# Versed as a sole RSI agent



## mso_kirk (Jan 4, 2011)

We've been fighting with our medical director for years to get RSI protocols.  He's resisted the whole time, despite the fact that every single ALS agency around us now has it.  In any case, he recently signaled that he would relent and allow us to have RSI protocols.  But what he's come up with has sort of thrown me for a loop.  He says he won't give us Anectine because of liability issues and because of concerns expressed by local anesthesiologists.  He says he'll allow us to use Versed to intubate patients, and he says it's safer since we carry romazicon that we can use to reverse it if we can't get the tube.  

I'm curious if there are any other agencies out there that are using or have used Versed as a sole intubation agent.  I've read several accounts from people saying that Versed doesn't knock them down far enough, and I also have concerns about our doc's assertion that romazicon can "easily" reverse them.  I used Anectine in my old department for years, and the worst I ever had to worry about was bagging them for 5 minutes if I couldn't get the tube.  

Thoughts?


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## Veneficus (Jan 4, 2011)

mso_kirk said:


> We've been fighting with our medical director for years to get RSI protocols.  He's resisted the whole time, despite the fact that every single ALS agency around us now has it.  In any case, he recently signaled that he would relent and allow us to have RSI protocols.  But what he's come up with has sort of thrown me for a loop.  He says he won't give us Anectine because of liability issues and because of concerns expressed by local anesthesiologists.  He says he'll allow us to use Versed to intubate patients, and he says it's safer since we carry romazicon that we can use to reverse it if we can't get the tube.
> 
> I'm curious if there are any other agencies out there that are using or have used Versed as a sole intubation agent.  I've read several accounts from people saying that Versed doesn't knock them down far enough, and I also have concerns about our doc's assertion that romazicon can "easily" reverse them.  I used Anectine in my old department for years, and the worst I ever had to worry about was bagging them for 5 minutes if I couldn't get the tube.
> 
> Thoughts?



Understand it? Yes. I worked at a service that did that about 8 years ago.

Agree with it? Partially

Ability to change it? None.

Versed in the right dose will sedate somebody enough to pass a tube. It is called sedation facilitated intubation. There is a thread around here somewhere on it. I can't find it on search.

But the long and short of it is, that it looks to me like your Med director doesn't want to give you RSI for whatever the reason, so is basically allowing for conscious sedation.

It'll work and you probably won't ever need more than 30mg of versed. More probably between 14-20mg.

I do not agree with giving EMS Romazicon. It is not a simple or benign reversal agent. The use of it or even the suggestion of it being used to reverse the benzo from a failed tube attempt doesn't appreciate the sequele of doing that.   

I hope your medical director will speak with anesthesia about using romazicon for such purposes. Especially on patients who will likely need to be intubated later.


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## Smash (Jan 4, 2011)

mso_kirk said:


> Thoughts?



Yes, I've had at least 3 thoughts today, thanks for asking!

In relation to this, I think it is a dumb idea.  RSI needs to be done properly or not at all.  Versed only isn't an RSI protocol, it's a protocol for death by semi-lethal injection, hypotension and messed up airways.

Why doesn't the Medcial Directory trust his medics?

EDIT: Sorry, I'm posting while caffiene deprived: romazicon?  Who on earth carries flumazenil these days?  Strange.


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## Veneficus (Jan 4, 2011)

Smash said:


> In relation to this, I think it is a dumb idea.  RSI needs to be done properly or not at all.  Versed only isn't an RSI protocol, it's a protocol for death by semi-lethal injection, hypotension and messed up airways.
> 
> Why doesn't the Medcial Directory trust his medics?



Wow, that is a strong statement!

Conscious sedation is used for all kinds of procedures, especially on kids, it is a relatively safe and widely accepted practice.

The use of a neuromuscular blocker is so lesser doses of the anesthetic agents are needed. It is not required.

I agree with you it is not the optimal way, but "semi-lethal injection" may be a bit extreme. 

I have used it, and the drop in BP isn't that dramatic in my anecdotal experience. 

It might not be a lack of trust in the medics, but the lack of desire to commit to the proper oversight of such a program.

Of course if they still have romazicon on the truck, it may be complete lack of interest on the medical director's part.


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## mso_kirk (Jan 4, 2011)

Smash - 

I don't know why we have romazicon.  It was in the protocols for years before I was hired.  Our MPD is of the opinion that if we carry any benzos that we have to have it.  It's never been used to my knowledge.  BTW, I appreciate the input of everyone so far.  This is stuff I can take back to the doc.


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## Smash (Jan 4, 2011)

I have sedation only as an option in my protocols as well, used it a number of times last year.  The trouble comes when that is the only option for drug assisted airway management.  Messing around with versed only in head injured patients for example is somewhat less than optimal, and can potentially add to catastrophic outcomes.


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## Outbac1 (Jan 4, 2011)

We have it for conscious sedation to facilitate intubation and/or to keep the pt from fighting the tube. However we only have 10mg of it. From the research I've done we should have 30mg available. I haven't had to use it yet for that but a coworker had a problem with it the other day. They had a GCS 3 pt who had vomited several times and then trismused. They tried 8mg of versed to try and relax the jaw enought to get a tube. It didn't work. The pt woke up briefly and told them off. Then went unc again. Pt survived inspite of themselves. 

 Versed is not the right drug for trismus and in low doses not normally sufficient for intubation. I've been present many times in the ER when it was used for reductions and it worked quite well. We don't carry Flumazenil.

Our MD is also not fond of field RSI. In a discussion with him a couple of years ago he expressed concern that anouther area that does do it has an unusually high number of field crycs to compensate for failed intubation attempts. Now that we have the King Airway perhaps he will reconsider. 

I am convinced there is a place for field RSI, but I am not convinced it should happen as often as it does. Some medics just do not take the time to assess the pt properly for how difficult the intubation will be. Then they rush and sedate and paralyse then can't get the tube. Just because you can doesn't mean you should. 

 Hopefully your MD will give you enough versed to work with. Consider it a step towards RSI.


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## MrBrown (Jan 5, 2011)

Oh good lord Brown is mortified somebody is once again considering the butcher shop half arsed ghetto Parathinktheyare approach of sedation only intubation.

