Prehospital RSI

[paramedic_32647]

Okay everyone, I would like to know everyone's opinion on trends for prehospital RSI. What your protocols are and if they work or do not work. My specific question is how would you feel if your protocol is having you use Versed and a low dose of Vecuronium for preintubation? I am doing some research and am just not sure these would be the best two choices for RSI, but I am not a doctor and there may be things I do not completely understand. I do know there are quite a few contraindications to Succinochylonine, but Vecuronium has such a long down time! Please help by replying with your thoughts!!! Thanks everyone =)

[paramedicmike]

Get, and read, this book. I think you will find it immensely helpful to you.

[mobey]

Low dose Vec? What does that mean?

No analgesic?

Sounds like baddness all around.

[paramedic_32647]

That is EXACTLY what I am getting at! That is why I am researching and am interested in hearing about other agencies protocols! I want to try and prove my point before something happens. There is nothing at all about any pain medication, we do not carry Fentanyl; only Morphine. So as I am understaing it is Versed, Vecuronium and Intubate....which I do not feel would be the best way about going at this at all!

[systemet]

Okay everyone, I would like to know everyone's opinion on trends for prehospital RSI. What your protocols are and if they work or do not work. My specific question is how would you feel if your protocol is having you use Versed and a low dose of Vecuronium for preintubation? I am doing some research and am just not sure these would be the best two choices for RSI, but I am not a doctor and there may be things I do not completely understand. I do know there are quite a few contraindications to Succinochylonine, but Vecuronium has such a long down time! Please help by replying with your thoughts!!! Thanks everyone =)

Opinions....

First thing, if you're really interested in "researching" RSI, then you need to look for some better resources than the opinions of a bunch of anonymous paramedics on-line. I'm not saying this to be rude, but check out the text paramedicmike referenced, it's fantastic, and go on over to www.pubmed.com, and throw in a few search terms like "paramedic", "EMS", "EMT", "prehospital" and "intubation". Take a look at the limited amount of real data that's out there. Learn the pharmacology of the different agents, and how to do a thorough airway assessment (if this wasn't already taught in your medic program). Having pointed out that empirical research should trump personal opinion, I'll now proceed to give you a whole ton of my personal inexpert opinion

Regarding trends in RSI in the future:-

(1) I think poorly-run systems are going to continue being poorly-run. Many places aren't going to change their practices. Many providers aren't going to act responsibly. Many medical directors are going to continue to collect a pay-cheque without doing their jobs. Their patients will suffer. These systems may have RSI, they may not. They'll continue to do a bad job.

(2) A lot of systems are going to question the value of paramedic RSI, and other forms of pharmacologic intubation. This is going to result in fewer systems providing RSI, fewer providers within individual systems performing RSI, hopefully greater oversight, and more restrictive indications for out-of-hospital intubation. The latter is potentially problematic, as we risk turning every prehospital intubation into a crash airway, if we refuse to allow providers to intubate until the patient is moribund.

(3) More widespread adoption of new technology. As of several years ago, any system placing as much as a combitube, let alone an ETT, regardless of whether they're using pharmacologic intubation should have access to waveform capnography. This may not be the case, but should be. I think any service even contemplating RSI should have a back-up airway, e.g. King, LMA, Combitube. This should also have been the gold standard for years. I think we'll see more use of technologies like the Glidescope, and I hope adjuncts like the Gum Elastic Bougie or Eschermann will see more widespread use.

(4) Better oversight in good systems. Hopefully some form of oversight in poor ones. Better recording and reporting of data, hopefully to a standardised template, so we can identify the effect of new technology, new guidelines, and ongoing education.

(5) Better pharmacology, and a greater percentage of intubations occurring without paralysis, e.g. ketamine + fentanyl +/- lidospray.

Regarding succinylcholine, there are indeed a number of contraindications, relative and absolute to its use. The most potentially problematic in EMS are going to be when intubating patients with unidentified hyperkalemia, e.g. acute renal failure, or if we end up inducing malignant hyperthermia in a susceptible individual. The bigger issue with any RSI is getting into a can't-intubate-can't-ventilate scenario. This is also a possibility when using other agents to facilitate intubation. If we generate apnea, we need to be able to ventilate at least as well as the patient was doing before we elected to intubate. There's also the ever-present risk of insult from hypoxia / hypercapnia / hypotension / ICP from repetitive, prolonged or unskilled laryngoscopy, and the risk of aspiration.

