RSI

[medic001918]

The most important tool in any intubation attempt is the one holding the laryngoscope.

+1. That's something that many people tend to forget when looking at studies or getting into discussion about RSI or any other airway. One of the best things I ever did for my airway management was the DAMS (Difficult Airway Management in the Streets) course. I believe the course was put together by the University of Vermont (I could be wrong on that). But it was a two day course that was a good review of anatomy, and more importnatly a compliment of different techniques to use. The biggest benefit came from the instructors who were MD's and Anasthesiologists full of great insight. Given the chance, I'd go sit thru the class again for the benefit of review.

Shane

NREMT-P

[Spock]

The logic here is quite impressive. You folks must have Vulcan blood in your lineage.

Live long and prosper.

Spock

[FL_Medic]

OK, So with all this said, what is the best RSI sequence?

(Lido - for head trauma, Atropine- for kids) Morphine>Etomidate>Succs/Roc>Diprivan??

It seems to me like the morphine is useless cause the pain associated with RSI is later onset, but this is without disputing that. Just give me your answer to the first question...everyone.

[AZCEP]

Go back to page one of the thread and look at the excerpt from Dr. Wall's book. All of your RSI questions will be answered accordingly.

[FL_Medic]

Go back to page one of the thread and look at the excerpt from Dr. Wall's book. All of your RSI questions will be answered accordingly.

Im asking what you would do, or do do.

[AZCEP]

The steps are clearly indicated, but I'm willing to discuss them a bit further.

1. Prepare equipment/personnel/patient: Get the tools out, including back up devices. Assign roles for each provider. Place the patient in an optimal position for the procedure

2. Preoxygenate: Non-rebreather at 15 lpm for at least 5 minutes, more if possible. You are trying to eliminate the residual nitrogen, and build a degree of oxygen reserve

3. Premedicate: This is where your question lies. L-O-A-D Lidocaine-1.5 mg/kg Opioid-Fentanyl is preferred, Morphine would be acceptable but has some negative side effects. Atropine-Primarily for kids Defasiculation-If you have Roc or Vec available, now's the time to use a bit. This step should happen 3-5 minutes prior to administration of the paralytic

4. Paralyze: Succinylcholine/Etomidate go in. Wait 40-50 seconds before you put the blade in the mouth

5. Protect: Cricoid pressure until tube is secured in place

6. Placement of the ETT

7. Post Intubation Management: Verify tube placement, Secure tube, Attach monitoring devices, Release cricoid pressure

In step 3, the Lidocaine can be deleted unless there are signs of head injury or excess sympathetic response (Tight Head/Tight Lungs). The opioid is used to blunt some of the sympathetic response. Fentanyl has less cardiovascular effects than Morphine. Atropine is mandatory for kids under 10 years, or for repeated Succinylcholine dosing. The Defasiculation dose is 10% of the paralyzing dose.

I hope I got all of the steps. It's been a while since I've had to write them down.

[Spock]

Good job AZCEP. The importance of denitrogination is not emphasized enough. Give etomidate (0.3mg/kg) before the suxs. The dose of suxs is 1.0-1.5 mg/kg but since there is 200mg in a vial I believe in the full syringe technique so give it all. You will have intubating conditions in 30 seconds. Also, the onset of morphine is to long to be useful in RSI so use fentanyl but it is optional. Lidocaine is used for head injuries but it has never been proven to be effective by research. Kids are one big vagal nerve so atropine is mandatory. Repeat doses of suxs or etomidate should be avoided.

Live long and prosper.

Spock

[Asysin2leads]

Okay, this has been an impressive discussion, my head actually hurts after reading all of the back and forth. But unfortunately, I'm just a bit confused here. Are we arguing about whether to give and opiate (morphine or fentanyl) ON TOP OF a benzodiazapine, or IN PLACE OF the normal sedative like Etomidate or Versed?

If its IN PLACE of, while I can respect the easily reversible effects of an opioid, I just don't think that fentanyl or morphine will produce the desired anesthetic and amnesic effect of Versed or Etomidate. I know that fentanyl was originally introduced as an anesthetic, but really I think of it more as an analgesic, that is, you can't feel pain, but you still know what's going on, same as with morphine, and that is not what we want in our RSI patient. An intubatiion performed correctly shouldn't hurt all that much, its just that being unable to move, from a paralytic, breathe from the pathology, and having a tube going down your throat is not something that anyone really wants to remember.

If its ON TOP of the Versed or Etomidate, well, I'm just gonna have to say no gracias. I may be a caring person and appreciate a patient's pain, but I'm still a medic first. That means I work in less than ideal circumstances. Perhaps the idea that the effects of an opiate are easily reversible in a patient may make sense in an anesthesiologists mind when considering the benefits vs. risks, but in my world, it just seems like an unnecessary complication. If the person is sedated with an amnesic on board, the lidocaine and the atropine are in and aren't causing any problems, and the person is not moving or fighting the tube, and we are on the way to the hospital, I'm really happy. Versed is very good for pain management. I had it while I was in the ER in agonizing pain from a kneecap that wasn't where it was supposed to be, and after they put it into my IV all was well until I woke up with my leg in a brace. Granted, for those of you with an extended transport time, Versed's short duration should be considered, but my opinion is that pain can be managed just fine with only benzodiazipines, if only from personal experience.

I mean, really, I don't even get to use RSI, just conscious sedation, and I'll tell you, just getting that onboard in some of the settings I've been in can be a challenge, heck, just getting an IV sometimes can be a major accomplishment.

