Be a kind medic

[firedoc5]

All I'm going to say is this "ET without sedation = Bad execution". As a rookie I saw some of the more senior guys do it, the puking, gag reflex, forcing of the scope and tube through it all. I knew when I "grew up" I wasn't about to do that to any patient.

[toutdoors]

I remember reading one of the highlighted boxes in our medic book in regards to RSI. It simply stated that using paralytics with no sedation to intubate a pt was a form of pt abuse. It struck me pretty hard, and I would have to agree with it. While sedating the pt prior to paralytics administration and thus intubating is not only the compassionate thing to do; more importantly it is the right thing to do. Learn the why as well as the how.

[iMac]

Dust - oh trust me, they got an earful from me later on. As I stated, this was not a pt of mine - it was an intercept pt and once in our hands was nicely sedated courtesy of fentanyl and versed. I'd be interested in talking with this patient later on to see what was remembered and what wasn't just to prove a point !

Has happened so many times. Tho it happened in a more "controlled" setting, I went thru the same thing earlier this year coming out of the O.R. To this day I could still tell you every single thing that was said between O.R. and recovery. Still tubed (tho in no pain)but obviously no longer sedated enough to have a -peaceful- awakening. To say the least I have that physician's name down.

Had I been in your situation I can imagine there is someone you could have reported to. I see very scary practitioners come thru our examinations and to hear some of the things they would do in given situations just kills me sometimes. Unfortunately regardless of the profession you will find people like that around.

[fallout]

I was in a situation about six months ago where I did a RSI without any sedation. It was a tough decision that I didn't like but I felt between a rock and a hard place.

The call was a suicide attempt overdose on an entire bottle of Ambien and entire bottle of Darvocet(I think? some narcotic pain control med). On arrival the patient was cyanotic, GCS 3, breathing 4 a minute. The vital signs were rate of sinus bradycardia at 50 bpm and blood pressure of 80/40. We started BVM ventilation and attempted to place an OPA which resulted in the patient gagging. Unfortunately my service only carries Versed as a sedation agent. I didn't feel comfortable administering versed with that heart rate and blood pressure. After five minutes of BVM ventilation she completely stopped any respiratory effort. The patient had very weak gag response at that point. I made the decision to withhold versed at the time of intubation and used anectine only. Perhaps if we carried etomidate I would have administered that because of the shorter duration. Eventually after the airway was established the heart rate and blood pressure improved and I was able to sedate the patient with versed.

To this day I wonder if that was the right decision and if the patient experienced mental trauma as a result of the intubation. I would appreciate people expressing their opinion on whether my treatment was appropriate.

[cynical_as_hell]

that is just horrible!!!! I am definetly un-educated with this procedure, but i thought that in order to RSI someone, not only did you have to paralyze them, but isnt there a medication given that pretty much wipes their memory? It must be a very scary feeling to be paralyzed, and be harmed, and theres nothing you can do.

[chbare]

I was in a situation about six months ago where I did a RSI without any sedation. It was a tough decision that I didn't like but I felt between a rock and a hard place.

The call was a suicide attempt overdose on an entire bottle of Ambien and entire bottle of Darvocet(I think? some narcotic pain control med). On arrival the patient was cyanotic, GCS 3, breathing 4 a minute. The vital signs were rate of sinus bradycardia at 50 bpm and blood pressure of 80/40. We started BVM ventilation and attempted to place an OPA which resulted in the patient gagging. Unfortunately my service only carries Versed as a sedation agent. I didn't feel comfortable administering versed with that heart rate and blood pressure. After five minutes of BVM ventilation she completely stopped any respiratory effort. The patient had very weak gag response at that point. I made the decision to withhold versed at the time of intubation and used anectine only. Perhaps if we carried etomidate I would have administered that because of the shorter duration. Eventually after the airway was established the heart rate and blood pressure improved and I was able to sedate the patient with versed.

To this day I wonder if that was the right decision and if the patient experienced mental trauma as a result of the intubation. I would appreciate people expressing their opinion on whether my treatment was appropriate.

It sounds like a judgment call. Too bad you did not have etomidate, as this could have been a good agent for a similar call. Also remember, many people say that in some situations you can utilize a paralytic agent without an induction agent. Some "crash airway" guidelines allow you to perform such a procedure. Remember, your patient must be unconscious and near death to meet most definitions of a crash airway. Not every crash airway will require a paralytic; however, specific cases could be managed in such a way.

Prior to heading over seas, I helped out in an ER with a person experiencing a massive overdose of narcotics. He was unresponsive and circling the drain; however, he still had intact gagging. The doc was actually very good and declared a crash airway requesting sux and a double airway setup. We were able to intubate without difficulty. So, in specific situations, this is a viable route to consider.

Take care,

chbare.

[spenac]

that is just horrible!!!! I am definetly un-educated with this procedure, but i thought that in order to RSI someone, not only did you have to paralyze them, but isnt there a medication given that pretty much wipes their memory? It must be a very scary feeling to be paralyzed, and be harmed, and theres nothing you can do.

The sedative acts to block memory of the event. You can use many different types depending on patients condition. Seems most common is midazolam (versed), some others are thiopental, ketamine, etomidate, diazepam (valium).

[spenac]

I was in a situation about six months ago where I did a RSI without any sedation. It was a tough decision that I didn't like but I felt between a rock and a hard place.

The call was a suicide attempt overdose on an entire bottle of Ambien and entire bottle of Darvocet(I think? some narcotic pain control med). On arrival the patient was cyanotic, GCS 3, breathing 4 a minute. The vital signs were rate of sinus bradycardia at 50 bpm and blood pressure of 80/40. We started BVM ventilation and attempted to place an OPA which resulted in the patient gagging. Unfortunately my service only carries Versed as a sedation agent. I didn't feel comfortable administering versed with that heart rate and blood pressure. After five minutes of BVM ventilation she completely stopped any respiratory effort. The patient had very weak gag response at that point. I made the decision to withhold versed at the time of intubation and used anectine only. Perhaps if we carried etomidate I would have administered that because of the shorter duration. Eventually after the airway was established the heart rate and blood pressure improved and I was able to sedate the patient with versed.

To this day I wonder if that was the right decision and if the patient experienced mental trauma as a result of the intubation. I would appreciate people expressing their opinion on whether my treatment was appropriate.

If your GCS of 3 is correct they would not need sedation as they are unaware of anything. Are sure that was correct because a dead person has a GCS of 3?

[chbare]

GCS of three and unawareness are not mutually exclusive concepts. Many conditions can produce a GCS of three, while the patient may be awake, aware, yet unable to communicate.

Take care,

chbare.

[fallout]

That is where it gets a little confusing. She briefly improved to GCS of 6 for a period of maybe one minute. She made a weak attempt to grab the BVM from my partner. This was prior to any medication administration. From that point on, GCS 3. I tried everything I could think of, hand drop hit her in the face, painful stimuli to nail bed, sternal rub, etc. I guess that is the practice of medicine. Knowing what the rules are and then choosing to break those rules for the given situation you are in.