RSI

[CBEMT]

Here is an example, 52 year old semi-homeless man riding a bicycle near the Middle School. 16 year old kid in dads blazer didn't see the bicycle rider until just before impact estimated to be 35 - 40 mph. Upon our arrival the patient is unconscious with obvious s/s closed head injury but is technically breathing on his own @ 24. Teeth clenched and impossible to open his mouth. Bleeding from nose and to a lesser extent from his mouth as evidenced by blood being forced through his teeth during expiration.

Yeah, that's the one I worry about. Best I could do is call Med Control and beg for an order of Versed and Morphine.

[spenac]

Yeah, that's the one I worry about. Best I could do is call Med Control and beg for an order of Versed and Morphine.

No succinylcholine?

[captainstandup]

Unfortunately this happened early in my career, you know back when God's dog was a puppy. "Back in the day" (early 1990's) when this happened we weren't even permitted to utilize drug assisted intubation and RSI was unheard of. Didn't have enough valium to make a difference and versed wasn't on the trucks. We couldn't even spell succinylcholine. The worst part of this situation was the only rescue airway technique we had available was the horribly useless needle cric. My how we have improved since then.

[CBEMT]

No succinylcholine?

Nope, and I hope it stays that way, for a lot of reasons. Just the idea of snowing somebody with versed/morphine for the purposes of intubation is not an idea that would ever cross the minds of 90% of our ALS providers (0.001% of whom are medics so that might explain it).

The possibility I mentioned is only glossed over in the protocols, it's clearly not something they expect people to even think about since our standard ALS provider's normal intubation requirement is actual respiratory arrest. Anything else, by the letter of the law, requires Med Control. Not that it always happens that way.

But it does say it's an option, so those of us non-medics with a brain always keep it open as an option. If it comes down to it we'll make the call, try to get the clearance, and do the best we can.

[captainstandup]

I'm not sure I understand what you were trying to say. Airway management is dynamic and our most sacred of skill in EMS. What manuvers actually "cross the minds" of 90% of your providers?

This is the first time I have heard of a situation that requires a patient to be in respiratory arrest before aggressive ALS airway manuvers are employed. The only exception I am aware of is in services without paramedic level care. If what you are saying is true I would really hate to be in acute CHF, or respiratory failure in your response area.

"Snowing" a patient for the purpose of intubation may be the only option available to EMS agencies where RSI isnt permitted. RSI is completely appropriate in certain situations, provided the person performing this skill is competent and has a back up plan and a backup to the backup.

Succinylcholine is a very safe and appropriate medication used in the proper setting. There are medications that would serve us better such as rocuronium which is a "medium duration" paralytic, but as I said in an earlier post, there exists' a reversal agent for rocuronium, that isnt available for Sux.

A failing airway / respiratory system is in my opinion "more important" than one which has already failed. By the time a person has deteriorated to a state of respiratory arrest, there is often little we can do to resuscitate them.

[drichards275]

:? I can almost say for certain, by the time my system see's RSI and it is an accepted by our medical director for our Paramedics to perform it will be an already established BLS skill by the state. You might say he likes to keep his thumb on us..

[Novisen]

I think you mean breathing on their own. If you did mean breeding this must be well some new sick fetish. Some people that are breathing on their own still need airway protected by RSI.

The patient must have breathing on their own to be breeding...... Actually I RSI an subarac bleeding yesterday with Propofol and Succ. The intubation failed and I used an LMA airway. In the ER they also failed to intubate and have to use a Fast Track LMA.

[captainstandup]

Hey Novisen, have you had any bad experiences with propofol admin? The reason I asked is virtually every time I have occasion to initiate a drip in the field or during interfacility transfers I have notice rather severe hemodynamic effects even with dosing @ a paltry 15 ug/kg/min. Perhaps I have just been treating really sick patients but I have found going lightly on the propofol and utilizing versed and MS in conjunction with propofol resulted in less negative effects.

[CBEMT]

'm not sure I understand what you were trying to say. Airway management is dynamic and our most sacred of skill in EMS. What manuvers actually "cross the minds" of 90% of your providers?

This is the first time I have heard of a situation that requires a patient to be in respiratory arrest before aggressive ALS airway manuvers are employed.

It's happened to me, and seeing as how my employer at the time chose to not to provide me with either versed or morphine, my remaining option was NPA, BVM and run.

At the ER, the patient was intubated without any drugs at all (after one failed attempt and one gut tube by a PA). I could hear the patient gagging on the blade every time. "Hell," I thought. "If I knew that's how they were gonna play, I'd have done it ten minutes ago. Least I could've done it in one shot."

Then I put my ego back in the box and decided that I should've taken the extra 5 minutes and gone to another hospital to begin with.

The only exception I am aware of is in services without paramedic level care.

Think bigger. Like, regions. But they don't have RSI anyway, so....

A failing airway / respiratory system is in my opinion "more important" than one which has already failed. By the time a person has deteriorated to a state of respiratory arrest, there is often little we can do to resuscitate them.

No argument from me. But we're also talking about a system that requires EOA's on every ambulance, but not glucometers, SPO2, or 12-leads.

[Novisen]

Hey Novisen, have you had any bad experiences with propofol admin? The reason I asked is virtually every time I have occasion to initiate a drip in the field or during interfacility transfers I have notice rather severe hemodynamic effects even with dosing @ a paltry 15 ug/kg/min. Perhaps I have just been treating really sick patients but I have found going lightly on the propofol and utilizing versed and MS in conjunction with propofol resulted in less negative effects.

Hypovolemic and older patients can get severe hemodynamic effects. With some Versed and some Fentanyl you can often reduce the dosing of Propofol down to 5 ug/kg/min in these patients. Maybe Ketalar and Versed is an better combination? The hemodynamic effects from Propofol is easy to adjust. When the patient starts to chew on the ET tube you just start the drip again :wink: .