For a number of years we had midazolam facilitated intubation and it was withdrawn after increase in mortality rate, adverse patient outcomes (like secondary brain inury due to hypovolaemia and increased ICP) and generally poor form.

We now have proper anaesthesia and paralysis based RSI with fent, ketamine, suxamethonium, vecuronium, electronic capnography and all that other good stuff.


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## Melclin (Jan 5, 2011)

I can't be arsed pulling up endnote right now so I just googled some links. If needs be PM me and I'll send you the papers/more detail on our RSI protocols etc. 

http://onlinelibrary.wiley.com/doi/10.1111/j.1742-6723.2006.00850.x/abstract
-Argues against prehospital intubation in trauma (head injury) with the use of sedatives only. This was based on data from the trauma registry showing poorer outcomes with SFI in TBI. Suggest trial of proper RSI.

http://onlinelibrary.wiley.com/doi/10.1046/j.1442-2026.2002.00382.x/abstract
-Earlier HEMS based successful RSI trial.

http://www.ncbi.nlm.nih.gov/pubmed/21107105
-THE RSI trial. Very successful. Early success saw the TBI RSI rolled out to other forms of hypoxic brain injury.

I had the privilege to speak briefly with Stephen Bernard who was largely responsible for these trials. I asked him if he thought our superior education (compared to the states) had anything to do with the success of our trial. He surprisingly disagreed and said the *most important* thing was close medical oversight and a good relationship between the medical oversight and the paramedics for training and QA/QI purposes. It doesn't sound like you have that.

The literature says do RSI and do it right. 

Vene,
I think there is a difference between the average procedural sedation and the prehospital intubation of a multitrauma pt. The Victorian trauma registry agrees. You'd have to agree that 25mg of midaz in a TBI pt with dicey BP is pushing it safety wise when there is a clearly better option.


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## MrBrown (Jan 5, 2011)

Melclin said:


> You'd have to agree that 25mg of midaz in a TBI pt with dicey BP is pushing it safety wise when there is a clearly better option.



The better option is to give Brown the 25mg of midaz so that when Brown wakes up we will have skipped to the end and found out how the patient did without all the hard work involved


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## Melclin (Jan 5, 2011)

MrBrown said:


> The better option is to give Brown the 25mg of midaz so that when Brown wakes up we will have skipped to the end and found out how the patient did without all the hard work involved



I thought you had shotgun on the special K, Bro. Stop camping the induction drugs dude.


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## Veneficus (Jan 5, 2011)

Melclin said:


> Vene,
> I think there is a difference between the average procedural sedation and the prehospital intubation of a multitrauma pt. The Victorian trauma registry agrees. You'd have to agree that 25mg of midaz in a TBI pt with dicey BP is pushing it safety wise when there is a clearly better option.



I think proper RSI is a better option in all cases, not just multisystem trauma. 

I wasn't arguing for it, only expressing that I have used sedation facilitated intubation, and that it can work. 

But like I said earlier, I don't think the OP is part of the most up to date system. (or even in the 21 century system)  As evidenced by not only the idea that romazicon would be an acceptable reversal if a tube failed, but having romazicon available prehospital at all.


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## mso_kirk (Jan 5, 2011)

Veneficus said:


> I think proper RSI is a better option in all cases, not just multisystem trauma.
> 
> I wasn't arguing for it, only expressing that I have used sedation facilitated intubation, and that it can work.
> 
> But like I said earlier, I don't think the OP is part of the most up to date system. (or even in the 21 century system)  As evidenced by not only the idea that romazicon would be an acceptable reversal if a tube failed, but having romazicon available prehospital at all.



We are admittedly not the most up to date system.  :sad:  We have tiny volunteer agencies surrounding us that have much more advanced protocols than we do.  We still have to call in to ask permission to give certain drugs like Lasix for pulmonary edema and narcs for pain control, and we don't even carry drugs like Pitocin, beta blockers, or mag sulfate (these are standards on all other drug boxes in the region).  I don't know if it's so much that our MPD doesn't trust us, it's more that he has virtually no experience in emergency medicine as he's a GP.  He is very gun shy about giving us new tools or drugs that he's not familiar with.  Yes, we've been looking at replacing him, but so far we've been having trouble finding another local doc to take over.


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## Melclin (Jan 5, 2011)

You've gotta hit the literature. Its clearly in support of your position and, importantly, very beneficial to your patients. 

Its pretty hard to argue with a hardcore lit review and a well made argument about raising the level of pt care to be in line with the rest of the developed world.

How well educated are the paramedics in your system? Are they willing to be involved in the professional development and on going oversight that an RSI program requires? Do they have the educational foundation to make it feasible?


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## Veneficus (Jan 5, 2011)

mso_kirk said:


> We still have to call in to ask permission to give certain drugs like Lasix



Unless you have a very long transport time this is probably a good idea.



mso_kirk said:


> and narcs for pain control,



This is not a good idea



mso_kirk said:


> and we don't even carry drugs like Pitocin, beta blockers, or mag sulfate (these are standards on all other drug boxes in the region).



I don't think you should compare your system advancement with other agencies around you, but rather compare what you have to your patient needs. A bunch of drugs is not superior to highly capable providers able to effectively serve their patients.



mso_kirk said:


> I don't know if it's so much that our MPD doesn't trust us,



I don't think it is usually a matter of trust, but a matter of involvement. Many medical directors in the US want to spend as less time as possible with EMS duties. The pay is usually symbolic and the assumed risk very high. You cannot blame the medics in a system for the lack of incentive to the medical director.



mso_kirk said:


> it's more that he has virtually no experience in emergency medicine as he's a GP.



I really wish people would quit thinking that an Emergency Medicine doctor is the only physicians who understand or know how to deal with emergencies. I'll say it again, many senior physicians who exclusively do emergency, even in large centers were trained prior to the specialization of emergency medicine. They are not less capable. Sorry, this is a pet peeve of mine.



mso_kirk said:


> He is very gun shy about giving us new tools or drugs that he's not familiar with.  Yes, we've been looking at replacing him, but so far we've been having trouble finding another local doc to take over.



