# RSI: Critical Decision Making (Advanced Provider response requested)



## 8jimi8 (Mar 4, 2011)

Sorry this may be reposted, because i hit send, but the I couldn't find my thread.


So I am doing my RSI homework and reading drug profiles.

Concerning paralytics, what do you consider prior to choosing your paralytic.  Do you have more than one option? Is it only a depolarizing or nondepolarizing?  Do you have a choice between benzylquinolinium compounds or aminosteroidal compounds? 

I see the various duration of actions, time of onset, side effects (histamine release, hypotension, tachycardia, increase in SBP, potentiation of hyperkalemia, bradycardia, increased intraocular pressure, among many others), 25% recovery times 

Is it easy to make a decision because of protocols, or do you have autonomy and an excellent tool box?


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## Shishkabob (Mar 4, 2011)

As far as paralytics go, we just have Roc, easy choice there.  If they need RSI, they get Roc.  

The decision comes in pre-medication drugs such as Fent, lidocaine and nebulized lidocaine... then the sedative, which while technically is supposed to be etomidate, we have Ativan and Versed as well.



Really, the tough decision for me is deciding who gets tubed, and who can wait till we're at the hospital with more resources.


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## johnmedic (Mar 4, 2011)

For paralyzing agents, the only options I've worked with in the field are Succinylcholine (depolarizing) & Vecuronium (nondepolarizing) & basically the reasoning behind one vs the other is duration of effect based on transport times.


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## NomadicMedic (Mar 5, 2011)

We have several choices for RSI. Our paralytic choices are Succinylcholine, Roc or Vec. Obviously we stay away from Sux with patients that are or may become hyperkalemic, have eye injuries, pregnant or present with liver or kidney disease due to the decrease of plasma cholinesterase in these patients.  

We also have a few sedation choices available; Versed, Ativan or Etomidate. I prefer to use at least 5mg of Versed and an analgesic like Fentanyl as my starting point for RSI. 

Every RSI that we perform is reviewed by the QI team and the medical director. It's a system that gives us some freedom to make good choices based on the patient.


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## M3dicDO (Mar 5, 2011)

You bring up an interesting discussion. I have personally never seen Benzylisoquinonlines being used in a transport setting. It's usually been the Steriodal compounds that have been the most popular in Emergency Medicine, both in-hospital and pre-hospital.

When I worked as a critical care provider, I paralyzed patients based on one important question: *Who long will I need to keep this patient paralyzed?*
I used a short acting paralytic (i.e. sux) when:
I was expecting a tough intubation and wanted the patient to resume breathing if intubation was not successful....just in case
The receiving facility wanted the patient to not be paralyzed on arrival for a neuro exam (i.e. CVA patient)
=]
After a successful intubation, I usually gave Vecuronium to keep them paralyzed so I wouldn't have to keep worrying about the vent beeping all the time with high airway pressures. Made life a lot easier for me, especially for for the patient (with enough sedation of course ^_^)

A lot of my professors (ER docs) only use succinylcholine in the ED, and use the alternative paralytics when it's contraindicated. An attending used Pavulon on a trauma patient as the initial paralytic for RSI. It was his choice to use a super long-acting paralytic, but I wouldn't have. Sure the ED has neostigmine on hand, but why mess with worrying about reversal agents if you can't get the tube??!!

Bottom line, most critical-care protocols give medics and nurses the ability to choose paralytics based on the patient's best interest. I was able to mix and match at both my critical care transport jobs. I guess it all depends on how much your medical director lets you play with.....:wacko:


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## rhan101277 (Mar 5, 2011)

Linuss said:


> Really, the tough decision for me is deciding who gets tubed, and who can wait till we're at the hospital with more resources.



This ......


studies show that intubated people are 8 times more likely to die than people not intubated even in the hospital.  Whether this is due to MOI or something else "not fully understood".  I will intubate someone if it becomes necessary, RSI or otherwise.  If I can effectively bag someone and they are not vomiting and there is not tons of blood around that could be aspirated then they are getting bagged.


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## rhan101277 (Mar 5, 2011)

Once you jump off that cliff, you can't climb back up.


