chrisu_thedragon4753 5 жыл бұрын

Min 4:50: The Patient is paralyzed with Sux, and the assistant fully ventilates over mask before intubation? This is neither part of RSI nor DSI! These are supposedly Not sober patients!!! Complete fail!

@fahad1448 8 жыл бұрын

@harish...the main difference between the two is the order.RSi has preoxygenation followed by induction and paralytic agent given in quick succession.preoxygenating a pt whos agitated is not effective.So DSI changes the order,induction agent followed by preoxygenation and then paralytic..yes there are multiple studies supporting it..check life in the fast lane and can google dsi..thanks

@tanweerize 4 жыл бұрын

Decabytes Fahad it will be help if u mention requirement for DSI. As I puzzle for secretion, and how to decrease risk of aspiration if pt loss consciousness. True such dose don’t allow unconscious yet , aspiration in lesser sedation is still reported. And ketamine can decrease BP too in sympathetically tired patient. How to approach such patient. Plz brief

@rumit9946 7 жыл бұрын

excellent.Thanks for sharing

@lloydzurn4562 5 жыл бұрын

Assuming that this was a proven NPO patient - which is not realistic. Ketamine does NOT give you all the time you want to take. What if this patient had vomited while intubation was in progress? The sequence after stopping ventilation took 1'28". This is unacceptable.

@ifree936 7 жыл бұрын

Amazing video. It's one thing to read about DSI but to actually see it is so much better. I have one question. If I am in an austere environment and need to intubate a patient and I have ketamine but no paralytic is it still possible to continue with the procedure? Does ketamine relax the patient so much the airway relaxes as well? Would i also be safe to pre oxygenate the patient with room air using a bag valve mask, due to lack of oxygen tank?

@JayTelly 5 жыл бұрын

Ketamine doesnt abolish airway reflexes. With propofol or sevoflurane u can intubate without muscle relaxant. Preoxygenation means u r removing nitrogen from lungs, using 100 percent oxygen. U cant pre oxygenate with room air.

@wrestle4life234 2 жыл бұрын

Ketamine will not relax your patient. But you can intubate, still. Have fun figuring out your sedation method after it wears off! But seriously, Reuben Strayer has articles on Ketamine-only

@jxl5998 5 жыл бұрын

Love the way you briefed the stepwise manner of the DSI.. A big fan of yours now sir..

@shyamjadhav5299 4 жыл бұрын

Sir, can we give Injection Glycopyrrolate as premeditation so as to reduce secretions and to avoid bradycardia if occurs.

@MrArunvilayil 2 жыл бұрын

1.If bp is on higher side ,can we use ketamine? 2.patient having CAD ,can we use ketamine?

@baijunair1720 Жыл бұрын

So incase u are starting vasopressor prophylactic, then which would you prefer and how would you administer, via syringe pump or as in with an infusion bag of saline or Dextrose?

@jared8251 5 жыл бұрын

Can you intubate without a paralytic?

@harisht45 8 жыл бұрын

Please elaborate differences between DSI and RSI. Are there any studies supporting advantages of DSI over RSI

@shanem6869 3 жыл бұрын

DSI is for when you have a combative patient. The first step is giving the special K to calm them, then O2 then if intubation is still needed (sometimes relaxing them will address the issue meaning no intubation is needed) then the paralytic can be applied. RSI is she you have a high risk of aspiration and need to intubate quickly. You will give the K and paralytic at the same time then intubate.

@anthonybruceplake 7 жыл бұрын

The assistant with the balding hair dropped the main oxygen line on the floor and then he dropped the endotracheal tube on the floor also. He never missed a beat "bagging" the patient --- too bad HE WASN'T GLOVED up ALSO !!!! JEEZZZZ GOD HELP THAT MAN !!!

@mangulicamoravka 2 жыл бұрын

He didn't drop the ET tube, you can clearly see it in the wrapping all a long, he picked up the bougie most probably from the bottom storage when the intubating Dr told him, and oxygen lines fall on the floor all the time, it has no consequence on anything

@isticb06 4 жыл бұрын

Why to use Ketamine in severe LV dysfunction? Why not fentanyl or morphine?

@kelogus 4 жыл бұрын

I think the educational intention was good but the procedure was unsafe, unsterile and disturbing.

@nicholaswhs0896 3 жыл бұрын

How so?

@Dev-wr7eb 3 жыл бұрын

Ketamine without any anticholinergic ??

@rajeshsiva3931 4 жыл бұрын

Thank you Sir 🙂

@bieniemonster2394 5 жыл бұрын

Oh my god, please save this patient. Medical nonsense... DSI, RSI. Big difference.