If he does not have the interest, help him by presenting the research and make your own case as opposed to asking for stuff and hoping he will take it upon himself to do the research. It is hard to say "no" to an overwhelming body of evidence. It is easy to say "no" to a request.


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## mso_kirk (Jan 5, 2011)

Veneficus - 

Sorry if it's a pet peeve of yours, but in our case the doc is the first to admit he doesn't feel comfortable with emergency medicine because of his GP specialty.  When we first floated the RSI protocol his comment was, "Guys, you have to understand I haven't intubated anybody or anything since medical school 20 years ago."  We get those sort of comments a lot, and it results in him having to run things by a bunch of other physicians before he'll agree to anything.  Since we have a bunch of turf-conscious docs at the local hospital who don't hide the fact that they don't really care for paramedics, we rarely get anything new because they'll tell our MPD that we shouldn't have it.  This is our primary problem.  And we have presented him a mountain of evidence supporting RSI over the past 5 years.  He'll look at it and say, "Wow, that's pretty strong evidence...let me look in to this."  A week later he'll come back and say, "I talked with one of the anesthesiologists over coffee yesterday and he told me paramedics shouldn't be doing RSI.  He thinks I'm crazy for even letting you intubate."  And then the conversation is over for a few months until we find something else to present him, and then it just repeats itself.  :wacko:

As to the Lasix question, we typically have transport times of over 1 hour, and we also have no CPAP.


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## Melbourne MICA (Jan 5, 2011)

*What are we good for?*



mso_kirk said:


> Veneficus -
> 
> Sorry if it's a pet peeve of yours, but in our case the doc is the first to admit he doesn't feel comfortable with emergency medicine because of his GP specialty.  When we first floated the RSI protocol his comment was, "Guys, you have to understand I haven't intubated anybody or anything since medical school 20 years ago."  We get those sort of comments a lot, and it results in him having to run things by a bunch of other physicians before he'll agree to anything.  Since we have a bunch of turf-conscious docs at the local hospital who don't hide the fact that they don't really care for paramedics, we rarely get anything new because they'll tell our MPD that we shouldn't have it.  This is our primary problem.  And we have presented him a mountain of evidence supporting RSI over the past 5 years.  He'll look at it and say, "Wow, that's pretty strong evidence...let me look in to this."  A week later he'll come back and say, "I talked with one of the anesthesiologists over coffee yesterday and he told me paramedics shouldn't be doing RSI.  He thinks I'm crazy for even letting you intubate."  And then the conversation is over for a few months until we find something else to present him, and then it just repeats itself.  :wacko:
> 
> As to the Lasix question, we typically have transport times of over 1 hour, and we also have no CPAP.



Perhaps it has something to do with his medical license being on the line if screw ups by staff wind up in the coroners court? Sounds like his conservative approach has a lot to do with that scenario. Is it also something to do with funding for training and education as well? Money and trouble -  two good ways to make a Doc nervous!

MM

Saving face also has a lot to do with peer credibility as well.


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## MrBrown (Jan 5, 2011)

Melbourne MICA said:


> Perhaps it has something to do with his medical license being on the line if screw ups by staff wind up in the coroners court? Sounds like his conservative approach has a lot to do with that scenario..



*Brown goes off to find something to hit the dead horse with "Paramedic registration" written on it.

Oh wow that was exertious, time for a bit more ketamine 

For now here rapid sequence intubation is only for selected, specially upskilled Intensive Care Paramedics and at last count they average just over one RSI per Officer per week.  Each must be followed up with a debrief by the regional Medical Advisor or Medical Director.  In time was with other things it will most likely open up to all Intensive Care officers but for now we are being judicious and taking small steps.  Our RSI guideline is (if Brown may say so) fairly advanced by the looks of things so its probably a wise idea.

Some sparky two bit Parathinktheyare who got thier Paramedic certification out the Weet Bix box should hardly be trusted with a drip and bag of fluids let alone suxamethonium/


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## Veneficus (Jan 5, 2011)

*the hard truth*



mso_kirk said:


> Veneficus -
> 
> Sorry if it's a pet peeve of yours, but in our case the doc is the first to admit he doesn't feel comfortable with emergency medicine because of his GP specialty.  When we first floated the RSI protocol his comment was, "Guys, you have to understand I haven't intubated anybody or anything since medical school 20 years ago."  We get those sort of comments a lot, and it results in him having to run things by a bunch of other physicians before he'll agree to anything.  Since we have a bunch of turf-conscious docs at the local hospital who don't hide the fact that they don't really care for paramedics, we rarely get anything new because they'll tell our MPD that we shouldn't have it.  This is our primary problem.  And we have presented him a mountain of evidence supporting RSI over the past 5 years.  He'll look at it and say, "Wow, that's pretty strong evidence...let me look in to this."  A week later he'll come back and say, "I talked with one of the anesthesiologists over coffee yesterday and he told me paramedics shouldn't be doing RSI.  He thinks I'm crazy for even letting you intubate."  And then the conversation is over for a few months until we find something else to present him, and then it just repeats itself.  :wacko:
> 
> As to the Lasix question, we typically have transport times of over 1 hour, and we also have no CPAP.



I was thinking how best to address this. 

I think your medical director has made a sound clinical decision in the best interest of both the patients and system. Probably not what you wanted to hear.

If one of my friends who was a medical director and came to me seeking advice on if he should permit his paramedics to RSI people, I would only have to ask a few questions and probably not have to reply. 

Q: "How many paramedics do you have?"

Q: "How many of them get at least 12-15 tubes a year to maintain proficency on the road or supervised in the OR?"

Q: "Are you comfortable enough with intubation to oversee the extensive QA and oversight this program will require to be successful?"

Q: "Are you willing to devote the time and effort in education and oversight for one of the most intricate EMS procedures known?"

Q: "You realize that the endgame of a failed tube and crash airway will result in the need for an immediate surgical airway?"

Q: "Are you comfortable are with that?"

Because if you are in for a penny, you are in for a pound on this one. 