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## Smash (Mar 5, 2011)

rhan101277 said:


> studies show that intubated people are 8 times more likely to die than people not intubated even in the hospital.  Whether this is due to MOI or something else "not fully understood".  I will intubate someone if it becomes necessary, RSI or otherwise.  If I can effectively bag someone and they are not vomiting and there is not tons of blood around that could be aspirated then they are getting bagged.



Would you mind posting these studies?  It's a bit of a meaningless statement without some context.

RSI is not necessarily just about airway control, there are many aspects of different patient presentations that may be managed with appropriate sedation and paralysis.

As for the OP's question: it comes down to what the MD is happy with you doing.  In the setting of emergent cases where RSI is considered, it typically comes down to an argument between suxamethonium or rocuronium (other stuff like cisatracurium and what not aren't very common, vecuronium... meh)  So really, it's either depolarising or non-depolarising.  

Proponents of depolarising will cite suxamethonium's short duration of action as a good reason to use it: if you can't intubate it wears off quickly and the patient can breath again.  On the downside there are a number of potential problems: hyperkalemia in some settings, raised intra-ocular pressure (although this may not be clinically significant) and so on.

On the other hand, rocuronium takes _slightly_ longer than sux to have an effect (although this may not be clinically significant either), but takes longer to wear off, leaving you with a non-ventilating patient.  However, there are not the same concerns with the side effects like there are with sux.

BUT!  While sux may wear off quickly, even healthy people will most likely still desaturate without ventilations being provided (1,2,3), so maybe the "short duration" argument is moot.  Of course on the flip side, neuromuscular blockade may actually make bag-mask ventilation easier (4).  Of course this is fine in your fasted patient, it may be sub-optimal in the typical "full of beer and pizza" patient we see.  I'm keen to try the no desat method put forward by Dr Rich Levitan to see how well that works, it seems compelling and may remove this problem.

Rocuronium on the other hand _may_ actually provide an increased amount of time to achieve intubation before desaturation occurs, possibly due to the lack of fasciculations with it's use (5).  However, how well this translates to the critically ill patient is unclear, as this study was in elective patients.

Sooooo..... where does this leave you?  Beats me, all I have is sux for initial paralysis to achieve intubation, pancuronium for ongoing paralysis!  To be fair I don't have too much of a problem with sux.  I think the "can't ventilate" scenario should be a relatively rare beast anyway, especially if you are judicious about who you decide to give drugs to.  A lot of the problems with sux are kind of irrelevant or at least not clinically significant.

However, if I HAD to pick ONE agent, it would be rocuronium which if nothing else is versatile.  

There, glad I cleared that up for you! :wacko: :unsure: 


1. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine.
Anesthesiology. 1997 Oct;87(4):979-8

2. Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers.
Anesthesiology. 2001 May;94(5):754-9

3. Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients
Anesthesiology. 2005 Jan;102(1):35-40

4.  The effect of neuromuscular blockade on mask ventilation
Anaesthesia. 2011 Mar;66(3):163-7

5.  Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction
Anaesthesia. 2010 Apr;65(4):358-61


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## Veneficus (Mar 5, 2011)

8jimi8 said:


> Sorry this may be reposted, because i hit send, but the I couldn't find my thread.
> 
> 
> So I am doing my RSI homework and reading drug profiles.
> ...



I have a big tool box  

Most of the anesthesiologists tell me that there are several drugs for several purposes that do an equally good job just usually in different ways.

Provider comfort is the largest deciding factor in what drugs are usually selected in anesthesia. Next is cost.

Personally I like vecuronium, and of course substitute Roc for head injury. Why? I am comfortable with them. I know what should happen, when it is happening, and the most common problems that creep up.


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## Shishkabob (Mar 5, 2011)

If you make a non-depolarizing paralytic like Roc, with the short onset and duration of Succs, but none of the downsides of Succs, man... you'll make a fortune.


