RSI vs. Pharmacologicaly Induced intubation

[pinymayu]

The idea behind using RSI in the first place is to optimize the first view of the vocal cords. By using PAI, you may not get that optimal view that we are all striving for.

"AZCEP,"

Not only are paralytics and the RSI sequences done in the manner as taught for those reasons, but additionally it is done to lessen the risks and blunt the physiological effects of direct laryngoscopy and entubation.

Pinymayu

[pinymayu]

Personally, if given a choice of Versed or Etomidate, I'm taking Etomidate. Versed bottoms your BP, and I've seen too many patients where 10 mg wouldn't even slightly sedate them. Etomidate works faster, and doesn't cause the hypotension that versed does. It doesn't last very long, but once they're intubated I would use valium to keep them that way. But to facilitate the tube, I'd rather have Etomidate.

Not to mention the cardio-respiratory-CNS protective properties.

[pinymayu]

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.

A rise in the numbers or decrease in the numbers should have no bearing. The issue is whether the procedure is clinically appropriate or not.

[Ridryder 911]

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.

Spock

This opens a whole new can of worms, but here it goes..

This is a system failure, not a procedure or "lack of proficiency". The principle is there is too many ALS personnel in this area to the ratio of request or need of that procedure. The same could be stated if any physician could perform surgery in lieu of referring to a surgeon. How many number of surgeries would each physicians would be proficient at ? Flooding the market with qualified personal and then expecting those persons to be "proficient" is unrealistic. What many always fail to see in the study was this poor ratio and demand. So the study is flawed in the attempt or actually gave a misguided perception that the "lack of intubations" was caused by the lack of knowledge or exposure. When an a first response arrives with 6- 8 persons qualified to perform intubations on each call how many times would those provider be required to keep that EMS proficient in any skill?

What should be addressed is why there is so many of these "qualified" responders in one system, when obviously it is not warranted. Does each 1'st response need to have a Paramedic on each engine company? I will even debate that even a Basic EMT level would be more than what most first responders need and have. A qualified medical 1'st responder is sufficient enough in majority of the responses, with a few EMT's. Reducing the number of ALS personal will increase the ratio of exposure and as will increase the number of intubations and hopefully success at the same time. .. I either failed to read or forgot that Wang adressed that issue..

R/r 911

[pinymayu]

"Rid,"

Another thing which Dr Wang and a number of other 'pre-hospital ETI researchers" have failed to address is the comparison between ED-intensivist and resident sucess and complication rates in house vs the field. This is additionally an understudied area. I think those of us whom have had the opportunity to see someMd's perform these skills in house can attest that they suffer a number of the same afflictions.

pinymayu

[tniuqs]

"Rid,"

Another thing which Dr Wang and a number of other 'pre-hospital ETI researchers" have failed to address is the comparison between ED-intensivist and resident sucess and complication rates in house vs the field. This is additionally an understudied area. I think those of us whom have had the opportunity to see someMd's perform these skills in house can attest that they suffer a number of the same afflictions.

pinymayu

Well stated, but we are comparing apples to grapes, the controlled enviroment of the ER would suggest a higher inital sucess rate one would hope.

My personal view is facilitated intubation is my first choice as the thought of identifing a patient with aytpical cholinesterase (without a medic alert) is a bit scary. I sure wish I had Propofol...but take my Sux "Hammer" away and I go home plain and simple. Odd but numerous years in ICU and very few crash intubations even required Sux, (true a very different senario too) many residents fail miserably but they all have to learn somewhere too.

Someone said too many ALS providers...is there no means of practice with in the OR for those that need a confidence boost, come on... Intubation is a skill that one can train a monkey.....in the majority of cases.

My view would be get the best qualified to the scene FIRST, not LAST!

I just can not fathom this rational at all, just like a first responder doing triage at an MCI?

cheers

[mediccjh]

Rid,

With the Wang numbers, there are a lot of flaws:

1. The condition of the airway when a medic first intubates. How many times does it take 2 attempts since you have to suction the oropharynx, find the cords, etc?

