UMEM Educational Pearls

Category: Trauma

Title: Use of delayed sequence induction in trauma pateints

Keywords: hypoxia, delayed sequence, RSI, Ketamine, succinylcholine (PubMed Search)

Posted: 5/7/2023 by Robert Flint, MD (Emailed: 5/14/2023) (Updated: 4/22/2024)
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Delayed sequence intubation can be valuable in the agitated, combative trauma patients who will not tolerate pre-intubation pre-oxygenation.  We know peri-intubation hypoxia leads to significant morbidity and mortality. DSI offers us an option to avoid peri-inubation hypoxia.

This study randomized 200 trauma patients into a rapid induction group (Ketamine followed immediately by succinylcholine with immediate intubation) vs. delayed induction group (Ketamine followed by a 3-minute oxygenation period followed by succinylcholine, followed by intubation).  The authors found: “Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02).”


Anjishnujit Bandyopadhyay 1Pankaj KumarAnudeep JafraHaneesh ThakurLaxmi Narayana YaddanapudiKajal Jain Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial. Anesth Analg. 2023 May 1;136(5):913-919. doi:10.1213/ANE.0000000000006171. Epub 2023 Apr 14.