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## Scott33 (Mar 5, 2011)

Alternatively, problem solved if the FDA ever get round to approving Sugammadex


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## usalsfyre (Mar 5, 2011)

rhan101277 said:


> This ......
> 
> 
> studies show that intubated people are 8 times more likely to die than people not intubated even in the hospital.  Whether this is due to MOI or something else "not fully understood".  I will intubate someone if it becomes necessary, RSI or otherwise.  If I can effectively bag someone and they are not vomiting and there is not tons of blood around that could be aspirated then they are getting bagged.



I'd be REALLY interested in seeing this research as well and how they adjust for ISS.


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## usalsfyre (Mar 5, 2011)

8jimi8 said:


> Sorry this may be reposted, because i hit send, but the I couldn't find my thread.
> 
> 
> So I am doing my RSI homework and reading drug profiles.
> ...



Smash pretty well covered this, but I'll throw my two cents in...

There are really only three neuromuscular blockers that you will commonly see on ambulances, and I dare say, EDs, all are aminosteroids (every once in a while you might see someone get fancy with something like cisatracurium in the hepaticly impaired patient, but not often). Succinylcholine, roccuronium and vecuronium are the agents in question. 

The first thing to cover is why we give a paralytic in the first place. The number #1 reason is to prevent active regurgitation in the non-NPO patient. If you paralyze them, they can't gack. Everything else, optimizing intubation conditions, release of trismus, ect is a happy side effect. 

For the initial induction the common choices are succinylcholine and roccuronium. Succinylcholine has a _slightly_ shorter onset time, but comes with a whole bag full of nasty side effects. The BIG, BIG one we're concerned about is the potasium release, followed somewhat by concerns over MH (bonus, who knows how to reverse malignant hypertermia associated with succinylcholine administration?). 

What's NOT (never, no way, do not pass go, ect) an approprite reason to chose succinylcholine is the short duration. More on this in my next post. 

Roccuronium has an onset that is nearly that of succinylcholine without the ugly side effects. We got rid of succinylcholine a year ago in favor of it. I thought I would miss the onset. I can't say I've honestly noticed a clinically significant difference. 

Vecuronuim is a longer acting med, with a longer onset time. The danger here is the patient will vomit prior to the vec taking effect (there's a reason it's nicknamed "vomidate"). It's probably not the med of choice, but if you put a gun to my head, there's still significant patient populations in which I'd choose it over succinylcholine.


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## usalsfyre (Mar 5, 2011)

M3dicDO said:


> [*]I was expecting a tough intubation and wanted the patient to resume breathing if intubation was not successful....just in case


Nope, wrong answer.  WRONG, WRONG answer. You've decided the patient needs their airway protected/mechanical ventilation. So you assess them and decide they're going to be a difficult airway. Why in the Jack Stout would you paralyze them at this point? Why not use another option like awake intubation? Or simply be willing to sedate and place an alternative device if intubation fails? Or for that matter just use good manual airway manuvers, optimal positioning, suction and BVM to assist the patient. Using paralytics in this manner is asking to fail. Succinylcholine's duration of action is not short enough to NOT kill you from hypoxia. Not to mention you are now EXACTLY back where you started, but we're 7-10 minutes down the line with likely no progress towards a recieving facility. An ETT is *NOT* the "Gold Standard" of airway management. Oxygenation, ventilation and prevention of aspiration are. None of which an ETT inately provides. Makes easier perhaps, but all of the above can be provided by a providers hands, a BVM and a couple of suction apparatus. Attitudes like this are what get succinylcholine taken away. 



M3dicDO said:


> After a successful intubation, I usually gave Vecuronium to keep them paralyzed so I wouldn't have to keep worrying about the vent beeping all the time with high airway pressures. Made life a lot easier for me, especially for for the patient (with enough sedation of course ^_^)



Again WRONG, WRONG answer. If you were routinely bumping high airway pressures, you almost assuredly did not have adaquately sedated and pain controled patients. The FIRST intervention if your continuely geting high airway pressures is pain control, followed by sedation. Understand that the doses that the hospital has been using may be inadaqaute in the transport environment, there's a lot more stimulus going on. I believe it was old_school recently made an excelent point about doing all you could to block out stimulus, meaning limbs are aligned, eyes lubed taped shut and hearing protection placed. Long-term neuromuscular blockade very rarely makes things "easier" for the patient. What your describing is inapproprite use of medication to make life easier on you, which is, in a word, lazy. 