I guess what I'm saying is in your arguements for or against use of anything, be it a tool or a drug, make sure that you take into special considerations that prehospital care faces so often but is so rarely addressed. Even in the back of the ambulance, which is about as a controlled environment as we get, you still have the cops banging on the back door for a copy of the patient's ID, and I gotta try and think of which hospital to go to and give orders to the EMT and keep the screaming family members out, but I don't have to tell you guys, you know. If its one less drug to draw up and one less interaction to consider and and one less possible sharp sticking someone, and one more moment to make sure the patient is being bagged correctly, I'm going to have to say that is the best thing for the patient given the situation. Just wanted to make sure that nobody got too ivory tower with the journal articles and kick us all a good kick back into the gutter in the rain and muck where we belong.

[Asysin2leads]

Okay, this has been an impressive discussion, my head actually hurts after reading all of the back and forth. But unfortunately, I'm just a bit confused here. Are we arguing about whether to give and opiate (morphine or fentanyl) ON TOP OF a benzodiazapine, or IN PLACE OF the normal sedative like Etomidate or Versed?

If its IN PLACE of, while I can respect the easily reversible effects of an opioid, I just don't think that fentanyl or morphine will produce the desired anesthetic and amnesic effect of Versed or Etomidate. I know that fentanyl was originally introduced as an anesthetic, but really I think of it more as an analgesic, that is, you can't feel pain, but you still know what's going on, same as with morphine, and that is not what we want in our RSI patient. An intubatiion performed correctly shouldn't hurt all that much, its just that being unable to move, from a paralytic, breathe from the pathology, and having a tube going down your throat is not something that anyone really wants to remember.

If its ON TOP of the Versed or Etomidate, well, I'm just gonna have to say no gracias. I may be a caring person and appreciate a patient's pain, but I'm still a medic first. That means I work in less than ideal circumstances. Perhaps the idea that the effects of an opiate are easily reversible in a patient may make sense in an anesthesiologists mind when considering the benefits vs. risks, but in my world, it just seems like an unnecessary complication. If the person is sedated with an amnesic on board, the lidocaine and the atropine are in and aren't causing any problems, and the person is not moving or fighting the tube, and we are on the way to the hospital, I'm really happy.

I mean, really, I don't even get to use RSI, just conscious sedation, and I'll tell you, just getting that onboard in some of the settings I've been in can be a challenge, heck, just getting an IV sometimes can be a major accomplishment.

I guess what I'm saying is in your arguements for or against use of anything, be it a tool or a drug, make sure that you take into special considerations that prehospital care faces so often but is so rarely addressed. Even in the back of the ambulance, which is about as a controlled environment as we get, you still have the cops banging on the back door for a copy of the patient's ID, and I gotta try and think of which hospital to go to and give orders to the EMT and keep the screaming family members out, but I don't have to tell you guys, you know. If its one less drug to draw up and one less interaction to consider and and one less possible sharp sticking someone, and one more moment to make sure the patient is being bagged correctly, I'm going to have to say that is the best thing for the patient given the situation. Just wanted to make sure that nobody got too ivory tower with the journal articles and kick us all a good kick back into the gutter in the rain and muck where we belong.

[Asysin2leads]

Okay, this has been an impressive discussion, my head actually hurts after reading all of the back and forth. But unfortunately, I'm just a bit confused here. Are we arguing about whether to give and opiate (morphine or fentanyl) ON TOP OF a benzodiazapine, or IN PLACE OF the normal sedative like Etomidate or Versed?

If its IN PLACE of, while I can respect the easily reversible effects of an opioid, I just don't think that fentanyl or morphine will produce the desired anesthetic and amnesic effect of Versed or Etomidate. I know that fentanyl was originally introduced as an anesthetic, but really I think of it more as an analgesic, that is, you can't feel pain, but you still know what's going on, same as with morphine, and that is not what we want in our RSI patient. An intubatiion performed correctly shouldn't hurt all that much, its just that being unable to move, from a paralytic, breathe from the pathology, and having a tube going down your throat is not something that anyone really wants to remember.

If its ON TOP of the Versed or Etomidate, well, I'm just gonna have to say no gracias. I may be a caring person and appreciate a patient's pain, but I'm still a medic first. That means I work in less than ideal circumstances. Perhaps the idea that the effects of an opiate are easily reversible in a patient may make sense in an anesthesiologists mind when considering the benefits vs. risks, but in my world, it just seems like an unnecessary complication. If the person is sedated with an amnesic on board, the lidocaine and the atropine are in and aren't causing any problems, and the person is not moving or fighting the tube, and we are on the way to the hospital, I'm really happy.

I mean, really, I don't even get to use RSI, just conscious sedation, and I'll tell you, just getting that onboard in some of the settings I've been in can be a challenge, heck, just getting an IV sometimes can be a major accomplishment.

I guess what I'm saying is in your arguements for or against use of anything, be it a tool or a drug, make sure that you take into special considerations that prehospital care faces so often but is so rarely addressed. Even in the back of the ambulance, which is about as a controlled environment as we get, you still have the cops banging on the back door for a copy of the patient's ID, and I gotta try and think of which hospital to go to and give orders to the EMT and keep the screaming family members out, but I don't have to tell you guys, you know. If its one less drug to draw up and one less interaction to consider and and one less possible sharp sticking someone, and one more moment to make sure the patient is being bagged correctly, I'm going to have to say that is the best thing for the patient given the situation. Just wanted to make sure that nobody got too ivory tower with the journal articles and kick us all a good kick back into the gutter in the rain and muck where we belong.