In all fairness, it sounds like this medical director recognizes his limitations. He is rightfully concerned about allowing RSI, and in all truth your replies haven't convinced me it is a good idea and I have nothing to lose by saying it should be allowed.

Depending on the answers to these questions I might even say you medical director is being extremely generous letting your service intubate at all. But I cannot speak for your answers.

LIke I said, probably not the support you are hoping for. But it sounds like it was a wise decision since I agree with what was said about physician involvement and oversight being the key to success.


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## mso_kirk (Jan 5, 2011)

Perhaps I'm not explaining our demographics and circumstances well enough, but it probably doesn't matter in the long run.  The person we have to convince is the doc, not the people here.  

We are a busy municipal department that runs over 6000 ALS calls per year in an all career department.  The reason that I was comparing us to surrounding agencies is that we have tiny volunteer departments surrounding us that run 100 calls a year that have protocols 100 times more advanced than ours (including RSI and even things like placing central lines) that we don't have.  In my mind, clearly we have the need and our paramedics certainly have the knowledge base and education.  In fact, we've trained most of the paramedics in these outlying areas.  

In any case, we may have a trump card, so to speak.  My chief advised me today he has a lead on a new doctor in town who has expressed interest in taking over the medical oversight role.  Apparently he's a former medic and has already expressed concern at what our protocols are lacking.  I guess if you can't get the top guy to give you what you want or need, you fire him and replace him with somebody who will.


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## MrBrown (Jan 5, 2011)

Doesnt matter how many calls you do a year if your providers are barely homeostasasing Parathinktheyares who got thier certification down at the local medic mill or out the Weet Bix box and have been left to rot by having to ring up on the Johnny and Roy phone evey two seconds or where the hospital is five minutes down the road.

These are the sorts of things people who are halfwy to being trusted with RSI can answer .... 

Describe the sliding fillament theory of muscle contraction and synaptic transfer/release of ACh?

Explain the significance of postassium and in particular hyperkalemia in [ab]normal cardiac conduction?

Compare and contrast the factors to be considered when choosing an induction agent including physiologic presentation, side effect, mechanisim of action and duration?

Outline the quality assurance process and best practices for peer-reviewed medical audit?

Discuss the factors to be considered when assessing need for airway intervention?  How might these factors be considered in context of the larger clinical picture?

... and so on and so on and that is without even considering the continuing praxis development and oversight parts of the program.


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## Veneficus (Jan 5, 2011)

I have nothing againt you or your department. You solicited opinions and I responded with the best information I have.



mso_kirk said:


> Perhaps I'm not explaining our demographics and circumstances well enough, but it probably doesn't matter in the long run.  The person we have to convince is the doc, not the people here.



A famous lawyer whos name I cannot recall once said "no jury is tougher than a jury of your peers."



mso_kirk said:


> We are a busy municipal department that runs over 6000 ALS calls per year in an all career department.



Just to put this in perspective, one of the busiest departments I worked for had some of the worst providers I ever saw at all levels of the organization. It is still the epitomy of a skills based service. 

16 ALS calls a day average in your whole service. 

I must apologize, but I am not impressed by that volume unless you have only 1 vehicle on the road. I have years of experience on units that routinely saw 14 ALS calls in a shift as well as an ED that saw 94,000 patients a year. 

Which brings us to: "What is considered an ALS call?" Starting an IV is an ALS call, but does not automatically mean a life threatening emergency. Giving your agency an extreme benefit, lets call 10% (double the accepted average) of your total calls "true emergencies" that is 600 a year/ 365 that is 1.64 a day divided by how many providers?



mso_kirk said:


> The reason that I was comparing us to surrounding agencies is that we have tiny volunteer departments surrounding us that run 100 calls a year that have protocols 100 times more advanced than ours (including RSI and even things like placing central lines) that we don't have.  In my mind, clearly we have the need and our paramedics certainly have the knowledge base and education.  In fact, we've trained most of the paramedics in these outlying areas.



One reason they might have more advanced protocols is they have fewer providers which allows greater oversight. They may also have a more involved medical director. A medical director more involved with EMS. There are just too many variables to make a reasonable comparison here.  



mso_kirk said:


> In any case, we may have a trump card, so to speak.  My chief advised me today he has a lead on a new doctor in town who has expressed interest in taking over the medical oversight role.  Apparently he's a former medic and has already expressed concern at what our protocols are lacking..



That is probably the best thing your service could hope for. Not as desirable, but probably also beneficial, even if this doc became an assistant medical director and could devote more time to your organization.



mso_kirk said:


> I guess if you can't get the top guy to give you what you want or need, you fire him and replace him with somebody who will.



Perhaps what you want, I hope there is a need. Just to be the devil's advocate, what if your wants conflict with the needs of the patients and system? 

You mentioned several skills, like RSI and central lines. 

I can find no benefit in a field placed central line unless you are giving blood. In an emergency that requires vascular access, a peripheral line or IO is faster, safer, and has been demonstrated as beneficial.

Several years ago one of the more respectable flight services in the US removed chest tubes from its scene response protocols after an internal study demonstrated poorer outcomes than needle decompression.

Surgery was once performed in the pts home. That didn't make it best practice.

I encourage you, do not become overly engrossed in skills or procedures. By your own comments, many of your protocols are outdated. Do you think it might be a better use of effort to try and update those first before worrying about something as grand as RSI?

I am not against you or your agency, but in my not always humble opinion, advice from people who can be brutally honest or tell you why your idea is bad is much better than advice from a bunch of "go team! yes men." I recall a time when Colin Powell was the only dissenting voice for going to war in Iraq.


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## mso_kirk (Jan 5, 2011)

Yes, we run that amount of calls out of one station with one ambulance, although occasionally we have to use a backup rig if our first out is on a long transport.

I understand what you're saying, and RSI is probably more symbolic of much wider problems (things like having to call in to be able to give pain control, etc).  We use RSI as the example, but there are a lot of smaller things that we lack that cause bigger problems.  But RSI is still no small issue as we've all had it beat in to our heads since school that controlling the airway is our most important goal.  If you can't do that, we were taught, you're screwed.  Last year alone we identified six patients (through our own internal QA process) that we believe died because of our inability to secure an airway during a long transport.  Four were drug overdoses and two were traumas.