M3dicDO said:


> A lot of my professors (ER docs) only use succinylcholine in the ED, and use the alternative paralytics when it's contraindicated. An attending used Pavulon on a trauma patient as the initial paralytic for RSI. It was his choice to use a super long-acting paralytic, but I wouldn't have. Sure the ED has neostigmine on hand, but why mess with worrying about reversal agents if you can't get the tube??!!



I agree, but why not place an alternative airway in this case, and call anesthesia to for further management if called for, or let them replace it with an ETT in the OR under controled conditions? This is a better option than letting them "wake up". 



M3dicDO said:


> Bottom line, most critical-care protocols give medics and nurses the ability to choose paralytics based on the patient's best interest. I was able to mix and match at both my critical care transport jobs. I guess it all depends on how much your medical director lets you play with.....:wacko:



Bottom line is you repeated some of the most common misconceptions that get people into trouble with paralytics. Understanding the endpoint goals here is key to best serving the patient's interest.


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## usalsfyre (Mar 5, 2011)

Scott33 said:


> Alternatively, problem solved if the FDA ever get round to approving Sugammadex



Ehhh, Combitubes, LMAs and King Airways have the problem pretty well whipped as it is. What's important is getting people to get over their egos enough to realize supraglotic airways aren't the "tube of shame" .


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## MrBrown (Mar 5, 2011)

Gosh Browns loves Smash to bits, Frank Archer would be so proud! 

We have suxamethonium followed by vecuronium and they seem to work very well, we have a close to 100% success rate with RSI.


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## NomadicMedic (Mar 5, 2011)

usalsfyre said:


> Bonus, who knows how to reverse malignant hypertermia associated with succinylcholine administration?



Dantrolene. A drug we don't carry, but should. It's cheap and has a long shelf life.

I asked a doc about it. He shrugged and said, "If you're RSIing a patient, MH is the least of their worries."


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## reaper (Mar 5, 2011)

Only option prehospital is active cooling and fluid challenges. Try to keep temps under control till you reach the ED.


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## usalsfyre (Mar 5, 2011)

n7lxi said:


> Dantrolene. A drug we don't carry, but should. It's cheap and has a long shelf life.
> 
> I asked a doc about it. He shrugged and said, "If you're RSIing a patient, MH is the least of their worries."



You win $100,000. The checks in the mail. You may wanna wait till Firday to cash it  

I will say MH itself can be a death sentence. MH on top of the condition your RSIing the patient for would certainly make for an uhhh "interesting" clinical course (yeah, that's it, interesting....)


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## usalsfyre (Mar 5, 2011)

Very sorry if I seemed blunt before. This is one of my pet peeve issues.


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## NomadicMedic (Mar 5, 2011)

I think he only said that because he knows that I don't just knock people down and tube them for the hell of it. I'll try everything I can before going there. Also, MH is relatively rare. It's certainly bad news, but the chance of seeing it in the field is pretty slim.


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## usafmedic45 (Mar 5, 2011)

Why not just skip the need for a paralytic and just use ketamine to induce anesthesia and then tube the patient?  The best part is you don't kill the patient that way if you can't get the tube.


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## MSDeltaFlt (Mar 5, 2011)

One paralytic is as good as another the majority of the time.  If you're worried about fasciculations Then I'd to with something other than Anectine.  However, if you have protocols written for both benzo's and opioites, especially of they're weight based doses, then I'd say give as much of the full dose of each as clinically allowed.  If the pt stops breathing and loses a gag then you won't even need a paralytic in the first place.

For my aeromedical company, we have 4 options: succ,  rocc,  vec, or no paralytic at all just benzos & opiotes.


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## M3dicDO (Mar 5, 2011)

usalsfyre said:


> Nope, wrong answer.  WRONG, WRONG.....Again WRONG, WRONG answer...lazy...Bottom line is you repeated some of the most common misconceptions that get people into trouble with paralytics. Understanding the endpoint goals here is key to best serving the patient's interest.




