Yep. I am that croaker260. My views are my own. Big fan of FOAMEd. Paramedic. FTO. Training Captain. MEd. Father. Husband. Geek.
Idaho
Joined November 2018
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Steve Cole, MEd, NRP retweeted
💉🩺Rapid sequence intubation in 2026: we are no longer “protecting the airway.”
We are managing physiology under extreme stress.
The latest evidence challenges one of the oldest dogmas in critical care.
RSI was designed to prevent aspiration.
But today, the real enemy is often hypoxemia and cardiovascular collapse.
1. Aspiration is no longer the central problem
For decades, RSI was built around one fear: aspiration.
But emerging data suggest:
RSI may not significantly reduce aspiration
It may increase hypoxemia and hemodynamic instability
The paradigm is shifting:
👉 From aspiration avoidance → to physiologic optimization
2. First-pass success is everything
Every additional attempt increases:
Hypoxia
Hemodynamic collapse
Mortality
Modern RSI is built around one goal:
Get it right the first time.
That means:
Videolaryngoscopy first-line
Stylet routinely
Team choreography, not improvisation
3. Preoxygenation is now a therapeutic intervention
Not just a step—a determinant of survival
NIV > face mask
HFNO as adjunct
Semi-upright positioning
And one key shift:
👉 Gentle ventilation is no longer taboo
Done correctly, it reduces hypoxemia without increasing aspiration risk.
4. Hemodynamics matter more than ever
Up to 40–50% of patients experience peri-intubation instability.
The modern approach:
Avoid propofol in unstable patients
Favor etomidate or ketamine
Consider prophylactic vasopressors
Fluid loading?
Not routinely beneficial.
5. Cricoid pressure: from dogma to doubt
No clear benefit in preventing aspiration
May worsen laryngoscopy and ventilation
Current thinking:
👉 Use selectively, or not at all
6. RSI is no longer a rigid protocol
It is now:
Patient-specific
Physiology-driven
Team-dependent
With tools like:
Gastric ultrasound
POCUS-guided decisions
Structured airway protocols
7. The real determinant of success: human factors
Preparation, communication, and coordination matter as much as drugs.
Because in critical care:
The airway is not just anatomy.
It is a moment of systemic vulnerability.
🤓Final message
RSI has evolved:
From speed → to precision
From protocol → to physiology
From individual skill → to team performance
And ultimately:
The goal is no longer just to intubate.
It is to intubate without killing the patient.
📃Reference
Boulos NM et al. Anaesth Crit Care Pain Med. 2026. doi.org/10.1016/j.accpm.2026…
ALT
Every ALS 911 EMS agency worth their salt should have pumps and vasopressor infusions.
Peripheral vasopressor administration in critically ill adults was associated with a low incidence of adverse events—major events were rare using short peripheral intravenous catheters, and use avoided central venous catheter placement in 60% of cases.
ja.ma/4btNGSr
ALT JAMA Network Open article titled, \"Incidence of Adverse Events in Peripheral Intravenous Vasopressor Use: A Systematic Review and Meta-Analysis\" by Shang-Jun Zhang Jian, MD, and others. Published March 16, 2026.
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Brigitte Bardot is dead. Memorizing the functions of the cranial nerves will never be the same....(H/T to Jimmy Edwards all those years ago...)
"Some Say Marilyn Monroe, But My Brother Says Bridgette Bardot Mmmm Mmmmm"
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I'm taking the AHA instr. updates & saw this: Apparently, a CCF of 60% is "high performing".
If you are "targeting" a goal of 60% on your CCF, you're a LOW-performing system. The MINIMUM should be 80%. We **often** see CCF of > 90% with HP CPR. 90% should be the GOAL, not 60%!
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In light of the recent AHA recommendations on the LUCAS: Do you care about your patient? Or do you care about making the Code "EASY"?