2. The numbers, I believe, stem from the fact that most of Pennsylvania is rural. The highest population in PA is east of the I-81 corridor, due to these things we have here that you don't in OK called mountains (Just busting your chops, bro).

Looking at my part-time job's statistics, there were only 6 endotracheal intubations last year, company-wide. This is a service that does about 2600 911 jobs a year, with a huge coverage area. In comparison, the company that I used to work full-time for, does 40000 jobs a year (both emergency and non-emergency), and I had 10 intubations there (14 total for the year including Newark). Sometimes, the numbers are just not there, and it's not due to oversaturation of ALS (though you know I agree with you that the oversaturation of ALS kills patients).

One must remember, as with all studies, numbers are skewed.

As a closing statement, I truly believe that education is the key. Being that I live and work in PA, I can't wait to get my hands on Etomidate. It'll be nice to have more tools to help take care of my patients in the boonies.

[tniuqs]

Very well stated as per your norm mediccjh, for well for a guy that wears a skirt (Just busting Your chops, bro).

.... :twisted:

(though you know I agree with you that the oversaturation of ALS kills patients).

Could someone please explain this... frankly I am confused.... how does more educated providers cause death?

Or is this the very old fire/paramedic argument.......am I missing something here ?

As a closing statement, I truly believe that education is the key. Being that I live and work in PA, I can't wait to get my hands on Etomidate. It'll be nice to have more tools to help take care of my patients in the boonies.

Thats the ticket....improved Patient Care....document, document, document!

[mediccjh]

Very well stated as per your norm mediccjh, for well for a guy that wears a skirt (Just busting Your chops, bro).

.... :twisted:

Could someone please explain this... frankly I am confused.... how does more educated providers cause death?

Or is this the very old fire/paramedic argument.......am I missing something here ?

It's all in the numbers, bro, which I pulled out from under my kilt.

A study was done, I belive in LA County, that showed oversaturating an area with ALS units caused higher mortality rates.

The belief is simple: oversaturate an area, the number of patients an individual sees goes down, and more importantly, the number of skills the provider does, ie endotracheal intubation.

This is why I fully support a two-tiered system of educated BLS and ALS. You don't need ALS for a toothache.

[Ridryder 911]

I do understand the rural and less numbers ratio, and as you described there are many times one has to suction and re-attempt because they have a reversed garbage disposal situation coming at you as they attempt to intubate. I have yet seen a real effective suction unit in EMS that can remove most of the debris and mucus. Majority of the medics will attempt to visualize prior to suctioning because of this and then afterward have an afterthought of suctioning when and if needed. Whereas I do predominately see suctioning performed before an attempt is even made in a hospital setting.

Although intubation is definitely a skill and one does need to be well educated in the process and have an in-depth knowledge of the respiratory process, I do wonder if we are not "over killing" a technique. If one was to step back and really take note, all one is really doing is visualizing the glottic opening. In reality one can wonder how hard is this procedure ?

I personally have found placing a NG tube is much more difficult than intubating someone at times, and believe if we studied NG tube placement it would demonstrate a high failure the first attempts as well. I do wonder if we not worrying too much on a simplistic procedure such as intubation. If the patient is being well ventilated in-between and monitoring for vagal stimulation; is there much difference if it was the first attempt or second attempt ? Yes definitely our goal should be 1'st time success. The main point again, that it was performed within a number of reasonable attempts and pre & continuous oxygenation occurred during procedure. And then that the procedure was successfully verified and continouslly monitored per EtCo2

Possibly addressing the problem of skill retention would be better stated than just "failure of attempts". Again if this was the case; there is no specific mention or correction was recommended such as Q.I. and clinical rotations to maintain proficiency was made. Maybe reinforcing suctioning prior to attempts ( better suction units) more emphasis on proper head placement angle and the level of the head is off the floor to permit better and more direct view of the hypopharynx.

One can begin to wonder though; if Wang (and et all) does not have a "hidden agenda" in their studies. This is not the first time he has performed studies on the same repeated subject (his first was found to be skewed) and one can wonder what biases the researcher is bringing to the table prior to the research.

p.s. : mediccjh, we don't have as many mountains (yes, we have some!) But we do have the worlds largest documented hill!...

R/r 911