Thank you for sharing with us your views and opinions. Your professionalism is admirable.

I'll have to do a better job next time making sure I add all the little details and disclaimers to avoid readers from making improper assumptions.


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## johnmedic (Mar 5, 2011)

Does fasciculation really contribute to hypoxia enough to be worth noting? Because like Mr Brown said, Sux to tube & Vec to follow seems like a good game-plan.. giving the best of both worlds. Short-term initial paralysis, & long-term paralysis once tube is established, one agency I've interned with does it that way & it's said to have worked well for them.


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## usafmedic45 (Mar 5, 2011)

johnmedic said:


> Does fasciculation really contribute to hypoxia enough to be worth noting? Because like Mr Brown said, Sux to tube & Vec to follow seems like a good game-plan.. giving the best of both worlds. Short-term initial paralysis, & long-term paralysis once tube is established, one agency I've interned with does it that way & it's said to have worked well for them.


No, most of the problem with fasciculations is with the providers rather than the patient.  Some people find it troubling or annoying.


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## usalsfyre (Mar 5, 2011)

M3dicDO said:


> Thank you for sharing with us your views and opinions. Your professionalism is admirable.



If you'll look, I later appologized for my bluntness. 



M3dicDO said:


> I'll have to do a better job next time making sure I add all the little details and disclaimers to avoid readers from making improper assumptions.



Your the one who advocated, in no particular order 1. using succs on a difficult airway "just in case" you can't get the tube 2. using long-term paralysis inappropritely 3. reversing a paratytic or letting the effects of paralytic wear off rather than placing alternative airways. None of these is an approprite action. This is not my view or opinon, this goes against accepted medical care. The way you stated you practice is out and out wrong. Part of the professionalism your so ready to condem me for is viewing your practice objectively, and making changes when needed in response to criticism and new information/evidence. Another part of it is not treating based on the myths/poor practices of others. So yes, I was vigiorous in my criticism of what you describe, but the reason I was so vigirous is because it's crappy care. 

Don't be "that guy", the one who continuely repeats the myths about RSI. We've got enough of those already. It's a legitimate technique that improves outcomes in the field if done correctly. There's not enough people doing it correctly to keep it in the tool box the way things are going though.


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## usalsfyre (Mar 5, 2011)

usafmedic45 said:


> Why not just skip the need for a paralytic and just use ketamine to induce anesthesia and then tube the patient?  The best part is you don't kill the patient that way if you can't get the tube.



"But don't people get HIGH on ketamine?!?"

(Agree with you to a point. I still think there's value to a paralytic in the non-NPO patient. However if there's ANY indication that there may be difficulty encountered in airway control awake is the better way to go. Most of the concerns about Ketamine I've found have been FAR more related to opperational and administrative concerns than anything medical).


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## reaper (Mar 5, 2011)

Here is a good article that gives you a good run down on all the different meds used.

http://emedicine.medscape.com/article/109739-overview


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## usafmedic45 (Mar 6, 2011)

> "But don't people get HIGH on ketamine?!?"



As opposed to morphine, fentanyl, midazolam, diazepam, lorazepam, etc? 



> (Agree with you to a point. I still think there's value to a paralytic in the non-NPO patient.



Can you show me anything that indicates a benfit to the use a paralytic versus disassociation?  If they are going to puke with one, they are just as likely to puke with the other so far as I am aware.  



> However if there's ANY indication that there may be difficulty encountered in airway control awake is the better way to go.



....or you go with the medication that renders them intubatable without knocking out their drive to breathe.



> Most of the concerns about Ketamine I've found have been FAR more related to operational and administrative concerns than anything medical



Yup.  That and that pesky rumor about it having negative effects on ICP.   I find it funny that people have no problem with the operational issues associated with narcotics and the shelf life on the rigs of some paralytics but should you mention ketamine and they look at you as though you are daft.


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## usalsfyre (Mar 6, 2011)

usafmedic45 said:


> As opposed to morphine, fentanyl, midazolam, diazepam, lorazepam, etc?


D@mn kids and their raves...



usafmedic45 said:


> Can you show me anything that indicates a benfit to the use a paralytic versus disassociation?  If they are going to puke with one, they are just as likely to puke with the other so far as I am aware.