Hopefully we can get some changes in place to improve the treatment we're able to offer our patients.


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## Veneficus (Jan 5, 2011)

mso_kirk said:


> Yes, we run that amount of calls out of one station with one ambulance, although occasionally we have to use a backup rig if our first out is on a long transport.
> 
> I understand what you're saying, and RSI is probably more symbolic of much wider problems (things like having to call in to be able to give pain control, etc).  We use RSI as the example, but there are a lot of smaller things that we lack that cause bigger problems.  But RSI is still no small issue as we've all had it beat in to our heads since school that controlling the airway is our most important goal.  If you can't do that, we were taught, you're screwed.  Last year alone we identified six patients (through our own internal QA process) that we believe died because of our inability to secure an airway during a long transport.  Four were drug overdoses and two were traumas.
> 
> Hopefully we can get some changes in place to improve the treatment we're able to offer our patients.



6 out of 6K is a very admirable number.

If I might inquire, what were the problems in securing the airways?


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## mso_kirk (Jan 5, 2011)

I don't recall all of the details right now as they weren't my patients (I drive a desk these days).  I remember the trauma ones.  I know that one of the trauma patients had trismus of some sort and they couldn't get him relaxed enough to use a laryngoscope.  The other one had significant bleeding in the airway and an intact gag.  One of the drug ODs was a barbiturate patient that had enough of a gag that they couldn't intubate.  Halfway in on the transport he vomited and aspirated and the resultant hypoxia led to his death several days later.  Unfortunately we don't have surgical airways or combitubes either.  

In my days as a street medic, I remember one patient where Anectine really saved my butt and the patient.  Severe asthma and the guy just locked down within seconds.  At the time we had strict orders that we had to check in with medical control before we could RSI.  I couldn't reach them with the limited cell phone coverage we had at the time, so I just did it anyway (we had tried some sub-q epi but it wasn't working).  He relaxed enough to get him intubated, after which time I shot some 1:1000 epi down the tube, which was an off protocol use.  It opened him up like liquid Drano on a plugged sink.  Medical director told me I was lucky that it all worked out because otherwise he would have gone after my license.  Ah, the good old days.  Now I get to sit at a desk and Monday morning quarterback everyone else's calls.


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## mso_kirk (Jan 5, 2011)

I forgot about the previous comment on central lines as well.  Our MPD at my old department was a big believer in them.  I started two in my career as a street medic (we were allowed to start sub-clavians only).  One was a trauma patient we couldn't get a peripheral line in and needed to get some fluids on board.  The other was a simple medical cardiac arrest that we also couldn't get a peripheral line in.  I don't remember after all of these years if it made a difference or not.  I know the cardiac arrest patient died and the trauma patient lived, but maybe despite my efforts for all I know.


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## Veneficus (Jan 5, 2011)

mso_kirk said:


> One of the drug ODs was a barbiturate patient that had enough of a gag that they couldn't intubate.



Is this supposed to be a joke to mess with me?

A barbiturate *OD* with a gag reflex? I am not sure that is even possible.

Barbiturates:

Prolong Cl- channel openings (enhancing GABAergic transmission) (inhibitory) GABA receptors are also found on skeletal muscle and inhibit the release of Calcium from the sarcoplasmic reticulum, which reduces spastic muscle tone. (like a gag reflex)

Directly blocks glutamate  (excitatory) receptors

Directly blocks Sodium Channels

At theraputic doses barbiturates are used medically to induce anesthesia and coma. At a different binding site on the same receptor and slightly different action than a benzo. (like versed) 

The most commonly prescribed Barbiturate was phenobarbital for seizure disorders, so it is most likely to appear on the street. Its effects last up to days and is measured in hours.



Was this an interfacilty transport after somebody treated the OD?

There was no NPA and BVM?

This really seems off the hook.


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## mso_kirk (Jan 5, 2011)

Not a joke.  The patient wasn't OD'd to the point of being comatose, but semi-conscious with decreased respirations.  They tried to scope him but he kept biting down enough to obscure the view.  The report said they were bagging him semi-successfully but not enough to keep the sats up, but then he started vomiting like a geyser and then they had a hell of time keeping him ventilated.  I had a similar case with a beta blocker overdose myself, but then again I had Anectine and was able to get the patient intubated eventually.  I have no idea if they were using an NPA.


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## usalsfyre (Jan 5, 2011)

A couple of thoughts here.

1. Rapid Sequence Induction (and it's offspring, rapid sequence intubation) was  devloped to prevent active regurgitation in the non-NPO patient during instrumentation of their airway. PERIOD. It is not for trismus or "hard tubes" (as I heard one idiot put it). The side effect/benefit is optimal intubating conditions at lower sedative doses, but it is certainly possible to snow almost anyone to the point you can intubate them. Just look out for the puke.

2. The 'barb overdose you described almost certainly puked from gastric distension related to poor BVM technique/poor laryngoscopy technique. A NG tube, couple of nasal trumpets and two people on the BVM might have been as or more effective at controling his airway. The guy with bleeding in his airway may have very well needed a cric more than RSI, is that going to be part of the bargin?

3. What are you doing wanting RSI if you don't even have appropriate rescue airways? This is a good way to start depopulating your service area.

4. What are you overall and first pass success rates? If they're not both in the 90%s (and overall better be in the high 90s), what makes you think your department is ready for RSI?

5. I'm much more impressed by a service that has adaquately pain management and sedation protocols, CPAP, strong education and QA and realizes RSI is more than they can handle than a half-@ssed RSI program. If y'all don't take airway seriously enough to have a back-up device, I suspect the latter is what your looking for.

There is no halfway here. Do it right, or kill patients.


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## Veneficus (Jan 5, 2011)

What I could find on this in my anesthesia resources states that if ineffective doses of barbiturate are given, laryngospasm may be induced by an OPA, suction tip, LMA or ET tube.

Which sounds suspiciously like it was the attempt at intubating (read more so than improper bagging and gastric distension) that triggered the vomiting. More so if you consider that the neuro vomiting centers would be depressed considerably more than the respiratory centers and only local stimuli of the intact reflexes would be working.