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W/ a patient-centric approach, (and supported by our own data, thanks to our Zoll systems as well as good studies outside our system) M-CPR borders on harmful the 1st 10 minutes, non-inferior in 2nd 10 minutes, & mixed benefit afterward W/ a + benefit during transport.
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n my agency, this month we are focusing on several OB and neonatal emergencies. This prompted the following post.
DID YOU KNOW: Most modern providers think of TXA in terms of traumatic blood loss, but it's earliest use was for postpartum bleeding! Some facts:
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(7/?)A really great video about PPH and Dr. Utako is here: youtube.com/watch?v=VbDDxzyp…
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(6/?) Dr. Utako lived to see the beginning of the landmark WOMAN trial of TXA in PPH on over 20 THOUSAND patients. She died 1 week after it concluded, but before it was published. When it was published in 2017, it confirmed what she had been advocating for for over 50 years!
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(5/?) Today, TXA is on the World Health Organization's list of essential medications, along with pitocin, to address postpartum bleeding. Dr. Utako's dream of reducing maternal mortality of PPH through use of TXA has been realized, only over 60 years after it was discovered.
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(4/?) Even into the 2000's, Japanese obstetricians resisted using TXA for PPH. It was DECADES before "modern" obstetricians and other providers recognized TXA for its original purpose: PPH!
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(3/?) They published their first paper in 1962! B/C Dr. Utako was a woman, she was prohibited/excluded from presenting her findings, limiting the awareness and use of the drug. Was once asked to leave a medical conference B/C "were not for women and children".
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(2/?) Because of blood shortages, they often had to study blood drawn from their own veins!
Because of a lack of resources and even facilities, they had to scrape together their laboratory in their own home. Yet they still did world class research.
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After WWII, Japan closely resembled a disaster zone and post-apocalyptic wasteland. In this environment, Dr. Utako Okamoto developed with her husband, A biochemist) worked to find a cheap and effective solution to this problem.
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Steve Cole, MEd, NRP retweeted
No child should go hungry. 🌍
We’re proud to sponsor Power Word Meal, a TTRPG community fundraiser fighting world hunger with @ShareTheMealorg.
Donate and get a FREE PDF bundle with D&D shops, recipes, and a food + foraging resource.
💜 Donate now: sharethemeal.org/en-us/chall…
Steve Cole, MEd, NRP retweeted
"Six Minutes to Live" Documentary Premieres
March 18, 2025 - The public is invited to view "Six Minutes to Live," a powerful short film that chronicles the fight to improve survival rates from sudden cardiac arrest (SCA) through immediate, effective emergency response.
This compelling film connects a preventable tragedy from 1999 to groundbreaking investigative journalism and the ongoing mission to eliminate needless deaths from SCA.
"Six Minutes to Live" weaves together multiple powerful narratives:
• The heartbreaking case of Julia Rusinek, a 21-year-old who died of SCA steps away from a fire station
• The landmark USA Today series "Six Minutes to Live or Die" that exposed nationwide disparities in emergency care
• The personal journeys of three founders whose lives were transformed by these events and who now lead this vital movement
Featured in the documentary are Bob Davis, the paramedic journalist who broke the original story; Hilary Gates, a bystander at Julia's cardiac arrest who was inspired to become a paramedic; and Tom Bouthillet, a paramedic and EMS chief who helped transform his department after reading the series.
The film also celebrates success stories like that of Amber Lee Curtiss, who survived SCA thanks to improved systems of care implemented on Hilton Head Island.
Screening Details:
Documentary link: youtu.be/_4XVn8cLZ9M?si=DYb3…
• Learn how communities can "care, measure and act" to prevent needless deaths from SCA
Care. Measure. Act.
Contact us: [email protected]
Steve Cole, MEd, NRP retweeted
We're hiring! Ada County Paramedics is currently accepting applications for EMT, Advanced EMT, and Paramedic. The application period is open until February 23. For more information: adacounty.id.gov/paramedics/…
