Intubation in 2012

[Swe112]

Hey. We have propofol, midazolam, celocurin, afentanil and ketamine in my region. RSI is very unsusual here. I usually use does drogs for pain, sedation and seizure controll, - celocurin ofcourse:-). Intubation is often done on RLS 7-8, without drugs. If drugs needed, propofol or midazolam is used. Other airway management is done with LMA. Sedation if needed.

Why use veccuromium?

Best regards from Sweden.

[paramedicmike]

Welcome, Swe112.

Vecuronium is a paralytic and will keep a patient paralyzed while the ET tube is in place. This helps in that the patient will not fight, bite, or otherwise buck the tube creating additional airway challenges.

It is not a sedative so sedation needs to be given in conjunction with the vecuronium.

What are RLS 7-8?

[Arctickat]

What are RLS 7-8?

Reaction Level Scale. Similar to GCS but for patients who have localised complications, such as swollen eyelids, (can't open eyes), already intubated (no verbal response) etc.

http://resources.metapress.com/pdf-preview.axd?code=q16q4kp46j458m67&size=largest

http://www.neurosurgic.com/index.php?option=com_content&view=article&id=694&Itemid=646

Edited September 6, 2012 by Arctickat

[BushyFromOz]

Fentanyl and midazolam and sux to induce then pancuronium afterwards with a morphine/midazolam infusion to maintain the sedation.

The fentanyl can be swapped out if the patient is likely or has recieved IV amiodarone or the morph/midaz infusion can be changed to fent/midaz if an allergy exists

Im told the fent/midaz pe-med will be ditched for ketamine soon

Currently RSI is for the post ROSC management and traumatic head injuries. Respiratory patients are tubed by sedation with fent/midaz and then paralysed, but im told this is under review and will be swapped for RSI protocol sooner or later.

We don't seem to have any issues with missed oesephegeal placements like is reported in the states, facilitiated untubation MUST have waveform capnography available.

The intubation algorithm here is backed by a comprehensive failed intubation drill which basically goes 1 attempt with or without bougie (based on grade view), missed tube, pre-oxygenated with OPA/NPA, attempt with bougie, miss, LMA, if unable to ventilated adequately, and cricothyrotomy at the end (its a bit more to it than that but its the general gist of it)

I understand RSI is contentious. Basically it was supported by in house data that said there was a significant reduction in the number of patients with severe neurological impairment at 6 months (i think) in the setting of traumatci head injury. Also, RSI enabled therapeutic cooling post ROSC which contributes to the 30% + survival to discharge for cardiac arrest we currently have.

[Vorenus]

Welcome, Swe112.

Vecuronium is a paralytic and will keep a patient paralyzed while the ET tube is in place. This helps in that the patient will not fight, bite, or otherwise buck the tube creating additional airway challenges.

It is not a sedative so sedation needs to be given in conjunction with the vecuronium.

What are RLS 7-8?

There is no valid reason for keeping a patient on paralytics after an ET tube is in place, apart from insufficient possibilities to sedate/keep up sedation.

[paramedicmike]

I disagree but am no in a position to counter point at the moment. I'll add more when I get home and on a real computer.

[Swe112]

Hey paramedicmike.

We use RLS here, not GCS. Dont ask me why. The RLS was created in Sweden so i guess we are kind of patriotic with our coma scale .

It sounds kind of strange to paralyze someone after you have the tube in place dont you think?

Thanks for the welcome btw =).

[paramedicmike]

There is no valid reason for keeping a patient on paralytics after an ET tube is in place, apart from insufficient possibilities to sedate/keep up sedation.

Ok. If there are insufficient possibilities to sedate/keep up sedation I'd argue that you shouldn't even attempt intubation much less throw a paralytic into the mix. Paralyzing without sedation is bordering on criminal.

As far as continued paralysis post intubation goes there are a few things to consider. The first is why you're intubating the patient in the first place. Next is the anticipated clinical course. Then there's ease of ventilation post intubation.

When you decide to intubate a patient you're making the decision to take control of a patient's airway away from him/her and giving it it yourself. Paralytics have been shown repeatedly to improve the success rate of intubation. The benefits of the paralysis in initial intubation assist in maintaining the airway post tube placement. For example, an intubated cardiac arrest isn't going to need continued paralysis. An intubated trauma patient will.

The anticipated clinical course covers anything from transport methods to what's going to happen at the hospital. I worked in an air medical environment for several years. Flying an intubated, non-paralyzed patient was deemed by our medical direction to be a threat to patient safety (and, ultimately, our safety). Then, what's going to happen after you get the patient to the hospital?

Finally, when an intubated patient is paralyzed there's a huge increase in the ease of ventilating. This is why many intubated patients in a hospital are paralyzed. Many times sedation alone simply isn't enough. And sometimes even sedated patients wind up bucking the tube and ventilation attempts.

Is post intubation paralysis indicated in each and every single intubation? No. Does it create an easier situation to maintain the patient's ventilatory status and everything that comes along with it? Absolutely. Are there exceptionally valid reasons to paralyze patients post intubation? Yes.

Swe112 and Kat,

Thanks for the references. I've got some reading to do and I happen to have a couple weeks off to do it.

[chbare]

Actually, we are very conservative about continued paralysis in the hospital. A paralysed patient cannot interact with the ventilator, cannot interact with us and may have issues with thermoregulation. Paralysis beyond the initial intubation is not something I commonly see. Paralysis for procedures such as bronchoscopy is not something I see as well.

Paralysis may be a consideration for transport if you can document valid safety concerns, but judicious should still be the word of the day.

[Eydawn]

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