Intubation in 2012

[Vorenus]

I have to pipe up as well... I have not seen continued paralysis in our ICUs. As a matter of fact, I have seen as part of early ICU mobility, people still receiving ventilator support (still intubated) standing at the bedside or marching in place. Those people often get weaned not long after that, but they are not kept totally sedated and certainly not paralyzed.

I could definitely understand keeping them paralyzed for flight, but what is the difference really between keeping them at a high level of medication induced sedation and keeping them paralyzed with sedation (as we all agree that paralyzing without sedation is a big mess)? Either way, they're not fighting you or the tube...

Wendy

CO EMT-B

RN-ADN Student

Exactly my point.

Especially since I seem to remember that continued/general use of paralytics seems to complicate/prolong the process of getting someone off the vent/weaning in the end.

[paramedicmike]

Because sedation isn't always enough. Sedation dosing can be enough to provide an adequate therapeutic response but not enough to stop a physical response especially in a transport environment. We know, too, that you can't just keep cranking up the sedative. It's fine if they're in the ICU in a "comfortable" bed with very little stimulation. Transporting, with all sorts of stimulation, is not so conducive to a restful patient.

This is, of course, to say nothing of circumstances where paralysis contributes to the conditions promoting recovery (I'm thinking specifically of post cardiac arrest hypothermia here).

There are times, many times, when sedation alone is enough. There are times when it's not enough and continued paralysis is warranted.

[Bieber]

I believe that in large EMS systems, as well as in smaller systems that are unable to either acquire sufficient field experience in intubation or clinical experience in an OR, intubation will in the not so distant future be a skill used only by a small subset of paramedics within the system.

Is it a skill that may have a benefit to a certain subset of patients, but frankly, if we can't remain proficient in it, it will be taken away from us. And because it seems like more and more services are choosing to aim for greater numbers of paramedics in their systems (as opposed to fewer, more proficient paramedics), I can't imagine that a lot of systems will be able to continue to justify permitting all of their paramedics to perform intubation. You just can't have four paramedics on an engine plus two paramedics on an ambulance, plus a medic supervisor that responds to all critical calls and expect to have enough opportunities for skills practice to divide up between the whole lot of them.

[wrmedic82]

I wanted to throw this out there mainly due to personal experience. (very recent actually)

Has anyone ever seen etomidate NOT work even when combined with 10 mg of versed?

[chbare]

Yes, started a new IV and readministered with desired effect.

[wrmedic82]

Yes, started a new IV and readministered with desired effect.

Whats your take on why it did not have the desired effect? Not enough drug perhaps? They gave me 60 mg and I am 96 kg. All I felt was tingling sensation all over my body and a Dr pulling on my dislocated ankle and me screaming lol. I can laugh about it now, not so much when it went down. They ending up RSI me in the end.

Edited September 14, 2012 by wrmedic82

[island emt]

You were RSI'd for a ankle dislocation???

Seems like overkill to me.

Relaxation & a neuromuscular block would be normal procedure, at least in all the reductions I've seen done.

[wrmedic82]

Their ( The hospital) rational was since they could not consciously sedate me, it would be better to put me completely under. Honestly I didn't complain because I was knocked out and didn't feel a thing when they did the closed reduction. I was just struck odd that the etomidate and versed didn't put me down.

Edited September 18, 2012 by wrmedic82

[scratrat]

I don't understand how, in this day and age, we continue paramedics) to have unrecognized esophageal intubations???

We have lung sounds, ETCO2 monitoring on most, if not all monitors, and other devices.

How can you not recognize a tube placed in the esophagus? I get that occasionally, you may intubate the esophagus and get near normal readings on the ETCO but it has to be infrequent.

I never found it to be a terribly difficult skill unless the patient was just ungodly fat. Even then, my paramedic partner was usually able to assit me or place the tube themselves. I can think of one time where we just could not tube for NOTHING. Instead, an LMA was placed. It wasn't the best, but it worked!

[Vorenus]

Their ( The hospital) rational was since they could not consciously sedate me, it would be better to put me completely under. Honestly I didn't complain because I was knocked out and didn't feel a thing when they did the closed reduction. I was just struck odd that the etomidate and versed didn't put me down.

For cases like yours, we use Propofol - short sedation, never experienced problems with this med in "easy" (I`m sure it was a most "un"-easy sensation for yourself ) cases like this.