fireresque51

ace that hurt my feelings as i do both fire and ems. lol

let me restate that last statement, i am looking to see if we need to try and talk the medical director into removing the attempt after the etomidate.

You are correct, the post intubation sedatives are utilized especially on our long transports, the etomidate does well for sedation for about 20 min. after that the fentynal is given to keep them down and from awakening, if signs of awakening are noticed befor the 20 min the it is given then. as far as the laryngeal spasm, you have a good point, and that is why im doing this thread so that i can get some ideas on how to convince our medical director to take out the attempt after the etomidate.

i agree to point, but not all pts that are being RSI'd actually need the RSI. Those would be the ones that are "close to the edge". I am a big proponent of RSI, but not all medics can tell who is or isn't on that edge. I hate to say it but the fact is true. That's why we do the fascilitated intubation, now that being said, I do understand the benifits of RSI and its not a matter of saving a few dollars, why nock out the drive when you may not have to, im not saying sit there for 3 attempts with out giving the sucs im saying take 10 seconds between the etomidate and sucs and see if they are complient enough or not. In my experience, if the pt is not loose enough for you to visualize the cords while sitting in the captains chair then you will need the sucs. If its trauma, use it. If its respritory, consider if you can do it with out. The majority of our intubations are done utilizing the sucs. without is just another option for the faint of heart, and the fact our medical director said we had to do it.lol.

OK I know there has been a lot of discussion on RSI, but I want thoughts and comments on RSI vs Conscious sedation or as some call it Pharmacological Assisted Intubation. My department for years did PAI using Etomidate and Valium. When we started getting the figures together for getting the Medical director to allow RSI we found that in 3 years we only had a 47% success rate with Etomidate only, the rest were RSI'd either in the ER or by the Flight Crew. Since implementation , 2 years now, we have had a 97% success rate. We do a Facilitated RSI meaning we give the Etomidate, if gag reflex is still present we proceed to the sucs and nurcoron and Phent. for sedation. I am for RSI, but like the way we are ding it , if you don't need the sucs you don't have to use it, but its there if you do. I believe this is a great compromise and should be used in all RSI protocols. I am interested in any other results or opinions you may have.

Some of the studies my department has looked at say the same thing. But LR being a large mollecule protine even though it is isotonic out side the body , once in it acts a a hypertonic solution due the the size of the protine mollecule, some say great it pulls more fluid, but that is bad because it decreases the amout if intracellular fluid and causes the build up of lasctic acid. Were NS is isotonic across the board and does not pull from intracellular there for it is better than LR in that since, but as we are all aware, only blood, and blood substitues like hemopure and the other in testing will reallyl benifit the pt. As long as we are having to do 3 to 1 repalcement we will never solve the problem. Untill then my department is using only NS in trauma, LR is used only in burns and OB.

The jice thing about hemopure is the fact it has 300 time greater affinity to oxygen than human hemoglobin so a little can go a long way in coranary profussion, but good pont.

Now if we can just get the FDA to approve it for Pre-Hospital use.

dust look at the relitive hypotension in trauma forum

Ace, To further on my comments on another forum, yes there is a definite need for us right out of school and as our career progresses, to further out knowledge and understanding of what we are doing, why we are doing it, should we do it, should it change, should stay the same, etc...... For those who do not want to further the knowledge they have, they ( i am sorry too say) are a large part of what is wrong with EMS now. The days of playing cowboy and flying by the Seat of your pants are over. More now than ever, every decision you make in regards to pt care needs to be well thought out, well planned, and based on a well educated field diagnosis, that is derived from a very thorough, and accurate pt assessment. For get the old excuse " Well its in our protocols so I did it". That will not fly nowadays. As aggressive as some EMS agencies are getting now (mine included) if you do something that they don't need, or do it wrong because you did not understand how to do it, you will kill your pt. If we as a profession want to receive better pay, better benefits, and more importantly, be viewed as a group of well educated heath care providers, then we have to further out knowledge and understanding, and those who refuse to progress, or don't care to progress, need to get the hell out of the profession that I love, and have devoted the majority of my life too. And yes AKROEZE this may be directly tied to another topic but i believe it is a very important part of out jobs, and therefor should be discussed, don't you?

Sign me up Nate

Nate just FYI talk to your suppliers, we use both here and both are in prefilled syringes.

Ace, I think that there are few out there that really understand the disease well enough to comment on your article. Not that they are dumb or stupid, but that EMS has taught cookbook medicine when it comes to trauma and not really explained it too the masses. I know that any one can understand, God knows i learned it, its just a matter of the teachers and lecturers or our industry getting educated on it and taking it back to there students and co workers and teaching them. I know for a fact that if it wasn't for my time and Vanderbilt I would still be saying "well its what our protocols say to do".

in my experience out comes are about the same although if you had a way of doing labs in the field lidocaine does better in people with higher sodium levels, since it is a sodium channel blocker, and amiodorone does better in people who are hyperklemic, due to it potassium channel blocking abilities, both stabilize the semi-permeable membrane of the heart just in different ways.

I know this is an older forum but I'm putting in my 2 cents. The service I work for does allow passive hypotension in accordance with PHTLS, that is in a contained internal hemorrhage bolus 20ml/kg only to maintain a sbp of 80, in external hemorrhage same bolus to maintain radial pulses, regardless of rate and quality. you may repeat once for a total of 40ml/kg. The problem with over fluid resuscitation is than by overloading the pt with NS or ringers you decrease the amount of cellular waste the blood can transport to the lungs, causing the pt to build up lactic acid and causing lactic acidosis. This being the major cause of death in the pt treated with aggressive fluid. Unfortunately until the hemopure trials are done here in the US, we will still be facing this problem, once accepted and implemented , hemopure will open up new areas of treatment in trauma and cardiac re-profusion in acute myocardial infarctions. Just in case anyone wonders where I got my great in-site (lol) I worked in the Trauma Unit at Vanderbilt University for a year and had great chances to learn more of the disease. Just food for thought.