Intubation in 2012

[Mediclt47]

In my region, we are all about king airways. Its a simple airway that has a great success rate that can be used even by our BLS Providers. It allows you maintain the airway well and you can still run you ETCO2 off of it.

As far as intubation most of us only intubate for reasons where we know you can almost totally fix a patients by oxygenation and ventilation.

RSI.... Now that is a great skill that a lot of us would like to see be taught seeing as our transport times to the closest facility can be anywhere from 30 minutes to 70 minutes. If we do feel that its absolutely necessary we have to call a helicopter.

[RuralKSEMS]

Since we have very few paramedics that run with us (only 2 medics, we have four nurses) the major portion of airways we put in are Kings because of their relative ease use.

[Jake Almand]

This topic is interesting and very diverse. The issues invovled with the current state and the future of prehospital intubation are multifaceted. Like any other treatment we are discussing there are several questions that should be answered before we begin using it.

To me, we as clinicians need to first look at available evidence to determien what is the best treatment for our common patients' conditions.

Then we need to evaluate that treatment to determine if it can be accomplished safely and effectively in the pre-hospital environment.

If it can be, then we must develop a evidence based protocols and a QA/QI process to monitor it's use.

If it can not, then we shold look for the next best treatment for the given condition that can be safely performed and then develop a protocl and QA/QI process.

These basic steps should be evaluated for more then just intubation. Really we should look at everything we do using this method. Our goal shuold be patient outcome.

In my opinion after evaluating evidence, There are certain patients (Trauma Patients with decreased GCS, respiratory failure, etc...) for whom intubation using RSI is the best treatment. However, it can only be performed safely and effectively in the field if it is afforded a suitable amount of education and ongoing practice. If these two things are not present then intuabtion should not be an option for EMS providers and SGA's should be the next best option (and the only option for CPR, pending further research on this).

Now, the piece of this whole conversation that got me interested was the discussion on paralysis vs. sedation & analgesia for post intubation management.

In my experience, including several years as a flght paramedic, I have seen many providers use unnecessary paralysis. Generally they use the excuse that it is for flight safety or because the patient "can't be sedated". Too many times though I have seem patients who are simply under-sedated and the provider uses paralysis to make their life easier instead of properly sedating and providing pain relief. Often these providers move immediately to long term paralysis post intubation and then neglect the sedation that must accompany it. This usually results in patients who lay perfectly still (so the crew is happy) but are under-sedated and in pain (the patient is being tortured). I generally will push to use liberal sedation and analgesia and try to avoid vec unless absolutely necessary.

Like someone else mentioned, there are issues with completely making someone vent dependant even for a short time. These patients generally do better if allowed to mantain their own respiratory drive and are placed on "support" instead of mandatory ventilation.

[Asysin2leads]

If the IAFF continues to insist to put together five paramedics on an engine all who have intubated once in the past 3 years, intubation success rates will continue to suffer. That's about all I can say on the matter.

[krumel]

I totally agree with Jake when it comes to the point of "paralysis does not compensate for undersedation".

My old service did mandate 100 proven&sucessful intubations+25 per year(5 of them RSI, 5 of them Ped) for Paramedics to allow them to RSI. For "resus" intubation 50 Intubations+15 per year were the minimum.

As most suisse services are hospital based or hospital "associated" it at least was easy to archieve this as during time off you were more than welcome to assist in the OR.

My current service is quite new to ET (as to any invasive skills). Therefore there are basically no rules..But we don't do RSI...So...In the end...Well...The rates are somewhere I better tell none...