Topics in this EM Quick Hits podcast
Anand Swaminathan on optimizing RSI medication timing (1:08)
Brittany Ellis on ED boarding challenges in older patients and improving ED overcrowding and ED flow (7:30)
Dave Jerome on managing prolonged tourniquet application (30:21)
Nour Khatib and Phil Gillick on a rural peer support program case (39:20)
Jesse McLaren on ECG reciprocal changes in acute occlusion myocardial infarction: the mirror image (54:43)
Melody Ng on practical nutrition tips for shift workers (best of University of Toronto EM) (1:01:23)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, January, 2025
Cite this podcast as: Helman, A. Swaminathan, A. Ellis, B. Jerome, D. Khatib, N. Gillick, P. McLaren, J. Ng. M. EM Quick Hits 62 - Optimizing RSI Medication Timing, ED Boarding of Older Patients, Prolonged Tourniquet Use, Rural Peer Support Programs, ECG Reciprocal Changes, Nutrition for Shift Workers. Emergency Medicine Cases. January, 2025. https://emergencymedicinecases.com/em-quick-hits-january-2025/. Accessed February 2, 2025.
Optimizing RSI Medication Timing

* Much of recent airway research relates to RSI preparation and tube delivery: Resuscitate prior to intubation, improve hemodynamics to decrease risk of peri-intubation hemodynamic collapse, improve oxygenation to increase safe apneic time, positioning, ramping, airway alignment, bed up, head elevated, and bougie first approach etc.
* Typical approach to RSI involves near simultaneous administration of induction and paralytic agents to rapidly result in ideal intubating condition. However, this approach often results in an induced but not paralyzed patient, causing difficulties with tube delivery as medication onset times differ:

* Succinylcholine: 45-60 seconds
* Rocuronium (1.2 mg/kg): ~60 seconds
* Etomidate: 30-40 seconds
* Ketamine: 30-45 seconds
* Propofol: 20-25 seconds


* As such, consider aiming for simultaneous onset rather than simultataneous administration of induction and paralytic agent.
* In studies by Driver et al. 2019 and Catoire et al. 2024, administering paralytic prior to induction agent is associated with lower first attempt intubation failure.

Bottom line => Consider administering paralytic first, then induction agent ~20-30 seconds later, ensuring simultaneous onset for optimal RSI while averting awake paralysis.
Expand to view reference list

* Driver BE, Klein LR, Prekker ME, Cole JB, Satpathy R, Kartha G, Robinson A, Miner JR, Reardon RF. Drug Order in Rapid Sequence Intubation. Acad Emerg Med. 2019 Sep;26(9):1014-1021. doi: 10.1111/acem.13723. Epub 2019 Mar 19. PMID: 30834639.
* Catoire P, Driver B, Prekker ME, Freund Y. Effect of administration sequence of induction agents on first-attempt failure during emergency intubation: A Bayesian analysis of a prospective cohort. Acad Emerg Med. 2024 Oct 18. doi: 10.1111/acem.15031. Epub ahead of print. PMID: 39425254.



ED Boarding for Older Patients
This segment is the first part of our series on The Best of The Internat...