Off the top of my head, no. I do know it's the anesthesia standard of care in a patient who's presumed to have a full stomach, to prevent ACTIVE puking. Of course it's also presumed that an anesthesia provider will use proper positioning and mask ventilation technique to prevent passive regurg. Proper positioning and mask ventilation are usually in short supply around EMS.



usafmedic45 said:


> ....or you go with the medication that renders them intubatable without knocking out their drive to breathe.


This is what I really meant. Very few providers are REALLY made aware of this or even the awake intubation using a topical. Instead it seems like they are given two options, "brutane" or a full RSI sequence including paralytic. This leads to people with questionable laryngoscopy skills and a dearth of backup options pushing paralytics on 350 pound no neck Mallampati 4s, and the subsequent bad outcomes associated with it.



usafmedic45 said:


> Yup.  That and that pesky rumor about it having negative effects on ICP.   I find it funny that people have no problem with the operational issues associated with narcotics and the shelf life on the rigs of some paralytics but should you mention ketamine and they look at you as though you are daft.



I wonder how much of it is because ketamine won't show up on a standard (read: cheap) UDS.


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## Veneficus (Mar 6, 2011)

usalsfyre said:


> Of course it's also presumed that an anesthesia provider will use proper positioning and mask ventilation technique to prevent passive regurg. Proper positioning and mask ventilation are usually in short supply around EMS.



I think the problem isn't so much positioning is it is actually bagging the patient 40+ times a minute. The reasons for such are numerous, but I would say that probably 80% of providers see so few actual emergencies, that they are just too excited.


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## AndyK (Mar 6, 2011)

Veneficus said:


> I think the problem isn't so much positioning is it is actually bagging the patient 40+ times a minute. The reasons for such are numerous, but I would say that probably 80% of providers see so few actual emergencies, that they are just too excited.



You would have thought the cramping sensation in the wrist would give 'em a clue they're going wayyy to fast B) The other one I tend to see is people crushing the bag instead of nice, gentle squeezes.


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## Veneficus (Mar 6, 2011)

AndyK said:


> You would have thought the cramping sensation in the wrist would give 'em a clue they're going wayyy to fast B) The other one I tend to see is people crushing the bag instead of nice, gentle squeezes.



Endophins, not always a good thing.


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## M3dicDO (Mar 6, 2011)

MSDeltaFlt said:


> If you're worried about fasciculations Then I'd to with something other than Anectine.



Are you able to pre-medicate with a defasciculating round of either low dose anectine or a non-depolarizing paralytic?


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## NomadicMedic (Mar 6, 2011)

M3dicDO said:


> Are you able to pre-medicate with a defasciculating round of either low dose anectine or a non-depolarizing paralytic?



I didn't realize anectine was used in a defasciculating dose of paralytics. I thought it was only a Non depolarizing agent. Am I wrong?


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## Smash (Mar 6, 2011)

n7lxi said:


> I didn't realize anectine was used in a defasciculating dose of paralytics. I thought it was only a Non depolarizing agent. Am I wrong?



Non-depolarizers are used. They aren't any use though. The idea behind using a non-depolarizers first was to reduce myalgia associated with sux, nothing else. Again it falls into the "least of their worries" category when we are talking about RSI in the field. 

Ketamine is a superb, versatile drug and it would be nice to break down some of the prejudice towards it. I don't think I would be using it as a sole agent to try to intubate though. For hemodynamically compromised patients I would love to be able to use it as part if RSI. But I can't


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## MrBrown (Mar 6, 2011)

Smash said:


> Ketamine is a superb, versatile drug and it would be nice to break down some of the prejudice towards it. I don't think I would be using it as a sole agent to try to intubate though. For hemodynamically compromised patients I would love to be able to use it as part if RSI. But I can't



Brown heard you blokes were a bit anti-ketamine .... silly nonsense about wanting to get paid more.  What would Frank say? 

Brown just loves ketamine to bits, its the words bestest induction agent ever since sliced [moldy] bread was used as an antibiotic back in the Civil War.