"Ineffective dose" does not sound like an OD to me.

The same sources also state that the gag reflex will return after the duration of action of the barbiturate starts to wear off. 

It is exactly the same case for succinylcholine and the nondepolarizing agents.

So the patient will still have to be further sedated to keep the tube in.

A sedative like a benzo is often used. However, a dose of barbiturate amplifies the benzo effect and duration. 

So why not just cut out the middleman and add some benzo to the Barb OD and pass the tube? It would even last longer. That also makes the use of the neuromuscular blocker superfulous 

I still do not see how somebody took enough barbiturate to be overdosed and still have some kind of gag reflex, because that would mean the effect of the barb was not extremely strong or wearing off.

I am also of the mind that an intact gag reflex is self protective of an airway. 

If the obstruction was the tongue, just like in severe ETOH intoxication, benzo, and opioid OD, the NPA would be the device of choice. Was a manual airway maneuver used and maintained? Was the patient supine? See the issues there?

Perhaps like a benzo or opioid OD, it is just better to bag them until they come around?

To once again steal a quote from one of my lecturers, 

"No one ever died from not having a plastic tube in their throat"

I agree with USALSFYRE about the guy with the bleeding airway needing a cric. If there was so much blood, the bubbling might be the only indication as to where the airway is. How does a neuromuscular block fix all the blood? Wouldn't suction be better?


Upon researching this possibility deeper from this discussion, I think RSI is definatly not something your organization should be pursuing trying to keep up with the Joneses or as a merit badge of how advanced your service is.

Sounds like your service gets along without RSI anyway. 

As for central lines, 

the femoral is a safer route than subclavian, there are a lot of important structures up there. Not to mention creating a potential pneumo.

Since fluids only definitively helps in stage I shock, transiently in stage II, and not at all in stage III or IV. it sounds to me like "needed to get fluids on board" might have been a conclusion based on what was thought to be true some time ago and disproven in the civilian world and 2 wars. ( by almost a decade now)

Rather than the medical director who understands a bit more, maybe it is time to look at replacing some of the providers?

Sorry to say, but your case for RSI is just getting worse. Perhaps the overall situation there is not as golden as it may appear because you run a lot of calls and probably why the surrounding volunteers seem more advanced?


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## MrBrown (Jan 6, 2011)

Sorry mate you are going to have to keep calling on Brown and Oz in the funny orange getup to swann out the sky in thier flying contraption to come anaesthetise and intubate people.

If anybody is interested our procedure for RSI is as follows:

6.3 RAPID SEQUENCE INTUBATION (RSI)
• Indicated for patients with a GCS <10 with airway or ventilatory compromise.

• Absolute contraindications:
a. Known history or family history of malignant hyperthermia or
b. Paraplegics/quadriplegics or
c. Any muscle disorder with long term weakness or
d. Hyperkalemia strongly suspected or
e. Electronic capnography unavailable or
f. No dedicated suitable assistant (2nd AP preferred).

• Relative contraindications:
a. Age < 5 or > 75 yrs or
b. Age > 75 years with stroke or COAD as underlying cause or
c. Predicted difficult airway or
d. Less than 15 minutes to hospital or
e. Underlying cause is likely to rapidly improve e.g. GHB poisoning or post seizure.

• Preparation:
a. Assess the patient for signs of difficult intubation.
b. Prepare all equipment and brief assistant.
c. Draw up and label drugs, ensure running IV line.
d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP.
e. Pre-oxygenate for 3 minutes with 100% oxygen via manual ventilation bag. 
If unable to pre-oxygenate administer 6 large breaths immediately after apnoea occurs.

• Medicines:
a. Give IV fentanyl over 1 minute, 2-3 minutes before induction.
b. Regimen 1. For all patients with neurological cause for coma
(e.g. TBI, stroke, post cardiac arrest) that do not have significant
shock - give IV midazolam and IV suxamethonium.
c. Regimen 2. For all other patients and particularly for those with
shock – give IV ketamine and IV suxamethonium.

• Intubate and confirm ETT position with capnography.
• If unable to intubate implement failed intubation drill.
• Give IV vecuronium once ETT confirmed in trachea.
• Ventilate to ETCO2 30-35 mmHg (exception – life threatening
asthma, ventilate at 6 breaths/min and ignore ETCO2).
• Give additional sedation (midazolam 1-3 mg and morphine 1-3
mg) and vecuronium as required.

RSI Drug Doses
• Fentanyl: 1mcg/kg (max 100mcg)
• Midazolam: 0.1mg/kg (max 5mg)
• Ketamine: 1.5mg/kg (max 150mg)
• Suxamethonium: 1.5mg/kg (max 150mg)
• Vecuronium: 0.1mg/kg (max 10mg)

• *Halve fentanyl and midazolam dose if: age > 60 yrs, or HR > 100/min or systolic BP < 100mmHg.
• Round the patients weight to the nearest 10 kg.
• Midazolam must be given using 1 mg/ml in a 5ml syringe.
• Ketamine must be diluted to 10 mg/ml in a 20ml syringe.
• Vecuronium must be diluted to 1 mg/ml in a 10ml syringe.
• Fentanyl in children must be diluted to 10 mcg/ml in a 10ml syringe.
• Suxamethonium in children must be diluted to 10 mg/ml in a 10ml syringe.


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## Melclin (Jan 6, 2011)

MrBrown said:


> Sorry mate you are going to have to keep calling on Brown and Oz in the funny orange getup to swann out the sky in thier flying contraption to come anaesthetise and intubate people.
> 
> If anybody is interested our procedure for RSI is as follows:
> 
> ...



Mate you're welcome to start inducing people. But Oz is going to stick with bumped knees and hypos until he's got the brain learnin' for sick people


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## MrBrown (Jan 6, 2011)

Melclin said:


> Mate you're welcome to start inducing people. But Oz is going to stick with bumped knees and hypos until he's got the brain learnin' for sick people



Thats why Browns jumpsuit says "DOCTOR" and yours ..... does not


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## rhan101277 (Jan 6, 2011)

Here is our protocol for facilitated intubation

http://img145.imageshack.us/img145/1975/facrsi.jpg


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## MrBrown (Jan 6, 2011)

So how much midazolam are you going to give? What about if your patient is head injured or has shock how much is your dose going to differ? Lets say your midazolam does not work and you cannot intubate them what are you going to do? 

