Be a kind medic

[fireflymedic]

ER doc- point well taken. No this wasn't the naples crew and I'm in agreement this service needs to have RSI pulled from them as their intubation rate currently sucks already and there are multiple other problems including pitiful medical oversight. I do look for an investigation to occur with this. That's the problem with this area, too many people have RSI that shouldn't 'cause it's the 'new toy' but fortunately the state since under new direction is changing that.

As I previously mentioned, I've had the experience of RSI with no sedation and know how unpleasant it is - I'm in agreement that would be a just revenge. Sadly it can't be given though...all well. At least hopefully this will prompt some change as I do intend to follow up with the patient.

[tniuqs]

I agree with Dust, WTF???? Since when do paralytics get them "down far enough?" Paralytics do not provide any sedation. In a just world this medic should have to see what it's like to be paralyzed and tubed without sedation. Part of RSI is sedation. Once you have them tubed, keep them sedated enough and you won't have to use any more paralytics. It sounds to me like this medic is the kind of guy that gets off on saying, "Yeah, I get to paralyze people to save their lives." I wonder if he was one of the 12 from Naples, FL, lol.

As for the helicopter crew, again, WTF????? I hope these parents took that medic for everything he had. I know we do not have the whole story, but why are they intubating a pt with femur fxs? It sounds to me like those morons are 100% responsible for that 15 year old's death.

Part of the RSI guidelines we work with is sub theraputic dosage of Pav or Vec prior to SUX ... this is a recipe for disaster first off ... if one is overly sensitive then if you do have a problem they are down for a long time, and if any difficulty finding the right hole there and you are in deep ca ca ..... SUX is short lived, if you dont get the tube ... they will breath again.

The rationalle being one does not fasiculate ? ....... In the OR fasiculation period ends ... then shoot the tube.

(the Gas Passers I have worked with look at me like I'm smoking bud when I tell them of EMS guidelines)

But then I pre sedate with versed and fentanyl every time, I have never used a sub theraputic dose of anything.

Umm I lied just looked, I am out of beer ... again.

[Dustdevil]

Ya know, I can't help but wonder if some people aren't doing this, charting that they DID give sedation, and pocketing the fentanyl and/or versed for themselves.

As sad as that is, it's really the only answer that seems to make any sense. :shock:

[chbare]

Well, there is some evidence that preventing fasciculation's will blunt ICP changes and prevent post-operative myalgias. Typically 10% of a full paralyzing dose of a NDNMB is given prior to your dose of Sux. I liken this to using lidocaine on head injuries. Not much definitive evidence that says it is particularly helpful. Agree that if you plan to defasciculate, you should be set up and ready for intubation prior to pushing a defasciculating dose of NDNMB.

As far as people "waking up" and starting to breath. I do not advocate for such an argument. We RSI patients to secure a compromised or potentially compromised airway with the hopes of preventing aspiration. So, we already have airway issues. In addition, we need to remember that a phase II block and prolonged paralysis can occur with Sux. We cannot expect every patient to develop spontaneous respirations following induction and paralysis. This is especially true with compromised patients.

I agree that premedication with an opiate prior to induction and paralysis is good practice. Personally, I like to use fentanyl.

Take care,

chbare.

[Freaknuggetz_chick]

very intersting.

what i've been taught, and as our protocols up here go, RSS first, and if that FAILS, then RSI.

what a horrible horrible thing to do to someone. must be certain grounds for suspension or something!

[chbare]

What is RSS?

Take care,

chbare.

[fireflymedic]

CB - my guess is something similar to DAI where you only use sedation in an attempt to knock out respiratory drive and relax 'em enough to tube without the use of paralytics

[tniuqs]

Well, there is some evidence that preventing fasciculation's will blunt ICP changes and prevent post-operative myalgias. Typically 10% of a full paralyzing dose of a NDNMB is given prior to your dose of Sux. I liken this to using lidocaine on head injuries. Not much definitive evidence that says it is particularly helpful. Agree that if you plan to defasciculate, you should be set up and ready for intubation prior to pushing a defasciculating dose of NDNMB.

As far as people "waking up" and starting to breath. I do not advocate for such an argument. We RSI patients to secure a compromised or potentially compromised airway with the hopes of preventing aspiration. So, we already have airway issues. In addition, we need to remember that a phase II block and prolonged paralysis can occur with Sux. We cannot expect every patient to develop spontaneous respirations following induction and paralysis. This is especially true with compromised patients.

I agree that premedication with an opiate prior to induction and paralysis is good practice. Personally, I like to use fentanyl.

Take care,

chbare.

Yes good points, speaking to the less confident it ETI, atypical cholinesterase is out there agreed, but etomodate is my choice in a possible increased ICP, thing is without a probe in place one has to rely on good clinical obsevational skills only, drop ICP and you may be doing harm and if we could include it in our scope Propofol would be nice instead of pulling up 5 meds (and its a neat drug) that said not without complications either.. the Rapid part unless your working with another Paramedic or RN is a bit of an oxmoron, IMHO.

cheers

In NO suspected increased ICP my preferance is a facilitated intubation, no point in dropping a BP and then have to treat that too, as with sometimes unknow underlying pathology then add benzos, opiates, SUX, and Pav or Vec its a turkey shoot as to why their BPs in there boots post intubation.

I would like to draw to your attention the contravesy with atropine with kids, so not the way to go at all its a myth, but still included in some guidelines.

[chbare]

I agree. Etomidate is a very good agent for RSI. Rapid onset, fairly predictable duration of action (around 100 seconds for every 0.1 mg/kg), and hemodynamically stable. Of course there are cases of masseter spasm and adrenal suppression; however, every medication has risks and benefits. I think propofol has a place; however, it is a very fickle medication and can precipitously drop blood pressure. Not a great situation with a head injury.

Fire, thanks for the heads up. I am not really a fan of this sedation intubation technique. A major reason we use a paralytic is to prevent aspiration. In EMS we have to assume none of our patients are fasting and thus need to proceed with the expectation that our patients are at high risk for aspiration. Of course, we have the added benefit of better intubating conditions when a paralytic is used. Snowing somebody until they can take a tube really is not an optimal situation IMHO.

If a special situation exists such as a predicted difficult airway, then an awake technique such as nasal intubation may be considered.

Take care,

chbare.

[Freaknuggetz_chick]

What is RSS?

Take care,

chbare.

RSI without paralytics. most protocols i've seen up here have *sedate, *attempt, *paralyze if required, *attempt, for the flow chart.