Steve Cole, MEd, NRP

Yep. I am that croaker260.

My views are my own. Big fan of FOAMEd.

Paramedic. FTO. Training Captain. MEd. Father. Husband. Geek.

[Dr. Chacón-Lozsán F .'. @franciscojlk]

💉🩺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. https://t.co/KWUfUtAMyP

[Steve Cole, MEd, NRP @croaker260]

Every ALS 911 EMS agency worth their salt should have pumps and vasopressor infusions.

[JAMA Network Open @JAMANetworkOpen]

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.

https://t.co/cInCBzu8x8

[Steve Cole, MEd, NRP @croaker260]

@EMSPAC1 I'm not sure that is something to celebrate

[Steve Cole, MEd, NRP @croaker260]

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"

[Steve Cole, MEd, NRP @croaker260]

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%!

[Steve Cole, MEd, NRP @croaker260]

@FLTDOC1 Do they have button type batteries?

[Steve Cole, MEd, NRP @croaker260]

@NicholasChrimes @Anaes_Journal I think it's important to seperate cric pressure vs. ELM , Something many providers lump together. These are two different techniques. One is often detrimental to your pt, one can be beneficial. If you don't know the difference, you prob. shouldn't be doing either.

[Steve Cole, MEd, NRP @croaker260]

If you can't get enough people on scene or otherwise can't to focus on High Performance CPR...then shake up your system. Don't hit the "Easy button" and give your patient inferior CPR.

[Steve Cole, MEd, NRP @croaker260]

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"?

[Steve Cole, MEd, NRP @croaker260]

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.

[Steve Cole, MEd, NRP @croaker260]

(8/?) She was born in Tokyo, Japan, on April 1, 1918, & died in Kobe, Japan, April 21, 2016, @ 98 years. Her obituary was published in the Lancet, one of the oldest and most respected medical journals in the world. In my opinion, they should have won the Nobel Prize for medicine.

[Steve Cole, MEd, NRP @croaker260]

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:

[Steve Cole, MEd, NRP @croaker260]

(7/?)A really great video about PPH and Dr. Utako is here: https://t.co/Hp3A8Cjgsd

[Steve Cole, MEd, NRP @croaker260]

(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!

[Steve Cole, MEd, NRP @croaker260]

(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.

[Steve Cole, MEd, NRP @croaker260]

(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!

[Steve Cole, MEd, NRP @croaker260]

@NYCEMSwatch (4/?) When she first presented her research, she was ridiculed by male physicians by being asked if she was going to dance for them.

[Steve Cole, MEd, NRP @croaker260]

@NYCEMSwatch Or expand the scope & education of paramedics so you do not need a doctor at the scene of most calls. Blood, RSI/DSI, POCUS, finger thoracostomy, & even field amputations for rare cases. Imagine what a master's level acute care paramedic practitioner could bring in their toolbox!

[Steve Cole, MEd, NRP @croaker260]

(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".

[Steve Cole, MEd, NRP @croaker260]

(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.

[Steve Cole, MEd, NRP @croaker260]

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.