Bloody Parathinktheyares and thier bootleg ghetto drug assisted intubation


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## Shishkabob (Jan 6, 2011)

Brown-- only 1mcg/kg of Fent?   Seems low.  1mcg/kg is more like for pain and not a pre-medication for RSI?

We pre-medicate with 3mcg/kg Fent, induce with 0.3mg/kg Etomidate, and paralyze with 1mg/kg Roc.  We also have Versed and Ativan to which we can call in if we think either would be better than Etomidate.


But we have not only RSI, but also difficult airway in which we just do DAI with a sedative and not a paralytic.  

Here's our RSI guideline


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## usalsfyre (Jan 6, 2011)

Linuss, don't forget we also have awake intubation as an option. If the airway is going to be that difficult I'd much rather neb some lido and look prior to giving anything that can cause apnea.


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## Commonsavage (Jan 6, 2011)

Brown, if Veneficus has faith in you....well, I'll go with it.  You're both awesome.  Love readining your posts.  Now, go back to sleep.


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## rhan101277 (Jan 6, 2011)

MrBrown said:


> So how much midazolam are you going to give? What about if your patient is head injured or has shock how much is your dose going to differ? Lets say your midazolam does not work and you cannot intubate them what are you going to do?
> 
> Bloody Parathinktheyares and thier bootleg ghetto drug assisted intubation



That is why it says "consider four factors" and is benefit > risk.  Versed is contraindicated in head injury and shock so I would not even consider it


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## usalsfyre (Jan 7, 2011)

rhan101277 said:


> Versed is contraindicated in head injury...



Considering it's one of the leading agents for post-intubation sedation, I'm not sure where this is coming from. Hypotension is contraindicated in head-injury, not midaz specifically.


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## rhan101277 (Jan 7, 2011)

usalsfyre said:


> Considering it's one of the leading agents for post-intubation sedation, I'm not sure where this is coming from. Hypotension is contraindicated in head-injury, not midaz specifically.



Well it is at least a relative contraindication.  Giving the medication may cause hypotension and I would not want to take a chance on possibly reducing perfusion to the brain.  If I suspect someone has increased ICP due to head injury, and they needed sedation, I think I would call med control to make that call.


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## usalsfyre (Jan 7, 2011)

rhan101277 said:


> Well it is at least a relative contraindication.  Giving the medication may cause hypotension and I would not want to take a chance on possibly reducing perfusion to the brain.  If I suspect someone has increased ICP due to head injury, and they needed sedation, I think I would call med control to make that call.



Assuming you use some brain power in titrating, it's not a problem. I've done it dozens of times and never had a problem. I know ICU nurses who have done it 1000s of times without an issue. Delaying treatment of the agitation in the intubated patient can cause an increase in ICP which in itself will cause CPP to be reduced. 

I will agree it's maybe not an ideal agent for the initial sedation during RSI in the head injured patient but it's used nationwide daily in EDs and ambulances for this purpose. It has a well established safety profile. If your providers can't use it effectively then it's a systemic problem, not a problem with the medication itself.


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## MrBrown (Jan 7, 2011)

rhan101277 said:


> If I suspect someone has increased ICP due to head injury, and they needed sedation, I think I would call med control to make that call.



Careful mate, that sounds dangerously like Parathinktheyare talk 

Now, if Brown may point out that the midazolam only protocol posted excluded head injuries as it is a contraindication for midazolam.  Hmmm which patients are likely to significantly benefit from rapid sequence intubation?  Brown rests his case against sedation only intubation.


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## bonedog (Jan 8, 2011)

I'm not sure how midaz only could be considered RSI, rapid maybe, sequence, hmmm, would that be the flumazenil arm?


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## mikie (Jan 8, 2011)

*Side question...*



MrBrown said:


> • Absolute contraindications:
> b. Paraplegics/quadriplegics or



I take pharm. next semester so perhaps it'll come up then; but with what little info I know about RSI (Sedation & Paralysis) why is that an absolute contraindication?


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## MrBrown (Jan 8, 2011)

mikie said:


> I take pharm. next semester so perhaps it'll come up then; but with what little info I know about RSI (Sedation & Paralysis) why is that an absolute contraindication?



Brown believes it has something to do with suxamethonium


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## boingo (Jan 8, 2011)

MrBrown said:


> Brown believes it has something to do with suxamethonium



Brown would be correct.


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## NomadicMedic (Jan 8, 2011)

MrBrown said:


> Brown believes it has something to do with suxamethonium



Yes, there is a potential for severe hyperkalemia in patients with motor neuron damage.


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## Fish (Jan 8, 2011)

mso_kirk said:


> We've been fighting with our medical director for years to get RSI protocols.  He's resisted the whole time, despite the fact that every single ALS agency around us now has it.  In any case, he recently signaled that he would relent and allow us to have RSI protocols.  But what he's come up with has sort of thrown me for a loop.  He says he won't give us Anectine because of liability issues and because of concerns expressed by local anesthesiologists.  He says he'll allow us to use Versed to intubate patients, and he says it's safer since we carry romazicon that we can use to reverse it if we can't get the tube.
> 
> I'm curious if there are any other agencies out there that are using or have used Versed as a sole intubation agent.  I've read several accounts from people saying that Versed doesn't knock them down far enough, and I also have concerns about our doc's assertion that romazicon can "easily" reverse them.  I used Anectine in my old department for years, and the worst I ever had to worry about was bagging them for 5 minutes if I couldn't get the tube.
> 
> Thoughts?



