RSI vs. Pharmacologicaly Induced intubation

[scratrat]

Could be lack of trust from your medical director, or perhaps he feels your system doesn't have a call volume and skill utilization level to warrant it....just a guess....

You are 1000% correct.

I worked for three projects in New Jersey, two with it, and one without. The two with RSI protocols, took FOREVER to get them. Then, once in place, they Q&A'd the CRAP out of our PCR. To the tune that not very many medics were eagar to use RSI. It actually made it a good thing. People weren't using it like a badge of honor, like someone else above me mentioned, because they knew the medical director would be Q&A ing their chart.

Also, the project that didn't, the medical point blank told me that it was because of poor intubation skills as a whole. Now, of course, he only said "missed opportunities" of intubations, but wouldn't tell me if they only tracked unconscious airways, or airways in need of assistance with drugs (IE head injury - fighting), that we couldn't establish with only versed (all we carried for sedation). Did I just explain that correctly?

Now in Florida, the same problem exists. Only this time, the medical director stated that it was in fact, unconscious airways that were successfully tubed in the ED without problems. So, I understand this doctors reluctance, if that's the case. Still wish I had it at times though.

[fiznat]

We hem and haw about it quite a bit in my system, especially since a nearby service has recently obtained permission from a local medical control (meaning: not regonal) to use etomidate for sedated intubation. Our medical advisory committee (docs that make the protocol decisions) is using this other service as a test-case on the subject.

I have done quite a bit of research review on the subject, and have found a few major points:

-Sedated intubation does make a large improvement in successful tubes when compared to non-sedated intubation. Another poster above has referred to these numbers. Successful intubation of sedated patients, however, remains low: around 60-70%. Still, this isnt necessairly a bad thing. These patients (who are getting sedated) are tough tubes to begin with- patients who probably would not have gotten a tube otherwise. 70% kicks the hell out of 0%.

-Versed and Etomidate have been shown in clinical studies to have similar hemodynamic profiles when used in the dosage ranges necessary for sedated intubation. Based on the literature that I have reviewed, neither drug has been shown to have a significant effect on blood pressure or heart rate. I'm not really sure where people are getting the claim that versed will "dump your pressure." Research has shown that to be untrue.

-There is argument as to whether these drugs are effective in relieving trismus. Some studies have shown that they do, some insist that it does not. It depends who you ask, and (probably more likely) which research they have chosen to believe.

I think the issue really is what posters above have said: trust. This is a potentially dangerous procedure that - if performed incorrectly - could significantly shorten a patient's life. Paramedics in general already dont have such a great record when it comes to intubations (although I expect this should change with the advent of ETCo2), its no suprise that medical controls nation wide are reluctant to give us more oppertunity to screw this up.

[scratrat]

-Versed and Etomidate have been shown in clinical studies to have similar hemodynamic profiles when used in the dosage ranges necessary for sedated intubation. Based on the literature that I have reviewed, neither drug has been shown to have a significant effect on blood pressure or heart rate. I'm not really sure where people are getting the claim that versed will "dump your pressure." Research has shown that to be untrue.

From experience using both medications.

Versed has crashed pressures many many times. And this is while puching VERY VERY slow.

Etomidate rarely does ever.

Research or not, experience prevails.

[chbare]

I am not sure about midazolam and blood pressure. I used versed on nearly every ER intubation and noted decreases in blood pressure. I have rarely noted any hemodynamic changes other than increased heart rate with etomidate. Etomidate is now the only med I can use for RSI, so I have been able to use both meds on similar patients. I was able to easily find research that indicates hemodynamic changes occur with versed.

http://emj.bmj.com/cgi/content/full/21/6/700

I do agree however, that comfort level is a major factor in what makes us decide to choose one medication over another.

Take care,

chbare.

[OzMedic]

In threads such as this and others I rarely see succinylcholine mentioned as a prehospital induction agent in the US. Is there a reason for this?

