Prehospital RSI

[mobey]

I knew there would be people that disagree with what I said, I felt that you answered it very well, thanks.

Removed duplicate quote.

Doc: I appreciate your input. I do agree with your opinion in the hospital/ICU setting (analgesia aside).

FM37: Don't take the chicken shit way out, Doc chimed in with his general opinion of my post and intentionally did not answer my questions directly using sources. I asked you direct questions, don't hang on doc's coat tails to carry you through critical thinking.

You state your protocol/standard of care is "Great", if you can't back it up with logic and science, you should not be touting it as superior.

[firemedic37]

Etomidate and a long lasting paralytic? That is all?

What about Succ?

What if you miss the tube and cannot ventilate?

Painful like having a steel blade inserted into your vallecula, or directly onto your delicate epiglottis, applying 8lbs+ of pressure, then placing a rigid tube in your airway and "choking" you from the inside with a air filled cuff?

Cite?

You mean there are times when it is not necessary to keep them safe?

That is the poorest excuse not to paralyze a intubated patient I have ever heard. That is as bad as not treating abd pain so the Dr can assess.

Just how exactly do you check the neuro status on a patient sedated to the point of intubation and manual ventilation?

Are they just assessing reflex's? Isn't that something you can report?

Do you have to restrain these "neurologically intact" intubated patients?

Etomidate and Vecuronium are used since that is what our Medical Director has selected for us to use. No Succs in the field but we do have access to it in the hospital (we are hospital based). If we cannot get the tube and truly cannot ventilate (which has never happened to me) it should be very easy to ventilate a sedated and paralyzed patient I do it all the time. If you are worried about the patient aspirating then place a NG or OG tube and turn on the suction, not guaranteed to work but better than nothing. And in the event if the patient is aspirating we carry quick trachs and surgical airways to get an airway.

Proper sedation will take care of the gag reflex. Intubation should not be traumatic, if it is then you are doing it wrong. If you are creating pain with the cuff then you are over inflating the ballon. Remember it should seal the trachea not stretch it.

By all means my patients are always kept safe. Sometimes you cannot adequately sedate a patient so a paralytic is needed in order to ensure that they do not pull the tube/IVs out or come up off of the cot. There are usually very few patients that you can not adequately sedate with Versed/Propofol. Here is my question to you, how many patients in the ICU are given paralytics regularly during their hospital stay? Not very many, they are commonly placed on versed or propofol infusions. These patient are able to open their eyes and watch TV and interact with staff and family. Thus they are neurological intact patients that need ventilatory support.

You sedate a patient to the point where they are not fighting the ventilator, of course you set the ventilator where the patient can trigger it when they breath on their own so they feel that they can breath on their own and are not waiting for a breath.

You can report that a patient was neurologically intact prior to RSI, but guess what they want to see it for themselves. You must not routinely transport patients that require ventilatory support. I routinely am required to transport these patients to Level I Trauma Centers and Cardiovascular Centers for further care. They are not happy when you deliver a patient that they cannot assess thus taking up valuable time before they start their interventions.

When you RSI a patient we are required to place them into soft restraints. This is not to restrain them, every patient reacts differently to drugs, so you never really know how long your sedation is going to last. So you place them into soft restraints so that they do not pull on the tube or IVs. It is the same thing that they do in the hospital.

If EMS continues to over RSI our patients or mismanage them once we do they are going to take it away from us. RSI can save loves but unfortunately it also can have detrimental effect on the patient if done incorrectly.

By the way we do provide pain management to abdominal pain patients. Thats different then trying to access their neurological status. Their pain will come back, nowadays as long as you can describe their pain and location it is fine since they will always have an abdominal CT done to diagnose the patient.

Hope this helps.

[usalsfyre]

Logic fail! (that may be my new favorite term)

*Rewrote*

If you have failed to provide a safe RSI/RSS for your patient, you may as well butcher thier airway to save thier life, and hand them off to someone more competent.

So you would rather do what exactly? Surgical airways as back up are PART of safe RSI. In the case I'm referring we can't intubate the patient and we can't ventilate the patient with a rescue due to airtrapping and high airway pressures. So your suggesting?!? A BVM is going to be less effective than the rescue airway.

Perhaps you should examine your own logic prior to calling "logic fail" on others.

[usalsfyre]

What about Succ?

What if you miss the tube and cannot ventilate?

While we're on the subject of "logic fails" last time I checked 7-10 minutes of hypoxia waiting for succinylcholine to wear off isn't exactly good for the patients. The ONLY people crowing about letting succinylcholine wear off are people with a misguided sense of what RSI should be. My question simply is, if you can simply let the sux wear off and go on like nothing happened, why in the fuck was the patient a field RSI candidate in the first place? I'd be seriously questioning your patient selection at that point.

Succinylcholine is the preferred drug for RSI because of rapid onset. Nothing else. It has some nasty side effects to boot. I don't like vec, however it's due to the long onset, not the duration.