Couple things here sounded strange to me, If someone needed to be RSI'd then they are usually a critical patient needing there airway to be taken over, why then would your Medical Director have you push versed and oops we can't get the tube reverse the versed with Romazicon and bag instead of keeping the patient sedated and insert a BLS airway like a King or Combitube? Also, do you guys have the Bougie? I think every agency that RSI's needs to carry the Bougie or some form of difficult airway device. Romazicon is a contreverisal drug, not to sure if I would be knocking down patients and then reverseing it as often as it sounds like you guys might end up doing. Why is he against Succs, Roc, or Etomidate? Medical Directors are far more knowledgeable than I so I am sure he has sound reason to these questions I have asked. But for purpose of discussion I wanted to ask them.

To answer your question, we have an RSI protocol, and the only time we do not use a paraylitic is if the pt. is less than 2, so for these pt.s we just use Versed. For every pt. over 2 we use versed to sedate, succs to paralyize, and roc and versed for maintence.


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## usalsfyre (Jan 9, 2011)

Fish said:


> To answer your question, we have an RSI protocol, and the only time we do not use a paraylitic is if the pt. is less than 2, so for these pt.s we just use Versed. For every pt. over 2 we use versed to sedate, succs to paralyize, and roc and versed for maintence.



Without getting into too much of a rant on the subject, why even bother with succs if you've got roccuronium on the truck already? Same rapid onset, much better side effect profile. We got rid of succs about a year ago and I can't tell you I've missed it even once.


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## Aidey (Jan 9, 2011)

We have Succs and Vec, with Roc as a back up because of the Succs shortage. We are not allowed to use Vec or Roc as first line paralytics becuase of their longer duration unless we call for orders. We are to use Succs, and then use Vec as a maintenance. When we only had Vec and Roc on the ambs we had to call for orders to RSI period. I flat out told my supervisor the conversation was going to go something like "Hi doc, I'm RSIing this person, what do you want me to use Roc and Vec?.....No, I'm not asking for orders to RSI, I'm going to RSI this person, I just need you to tell me what med to use because we are out of Succs right now." 

Don't ask me to explain it.


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## Fish (Jan 9, 2011)

usalsfyre said:


> Without getting into too much of a rant on the subject, why even bother with succs if you've got roccuronium on the truck already? Same rapid onset, much better side effect profile. We got rid of succs about a year ago and I can't tell you I've missed it even once.



Roc is a lot slower than succs, and longer acting. That is our systems reasoning


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## usalsfyre (Jan 9, 2011)

Fish said:


> Roc is a lot slower than succs, and longer acting. That is our systems reasoning



Granted is andecotal, but I haven't noticed Rocc to be significantly slower clinically.

Short action is a crappy argument for sux. If they can wake up and maintain their own airway, did they need prehospital RSI in the first place, or could we have optimized their ability to maintain their own airway?. Doing an RSI with anything other than the attitude that you will secure an airway, even by way of scapel, is accepting failure, which your patient can ill afford.

Another question, what happens when you patient has a pseudocholinesterase deficiency, and won't burn the sux off for a few hours?  

Sorry for the rant, this is one of the big attitude issues I see with prehospital RSI.


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## Aidey (Jan 9, 2011)

I think the theory is that breathing badly is better than not breathing at all. 

I'm with you. If I'm going to RSI someone I am going to get an airway, period. If I end up crich-ing* someone I RSId I better be prepared to explain, but my hope is that by RSIing the patient I'm avoiding letting things get that bad (thinking of burn and anaphylaxis patients here). 


*How the heck do you spell that?


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## Shishkabob (Jan 9, 2011)

Aidey said:


> I think the theory is that breathing badly is better than not breathing at all.




Luckily, usalfyre and I have bougies, LMAs, Kings, needle crichs and surgical crichs.   


If they need an airway, they're getting an airway.  Preferably one that won't make me go "Oh God oh God oh God" in the process.


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## usalsfyre (Jan 9, 2011)

Aidey said:


> I think the theory is that breathing badly is better than not breathing at all.
> 
> I'm with you. If I'm going to RSI someone I am going to get an airway, period. If I end up crich-ing* someone I RSId I better be prepared to explain, but my hope is that by RSIing the patient I'm avoiding letting things get that bad (thinking of burn and anaphylaxis patients here).
> 
> ...



Cricothyrotomy, that's too much of a keyboard full so I usually just put in cric  .

Maybe it's just me, but I take control on airway only when U anticipate they're not going to be breathing if I don't intervene,  which puts you in a worse position post sux, as your that much farther behind the 8-ball.

The exception to this is combative patients that can't be controled by other means, but that's another issue altogether.


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## Fish (Jan 9, 2011)

usalsfyre said:


> Cricothyrotomy, that's too much of a keyboard full so I usually just put in cric  .
> 
> Maybe it's just me, but I take control on airway only when U anticipate they're not going to be breathing if I don't intervene,  which puts you in a worse position post sux, as your that much farther behind the 8-ball.
> 
> The exception to this is combative patients that can't be controled by other means, but that's another issue altogether.



As far as the succs or Roc and which should be used or which should come first, I don't have enough experience with to argue. The system I work for now is the only one I have worked for that RSI's, so for me it is our way goes(Not to mention it seems to be the way of most systems around us). Our Medical Directors Reputation, 30yrs+ experience, and Book shelf filled with Medical Director of the year awards vastly outways another medics thoughts on his RSI protocol in my mind(that was in no way attended to be rude). That being said, when it comes to RSI in our system, it is a big deal you DO NOT RSI for the hell of it, it is a must do basis. And after an RSI we have a review with our Medical Director to go over the reason, and need. Also, we do have Bougies, Crics, and kings, so if we RSI the pt. WILL have an airway.


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## Aidey (Jan 9, 2011)

usalsfyre said:


> Cricothyrotomy, that's too much of a keyboard full so I usually just put in cric  .
> 
> Maybe it's just me, but I take control on airway only when U anticipate they're not going to be breathing if I don't intervene,  which puts you in a worse position post sux, as your that much farther behind the 8-ball.
> 
> The exception to this is combative patients that can't be controled by other means, but that's another issue altogether.



Cric/Crich I was close, lol. 

My last 2 RSIs were both unconscious with complications. One guy went into status seizure after giving him narcan, and the other had been strangled and was posturing and combative with blood in his airway. I wasn't so much worried about either of them not breathing at all, but the adequacy of their breathing.


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