[AZCEP]

Perhaps because succinylcholine is a paralytic, not an induction agent.

Sux is the most prevalent NMBA used prehospitally, but many systems have added Norcuron (vecuronium) as a follow up to maintain the paralysis.

Etomidate and Versed are easily the most common "induction" agents. Some may use Ativan, or Valium as post intubation sedatives. There are a few that get propofol, but those are few and far between.

[Spock]

Thanks for clearing that up AZCEP. Suxs as an induction agent is a common misconception. Many people also think vecuronium or rocuronium are induction agents when they are not. Paralyzed but awake is a very bad thing.

Pennsylvania just added etomidate and a sedation assisted intubation (SAI) protocol statewide. Each region has to approve its use and then the local medical director has to credential the paramedics under his/her control. The QA process is three level: local, regional and state. I'm not sure how this will work out but I'm on the committee setting up the process for my region. I have mixed emotions about it. Some medics I would trust but most I would not.

There is a great deal of research out there on this topic and I can't cite all of it just off the top of my head but a few things come to mind some of which have already been pointed out.

Versed will drop the blood pressure in any dosage. Simple fact supported by literature and experience. Etomidate will cause less of a BP drop although at higher dosages it will drop the BP just as much as versed.

Anyone can learn to intubate but to be proficient you must do the skill on a regular basis. Medics don't. Wang reported almost 40% of PA medics intubated nobody in one year and the average was 2. If you were a medical director would you give RSI or SAI to medics with 2 tubes in a year? Think about it.

The jury is still out on whether or not SAI improves intubation success rates. Some literature says it does but most say it does not. I've tubed people in the ambulance using only versed and fentanyl and I am not fond of the procedure. I got the tubes only because I'm experienced since the conditions were suboptimal at best. Rescue airways are crucial for any intubation protocol. I like the King LT but the combitube or LMA are also reasonable.

The number of prehospital intubations will decrease as more services start to use CPAP. This happens in the ED and the ICU already. In five years most medics won't be intubating. Just my opinion.

Good topic and dialogue.

Live long and prosper.

Spock

[Spock]

I knew I would forget something. Chbare mentioned a new alpha-2 agonist. It is called dexmedetomidine. It has a short half life (1.5 hours) and rapid onset of action (<5 min) with peak effect in 15 minutes. We just added it to our formulary and I have not used it as of yet. It's use would be for sedation because it has little to no effect on respiration. It is supposed to sharply decrease endogenous catecholamines which would drop the BP and heart rate. I'll try to get back to you all after I've used it a few times.

Live long and prosper.

Spock

[CBEMT]

Anyone can learn to intubate but to be proficient you must do the skill on a regular basis. Medics don't. Wang reported almost 40% of PA medics intubated nobody in one year and the average was 2. If you were a medical director would you give RSI or SAI to medics with 2 tubes in a year? Think about it.

Honest question- wouldn't it stand to reason that with RSI, there would be more intubations?

I mean, I once met a medic from a 911 service in CT who had 26 tubes between January and September- he lost the rest of the year due to injury. His service has MAI. How many would he have had without it? Who knows. I've never watched a system go from no MAI/RSI to having a program, so I'll be the first to admit I don't know what one looks like before and after as far as numbers.

The number of prehospital intubations will decrease as more services start to use CPAP. This happens in the ED and the ICU already. In five years most medics won't be intubating. Just my opinion.

Sounds like firefighters putting themselves out of business with fire prevention.

[pinymayu]

In my system we use Etomidate and Versed in order to facilitate intubation. Can anyone tell me why a system would choose one over the over as in RSI vs. PII?

Thanks

Scott

You should buy "Ron Walls book Emergency Airway Management"; furthermore the explanations you seek could be found by doing a site search for RSI on this forum. If you expend some effort you'll find some great posts by Spock, rid, asys, ace, azcep, flmedic, and many others, etc...

Pinymayu