Using midazolam alone as an agent for induction is problematic due to the relatively large doses required as a single-agent, and the hypotension it can cause. This renders it unsuitable for intubating hypotensive patients. Benzodiazepines also rarely relieve trismus completely (and often have negligible impact) in patients with increased ICP. This presents the very real scenario of (1) generating a hypotensive, apneic / hypoventilating mess, without having generated intubating conditions --- i.e. having made the situation much worse, or (2) underdosing the patients sedation, so that when you do paralyse they exert a physiologic response to a painful, noxious process, and potentially remember the procedure.

The long duration of action of vecuronium relative to succinylcholine would scare me, if I was using it as a paralytic for induction. On the other hand, many of the patients we intubate prehospitally will exhibit critical hypoxia before the succinylcholine wears off in a critical RSI. Sux may be slightly safer if the intubation attempt goes south. It's difficult to tell from the post you've written, but it seems possible that by "low-dose vecuronium" you may be talking about using a defasciculating dose prior to succinylcholine? I don't have any experience with this, but was told by several EPs that it was largely unnecessary (I recognise this isn't a decent answer).

This site is quite useful, too:

http://crashingpatient.com/resuscitation/001-airway.htm

Edited August 25, 2011 by systemet

[paramedic_32647]

Well actually, the OMD does not want us to use Succinocholyine. I have not see the actual protocol yet. This is just what we are being told is going to happen. I am not sure everyone understands that the low dose vecuronium is suppose to be used just to prevent fasiculations. I have read about that! Also, no hard feelings about people's opinions. I was just wondering and I have been using those websites. I am trying to do as much research as possible and when I mean research, I mean from a lot of different sources. I really do not understand the sedate, but no pain medication. I believe we should have some type of pain medication. We have long transports and our back up airways are going to be the King LT!!!!

Thanks for your input and advise!

[systemet]

Well actually, the OMD does not want us to use Succinocholyine. I have not see the actual protocol yet. This is just what we are being told is going to happen. I am not sure everyone understands that the low dose vecuronium is suppose to be used just to prevent fasiculations. I have read about that! Also, no hard feelings about people's opinions. I was just wondering and I have been using those websites. I am trying to do as much research as possible and when I mean research, I mean from a lot of different sources. I really do not understand the sedate, but no pain medication. I believe we should have some type of pain medication. We have long transports and our back up airways are going to be the King LT!!!!

Thanks for your input and advise!

* Using a low dose of vecuronium as a defasciculating agent only makes sense if you're then going to give succinylcholine. From what you described earlier it sounds like you're using vecuronium as a paralytic instead of succinylcholine?

* I agree that you need pain medication. Midazolam is not an analgesic.

* The King sounds like a good idea. Hopefully you also have waveform capnography and the option to do a surgical airway.

All the best.

[paramedic_32647]

Yes we do have waveform capnography and the option to do a surgical airway. Yes, the Vecuronium is going to be used as the Paralytic instead of Succinylcholine.

[systemet]

Yes we do have waveform capnography and the option to do a surgical airway. Yes, the Vecuronium is going to be used as the Paralytic instead of Succinylcholine.

Well, there's no question that vec alone will get you intubating conditions.

But it's a little committing. If you can't intubate you're left with a paralysed patient with a rescue airway device that may not be that great for preventing aspiration.

Midazolam as a sedative is going to be dangerous / contraindicated in hypotensive patients. And it's probably going to make some of your normotensive patients quite hypotensive, depending on the dose. Which might not be good for them.

Not having analgesia is going to produce a stress response and sympathetic output that won't be good for your patients with elevated ICP. It seems like adding fentanyl to the protocol would be a good idea. It would also allow the midazolam dose to be decreased.

Edited August 25, 2011 by systemet

[Just Plain Ruff]

Systemet, excellent responses. I've learned a bit today.