@shahidarman747 6 жыл бұрын

very great

@drvinod0072004 3 жыл бұрын

Thanks

@GustavoMontanha 7 жыл бұрын

Great video, very cool and clear doc. Deeply appreciated.

@anthonybruceplake 7 жыл бұрын

Did anybody save ME notice the lack of STERILE GLOVES and THINGS FALLING ON THE FLOOR then PICKED UP and put into the patient ????

@glennauger1205 6 жыл бұрын

what the heck happened to this guy other than the fact of getting a URI

@pjhaebe 6 жыл бұрын

what in the name of God did we just watch? remind me to never get hurt in India...

@lorenzofornaciari9688 3 жыл бұрын

"Bagging assistant" clearly cleaning his nose with the gloves. In COVID era this hurts. Also he's bagging a breathing patient and re-using dropped equipment!!

@enzomarceloamelia9127 4 жыл бұрын

May god take care of that patients' teeth.

@sapmttamimi977 3 жыл бұрын

wow! different technique there. stylet first then entubation tube follows.

@soumyaagrawal743 3 жыл бұрын

That's actually a bougie not a stylet..different instruments with different functions☺️

@iloveservicedogs104 7 жыл бұрын

Question I've heard ketamine before was in a great experience I was conscious enough to scream remember everything that was going on and was terrified I was suffocating to death. So my question is how are you sure that he's unconscious enough to allow for a paralytic to be given it into baited how do you know that he is not still partially conscious and awake fully aware that he can't breathe I can't imagine anything more terrifying. Also why is none of you talking to him he's obviously scared although I can understand what you saying not one person is sitting there speaking to him.

@shaheerhamza 3 жыл бұрын

That's because u were given inadequate dose...😁😁😁 If u would hav received adequate dose u would feel like flying in the clouds...😁😂😁... Who the hell have u dat ketamine?? Either the drug is not ketamine else the person who gave u is unqualified to use that drug...🙏

@YAMI-co8fq 4 жыл бұрын

Lol .. Preoxygenating an emergency case ?! ( who is considered having a full stomach) .. And giving sympathomimic ketamine to a patient who's already hypoxic and having sympathetic overstimulation ?!

@tanweerize 4 жыл бұрын

Roger Federer , this was giving me headache all through this video..

@leonardonobrega9844 2 жыл бұрын

Nice!!!

@dp8685 4 жыл бұрын

How bad is this. Bag supply hose falls off, instead of lifting laryngoscope try’s to break as many teeth as possible, try’s et tube before getting line of sight to epiglottis then try’s bougie, hell why not try doing it blind as well!

@mattupallibalaiah9698 4 жыл бұрын

It is good for learning but no body was wear ppe

@tomaszstarling 7 жыл бұрын

Didn't give Roc first?

@nicholaswhs0896 3 жыл бұрын

Why the hell would you do that??? Paralyze before sedation???

@laithsubhemohee6356 2 жыл бұрын

Put some pressure on his cricod man

@sudiptaandroid1616 3 жыл бұрын

Ketamine to a pt with CCF ?? LOL !!

@tanussc 7 жыл бұрын

I found this video disturbing. The assistant was bagging the patient in a very unprofessional way. He was just squeezing the balloon, you can clearly see that the patient is struggling to breathe before intubation, after intubation he was just as casual about it. Small volume of air, no consideration to peep. I hope you understand the patient may be feeling some of this and it might be very uncomfortable for him. Ketamine is only as good as the the dosage tolerated by the patient. I once saw a patient talking after being given 10 units of ketamine. Unbelivable, yes. Imagine if she had been then given succin and intubated. She would have felt the whole thing. Just be careful and remember they are people. Not test subjects. Not trying to be rude, just a bit worried. i hope you are doing great.

@rockycycle2682 6 жыл бұрын

I noticed the same thing and was wondering if I was the only one pissed of at his demeanor.

@profheadramnandanprasad9137 8 жыл бұрын

Audio quality is very poor.Think using oral airway during oxygenation.Give positive pressure breath during pt's inspiration.your pt,was breathing nicely.

@andrewmackay5284 7 жыл бұрын

Did the patient consent to the public use of this video ?

@fahad1448 7 жыл бұрын

we took a written consent from the patients family and explained them about the educational detail it would serve...as i have mentioned in the disclaimer.

@andrewmackay5284 7 жыл бұрын

+Decabytes Fahad thanks. It's interesting to a UK audience where the family consent would unlikely be sufficient to publish on internet.

@moisestyu12 5 жыл бұрын

You are not wearing your MASK .

@zeeshanalientguru5459 5 жыл бұрын

Yar amazing, the best video that I ever saw.... I know most of you will say that this video should not have been made on live patient but I disagree... Well done and keep making more of such. Regards