Prehospital RSI

[ERDoc]

If you are doing this to present an argument to your medical director, I recommend you tread very lightly. A lot of the latest research looks bad for prehospital RSI, and intubation in general. Is there any reason they are using versed over etomidate? Etomidate is quicker on/quicker off if things go bad. From personal experience, it works much better for sedation anyway. If you adequately sedate there is no reason to complicate things by adding more meds such as an analgesic. I'm a simple person and like to keep things simple. If someone is being RSI'd they are sick to begin with. You are now going to throw a bunch of meds at them. If they deteriorate, how will you be able to decide if it is from there underlying disease versus medication issues? I'm also not a big fan of pharmacologically assisted intubation. You either go all in, or not at all (yes, I realize there are exception, but as a general rule). If they are going to have you sedate and quasi-paralyze, why not just go all the way and make sure it is done correctly to optimize your chances of success? In that case, the sux would be a much better option as it is quick on/quick off. There are a few instances where it may not be the best option but more often it will be fine.

[usalsfyre]

Here's the issue I have with the "short off" when discussing sux. In the OR, this is potentially fine. You do apenic oxygenation, the patient wakes up, we try a different option. If your counting on this to save you from the CI/CV scenario in out of hospital medicine a question if you should have been screwing around with the patients airway in the first place, as we're now 5-10 minutes further into the call, with a patient that still has crappy ventilatory status and/or can't protect their own airway. Field RSI is generally less than elective. If I dive off into a RSI and can't get the tube, I best be looking at a backup airway or scalpel post-haste. As such, a long acting NMBA isn't a horrible choice. I dislike vec, esp at low doses, due to the long onset. The best thing sux has going for it is rapid "on". Rocc is another good choice.

[kohlerrf]

ERdoc said it all. Most of all remember that intubation is a very simple skill. The problem and the bad press about it come from poor education and quality control. Although we have versed, Ativan, Valium, Etomidate,morphine and Sux all at our disposal I rarely need anything more than Lidocane spray 10 of versed and a boogie to get the job done. and then an Etomidate chaser to keep them comfortably numb but breathing on their own. Practice the skill and do this skill and you will need the drugs less and less and that is good. Lastly we use to use low and high dose Vec but Rock is a better substitute but frankly I would drop the Vec from your protocol in the first place and replace it with Sux.

[usalsfyre]

and then an Etomidate chaser to keep them comfortably numb but breathing on their own.

Are you sure you don't have the midaz and etomidate reversed?!? Etomidate is a short acting sedative hypnotic that shouldn't be used for ongoing sedation. A better way to keep patients comfortable, but breathing on their own is a fentanyl infusion with just a touch of benzodiazepine PRN.

[paramedic_32647]

@ Systemet....thanks for your input! I guess what is concering to me the most is the vecuronium prior to intubation.....I would prefer Rocuronium over Vecuronium just because Roc usually only lasts about 20 mins, where Vecuronium can last up to 40 or more! It is good to have back up airways, but what if they fail!? Without a secured airway, it can be very difficult to ventilate a patient with respiratory conditions like COPD or Asthma....just seems very scary to me, but maybe I am wrong!!!!

If you are doing this to present an argument to your medical director, I recommend you tread very lightly. A lot of the latest research looks bad for prehospital RSI, and intubation in general. Is there any reason they are using versed over etomidate? Etomidate is quicker on/quicker off if things go bad. From personal experience, it works much better for sedation anyway. If you adequately sedate there is no reason to complicate things by adding more meds such as an analgesic. I'm a simple person and like to keep things simple. If someone is being RSI'd they are sick to begin with. You are now going to throw a bunch of meds at them. If they deteriorate, how will you be able to decide if it is from there underlying disease versus medication issues? I'm also not a big fan of pharmacologically assisted intubation. You either go all in, or not at all (yes, I realize there are exception, but as a general rule). If they are going to have you sedate and quasi-paralyze, why not just go all the way and make sure it is done correctly to optimize your chances of success? In that case, the sux would be a much better option as it is quick on/quick off. There are a few instances where it may not be the best option but more often it will be fine.

I am not trying to put down our medical director AT ALL! We are just a small agency and we transport to a smaller hospital. This is just to find out if anyone thinks there would be better medications to use. Most city agencies do not allow their providers to do RSI unless you are a EMS Supervisor. A little hesitant of going to our OMD. One I do not have that power, there is a chain of command. I just think by hearing other physicians/ems providers experiences with RSI will help answer some of my questions. I mean there very well could be strong reasons why our OMD set them up this way. Thanks for your input!

[usalsfyre]

@ Systemet....thanks for your input! I guess what is concering to me the most is the vecuronium prior to intubation.....I would prefer Rocuronium over Vecuronium just because Roc usually only lasts about 20 mins, where Vecuronium can last up to 40 or more! It is good to have back up airways, but what if they fail!? Without a secured airway, it can be very difficult to ventilate a patient with respiratory conditions like COPD or Asthma....just seems very scary to me, but maybe I am wrong!!!!

If they're sick enough to need intubation from asthma or COPD, they're sick enough to break out the scalpel if you can't intubate them and a backup airway doesn't work.

[JakeEMTP]

RSI is a great tool, but I struggle sometimes to justify it. I don't like to dick around on scene in an emergent situation. If I can manage the airway w/o RSI, I will. CPAP works great for the COPD'ers. I can be 5 or 6 minutes down the road towards the hospital instead of knocking the pt. down and tubing them. Have I done it? Sure I have. But just because I can doesn't mean I have to. Total pt. care. Be careful when contemplating intubating the COPD folks. Some, (read most) will never get off the vent. If you can manage the airway w/o a tube, do it.

[Quakefire]

Saskatchewan has an MFI protocol (about two weeks old) that is not in use yet. Versed (0.1mg/kg max of ten) and Fentanyl (3.5mcg/kg ax 250mcg) or Etomidate (0.3mg/kg) and fentanyl. No paralytics. Although we do carry narcan we have no reversal for the midazolam.

[Paramagic]

It's really not (or shouldn't) be a matter of reversal agents being available for particular drugs. RSI is something you are doing because you have determined a clear need. If you are dicking around half-way through thinking about "revesing" it, then I suggest that the need wasn't there in the first place. It's no excuse for medical directors to implement half-baked protocols that are likely to cause more harm than good. Educate your medics, trust your medics or don't: there's no half way.

[BushyFromOz]

http://www.ambulance.vic.gov.au/Media/docs/Adults2-7914fa4e-3ede-4329-9acf-c2adcc77a5be-0.pdf

It's buried these somewher, you can probably infer the rationale from the guideline

gotta run