[ORmedic65]

I guess I'll try to add to the discussion a bit.

I must say that at this point in career (the very beginning) I'm kind of neutral to my systems RSI protocol, I don't really have enough experience to thoroughly critique it just yet. That being said, my systems protocol for RSI gives us the option of using either Versed or droperidol for pre-sedation, and of course we have the usual options of atropine for peds or lidocaine for ICP. Then we just recently replaced Vec with Roc and no longer have the option of a defasiculating dose. We use succinylcholine for induction of paralysis, and then Roc for continued paralysis with a maintenance dose of Versed for continued sedation.

Our backup airways are the King and we also carry Per-trachs (which seem to just overly complicate what should be a somewhat simple task). Unfortunately we don't carry bougies. We do have waveform capnography.

I would like to see our medical director bring fentanyl and Etomidate into the mix, but it seems that we've been trying for while and he just won't budge. Like I said though, with my limited experience I'm not really in the position to make a push for any changes in our system, especially only have a few RSI's to compare.

Question, does anyone else have a protocol for doing RSI via the IM route?

[croaker260]

Hey all, I almost went back, read and tried to catch up on this discussion, until I saw the last few posts.....I am afraid that if I do my head will exlode based on some of the hate I see it has generated. So if I repeat what someone else has said, I am sorry.

Our agency has a rather liberal RSI protocol, though at the same time a bit old fasioned (no ROC, etc).

Our pre-medication includes any and/or all as apropriate: Opioids (Morphine or Fentanyl), Benzo's ( Versed or Valium, Versed prefered), Short acting sedatives (Etomidate),Lidocaine (for CVA and CHI) and Atropine (Peds).

We use Succs for actual paralysis. We do not use a de-fasc dose of vec (though I have very seldom seen fasciculations when I use versed in the pre-medication phase). Though our orders allow us to place an ETT without actualy using a paralytic (sedation only airway management) if the situation calls for that, both the evidence in the literature and the medical directors preference is for using both sedatives and a paralytic whenever the situation alows.

For post intubation management we also have Opioids, Benzos, and vec.

To improve out success at ETT we have the Bougie when needed, and for rescue airway we have Kings and BVM's. For the Cant intubate/Cant ventilate situation we have the options for needle/surgical/quicktrach crics.

To answer your question regarding IM, yes we have that option, though with the advent of the EZ IO (and quite frankly we have pretty goood success with IV's - unlike some of our ALS first responders who see fewer patients).

As an alternative to the RSI with IM medications....we also have the option to nasaly intubate, and we practice this in our bi-annual critical skills labs as well, though it is truely a lost art from.

Anyay, here is our SWO appendix on the RSI/MAI portion of airway management. FWIW, we have seperate protocols/documents for the various flavors of ETT, advanced airway, and crics, so this is not a stand alone document but instead fits within our larger SWO's.

http://www.adaweb.ne...B8%3d&tabid=798

Edited October 7, 2011 by croaker260

[Kiwiology]

If you are going to do RSI do it bloody properly. our RSI is as follows

- Only for selected Intensive Care Paramedics (who all have four to six years education + experience minimum) and have already been intubating dead people without medicines

- Only for those selected ICPs who pass a three stage selection, training and exam process written by our Medical Director who is a Consultant Anaesthetist and a Consultant Intensivest (FANZCA/FJCICM)

- For patients with poor airway and/or breathing who need intubating but cannot be intubated without medicines

- Only two attempts at intubation

- Each attempt must use a bougie and anterior laryngeal pressure is highly encouraged

- Each attempt must be able to visualise cords within 15 seconds of laryngascopy and intuate within 30 seconds total

- We use fentanyl, suxamethonium and vecuronium

- Inducation is either with midazolam for patients with neurogenic cause for coma with GCS<10, ketamine for everybody else

- Post RSI management is midazolam, morphine and vec

- Each RSI or potential RSI must be debriefed with a Medical Advisor or Medical Director

- Since 2003 we have >97% success rate with all failed intubations managed without cricothyrotomy

[chbare]

Do you have good, peer reviewed, quantative data that your method is clearly superior? There are many variations of this theme and many pros and cons to each.

[Kiwiology]

I'm not saying ours is definately superior, what I was saying is that you need to do RSI properly or not at all i.e. the benzo only crowd, or etomidate only, or lets give everybody RSI and see what happens etc

The available evidence seems kind of mixed and not many studies show positive outcomes, yet we have consistently demonstrated extremely high success rates for nearly 10 years and as far as I can see the only thing we do different is tightly controlling who gets RSI and how they do it e.g. mandatory capnography, bougie, only two attempts at intubating with strict time limits on how long you can attempt laryngascopy for

One thing I am interested in is seeing if we can get our data published somehow; I'm not sure it wouldn't be an RCT because there is no "control" group, it might be in the form of an abstract or something I am not sure, gah, where is my research book when I need it!

[chbare]

I got you now mate. One thing you could do is look at publishing your data as a review of all your cases over a certain number of years.