Forcing the Tube

[Kiwiology]

So, I am just wondering, if there is a concern over using it for intubation...why isnt there a concern for using it with seizures? Is it because the dosage for seizures is so much lower?

Several fold issue here; dosages used for RSI are much higher than for seizures and patients requiring RSI are often very unwell with low physiologic reserve and/or have lost the ability to auto-regulate their cerebral perfusion. Administering large dosages of a medicine which is known to cause hypotension and cardiorespiratory depression in a patient who is unwell is not a good idea.

Midazolam can be used in combination with other medicines for intubation such as fentanyl (not the best idea but OK for somebody who is cardiovascularly stable) or ketamine (a much better idea especially for patients who are significantly shocked or unwell).

[chbare]

The concern with intubation is it's relatively slow onset and potential haemodynamic issues. Another consideration is under dosing. I find many providers are not keen to give more than 5 mg when you will need to give least 0.1-0.3 mg/kg IV ( some will even say 0.4 mg/kg) for a good induction dose. When was the last time you slammed your 70 kg patient with 20+ mg of midazolam? Also, you will need to wait 2-3 minutes following an induction dose of midazolam prior to administering your paralytic. This only increases the chances of desaturation.

I thought we addressed your concerns about midazolam in great detail on the other thread. Using midazolam as an induction agent is very different than as an anti-seizure medication. Apples to oranges comparison if you will. However, the side effects profile of midazolam still applies regardless of who receives it.

[Vorenus]

We use Midazolam only in combination with Ket in RSI, otherwise we use Propofol (in haemodynamical stable pat.).

[krumel]

I know of only three jurisdictions globally that have what you could call a good RSI program; New Zealand, Victoria (AU) and Alberta (Canada). RSI done well is bloody brilliant, RSI done badly kills people. In each place mentioned RSI is available only to a group of highly educated, highly experienced practitioners with sufficient exposure to maintain competency; for example here and in AU you need five to six years of education and experience before you will be considered for the RSI program.

WA has a pretty decent one for it's flight paramedics....

And some parts of switzerland as well..

[Kiwiology]

haemodynamic

Stop stealing my funny spelling!

[Asysin2leads]

Orthopaedics, paediatrics, grey, theatre, centre...

[sihi]

Midazolam assisted intubation ("sedate to intubate") has been banned by any self respecting ambulance service long ago; we had it in the 1900s but hell we had MAST pants and ideas that long spine boards and big volumes of crystalloid were good ideas too ...

I know of only three jurisdictions globally that have what you could call a good RSI program; New Zealand, Victoria (AU) and Alberta (Canada). RSI done well is bloody brilliant, RSI done badly kills people. In each place mentioned RSI is available only to a group of highly educated, highly experienced practitioners with sufficient exposure to maintain competency; for example here and in AU you need five to six years of education and experience before you will be considered for the RSI program.

In the UK there is much kerfuffle about RSI and the whole SECAmb CCP vs the BASIC Doctors thing ... I think Doctor-led RSI is appropriate for the UK

If you don't have neuromuscular blockade you shouldn't really be intubating people who are not dead (very unconscious with GCS of 3); and then you shouldn't really intubate those people anyway ... prehospitally at least

I dont agree about muscle relaxants. If you use only anaesthetics/sedatives in appropriate doses you can get good conditions for intubation without using NM-blockers. I agree using of relaxants for intubation needs great experience and paramedics or nurses mustn't use that. Anaesthetics can be enough.

Sometime we have to secure airway prehospitally and intubation is the best for it.

Patient with status epilepticus, SpO2 with O2-mask was ~82%, temperature 39,5; Diazepam 10 mg and Midazolam, little of Fenytoin didnt help. BP after Diazepam 80... what to do. We started infusion 1 L of cristaloids, added Noradrenaline infusion and on this background decided to intubate becouse of hypoxemia and convulsiones.

So we administered Midazolam 10 mg and little Propofol ~40 mg --> intub. was nice and soft. For transport did boluses of propofol 20 mg --> convulsions finished, SpO2 100, temperature lowered,

without Neuromusc. blockers.

Midazolam is less dangerous for hypotension, it is why i combine it with Propofol in hypotensive patient (add Midazolam and you need less of Propofol). We dont have Etomidate nor Ketamine in nurse teams. And I dont want to use Suxinylcholine.

Edited January 21, 2012 by sihi

[chbare]

Sihi, I appreciate your involvement with this discussion. However, you provide little evidence to support your stance with the exception of a n=1 case study.

The topic of paralytics is not as easy to debate as some would think. This is especially true when we consider what occurs outside of the hospital in some countries. Attached is what I believe to be a good link where two physicians debate this topic as it relates to in-hospital intubations. Additionally, new evidence is utilised.

http://emcrit.org/podcasts/paralytics-for-icu-intubations/

Unfortunately, I am not aware of a significant body of literature regarding the pre-hospital provider. At this time I have to error on the side of the traditional approach and perhaps more conservative option of using a paralytic. Of course, I admit that I have a bias against pre-hospital intubation in general and the context of my point is based on pre-hospital care and literature within the United States.

[mobey]

.

http://emcrit.org/po...cu-intubations/

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+1 for first poster to use Emcrit as a teaching tool!

I am secure with the fact I have a man-crush on Scott W.

[chbare]

+1 for first poster to use Emcrit as a teaching tool!

I am secure with the fact I have a man-crush on Scott W.

Have you checked out something called ICU rounds at burndoc.com? It's created by Dr. Jeff Guy and the pod casts are outstanding if you are at all interested in critical care. Plus, I am secure enough to say I have man crush on Dr. Guy.

http://www.burndoc.net/