RSI VS Concious Sedation

[Ace844]

Sorry, Ace, I fail to see the point here.

'zilla

"zilla,"

it seems there recently here we have had a spate of posters and members who neither understand what RSI/Airway Management, adjuncts, pharm, etc..is and or when it is approprite and should be done. So i decided to post soem studies to help educate and refresh others, and or students..

hope this helps,

ACE844

[1EMT-P]

RSI is a great tool to have if you have a good airway training program, good facilities & a good medical director, but it's not for everyone.

If you have a low call volume, RSI is probably not the way to go, but PAI is an alternative like the CBT or LMA.

[Doczilla]

I was referring more to the last post on propofol infusion syndrome and the comment at the top.

'zilla

[Doczilla]

I'm sure this has been posted somewhere on this board before, but I thought I'd refer to the NAEMSP's position paper on RSI. Regarding the initial question, the studies cited in the paper seem to indicate lower success rates with sedation-only when compared with RSI. Anyway, a good read about some of the pros and cons.

http://www.naemsp.org/Position%20Papers/pr...lintubation.pdf

Incidentally, the position papers are a good resource on a number of controversial topics such as field termination, clearing c-spine, etc.

'zilla

[EMS-Cat]

A nice collection of articles in general.

Nat'l Association of EMS Physicians - Position Papers

[kevkei]

PAI, MFI, RSS (whatever you want to call it) and RSI are for all intents and purposes the same thing with one difference, RSI utilizes paralytics- in most cases an ultra short acting agent, succinylcholine.

Whetether you are using a single agent (narcotic, benzo, anesthetic, etc) or a combination of them, your goal is to get the patient to be adequately sedated. As long as we are expected to adequately capture a patients airway, there will always be a certain percentage of patients that will require paralysis to intubate them. On these patients, you will never be able to give enough versed, fentanyl, propofol, etomidate, etc. to decrease their airway tone, abate trismus, etc.

Generally I agree with success rates and proficiency in intubating. The problem is, if the patient has a GCS of 3 in cardiac arrest, no one really cares about when the last time was they intubated or what their success rate is, because it needs to be done. What happens if they can't intubate that patient? Either learn from what didn't work and try again or use a back-updevice. The same can be said for RSI.

Either we should expect people to do it all, or not at all. Not half assed somewhere in between. If you have a protocol for PAI (RSS, MFI), you should probably have an RSI protocol instead.

[northernmedic]

Hey Kev I heard you guys have an RSS protocol in Edmonton. What do you use and how do you like it?

[kevkei]

Hey Kev I heard you guys have an RSS protocol in Edmonton. What do you use and how do you like it?

Yes we use it. Pretty standard dosing Versed 0.1 mg/kg to max of 5 mg single dose (max of 5 mg if given with fentanyl) and/or Fentanyl 3-5 mcg/kg to max of 250 mcg single dose, can be repeated prn. I think it works okay if you adequately dose the patient and if there is no underlying pathology that won't be overcome, as described earlier. I have in the past elected not to attempt to intubate because I knew it would fail for those reasons so I will scoop to the hospital and let them use their sux. Usually I'll ask the ER Doc if I can do the tube, only been turned down once, so at least I get the stat and the exposure.

In the last 3 years our overall intubation success rate has been 87%, most failures from QA/QI seem to stem from failed RSS or pharmacology assisted's (as opposed to cardiac arrest), especially in trauma. Why? I'd like to assume it's a combination of poor decision making and not having the right adjuncts. Our medical director adamantly opposes the use of sux prehospitally in a larger system like ours, despite the fact that we meet or exceed every recommendation from the NAEMSP position paper.

[northernmedic]

very similar to us. Our intubation success rate is about 96% and I think has gotten better since we got bougies in our system. It would be nice to have paralytics but our medical directors seem to have a similar philosophy to yours. Is Dr. Sookram still your director?

[kevkei]

Is Dr. Sookram still your director?

Unfortunately, yes.