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## M3dicDO (Mar 6, 2011)

n7lxi said:


> I didn't realize anectine was used in a defasciculating dose of paralytics. I thought it was only a Non depolarizing agent. Am I wrong?



I was surprised when I first saw it too, but yes Anectine can be used at low-dosage for defasciculation. One of the flight programs in northern IL uses 0.5 mg/kg Anectine as defasciculating agent before the regular full dose.



Smash said:


> Ketamine is a superb, versatile drug ...... I would love to be able to use it as part if RSI. But I can't



Absolutely. All the benefits of anesthesia without the negative cardiovascular side effects. Just curious, does anyone know of transport programs (w/o a physician) that use Ketamine? If so, what kind of dosage and provisions do they have?


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## the_negro_puppy (Mar 6, 2011)

M3dicDO said:


> I was surprised when I first saw it too, but yes Anectine can be used at low-dosage for defasciculation. One of the flight programs in northern IL uses 0.5 mg/kg Anectine as defasciculating agent before the regular full dose.
> 
> 
> 
> Absolutely. All the benefits of anesthesia without the negative cardiovascular side effects. Just curious, does anyone know of transport programs (w/o a physician) that use Ketamine? If so, what kind of dosage and provisions do they have?



Our Intensive Care Paramedics can use Ketamine  as an adjunct to morphine in patients with severe traumatic pain associated with:
- A. Fracture reduction and splinting
- B. Multiple or significant fractures requiring facilitated extricatin

Dosages (IV)

Adult - 10-20mg repeated every 2-3 minutes- total max dose 1mg/kg

Paed- ( = or above 1 years) 100mcg/kg repeated every 2-3 minutes- total max dose 1mg/kg


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## NomadicMedic (Mar 6, 2011)

M3dicDO said:


> I was surprised when I first saw it too, but yes Anectine can be used at low-dosage for defasciculation. One of the flight programs in northern IL uses 0.5 mg/kg Anectine as defasciculating agent before the regular full dose.



That really doesn't make sense to me. Depolarazing agents will cause fasciculations. Why would you give one to stop them?


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## 8jimi8 (Mar 6, 2011)

Do you include lidocaine as part of your RSI?  Nitrogen washout?


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## Aidey (Mar 6, 2011)

8jimi8 said:


> Sorry this may be reposted, because i hit send, but the I couldn't find my thread.
> 
> 
> So I am doing my RSI homework and reading drug profiles.
> ...




We have Anectine, Vecuronium and technically Rocuronium. The only reason we have the Roc is because of the Succs shortage a few months ago. I don't think any of the ambulances have Roc on them now that Succs is back in stock. Succs is our first line drug, and we are only supposed to use the Vec after calling for orders or after the patient is successfully intubated and we have more than a 20 minute trip to the hospital. We can also use it if Succs is contraindicated. 

We have Etomidate, Versed and Fent for sedatives. Thus far I think I like Etomidate better, as I have had a couple of patients burn through Versed stupid quickly.* 

So in short, it is an easy decision because of protocols. Like you, I was recently reviewing other RSI drug profiles and I have no idea why we didn't just totally replace Succs with Roc. I suspect it has something to do with the concern of failed intubations, but that is just a guess. From talking with different ER MDs none of them seem to be a fan of Succs for in hospital RSI. 

Like Linuss my biggest debate is "Should I do this?". None of my tubes have been questioned by the ER MDs or my Med Director, but I still wonder "is the patient as sick as I think they are?". 



Question for those with Ketamine, do you administer it alone or with a benzo? 



*One of these patients needed 10mg of Versed just to get though a head CT, it was pretty crazy.


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## 8jimi8 (Mar 6, 2011)

Aidey said:


> We have Anectine, Vecuronium and technically Rocuronium. The only reason we have the Roc is because of the Succs shortage a few months ago. I don't think any of the ambulances have Roc on them now that Succs is back in stock. Succs is our first line drug, and we are only supposed to use the Vec after calling for orders or after the patient is successfully intubated and we have more than a 20 minute trip to the hospital. We can also use it if Succs is contraindicated.
> 
> We have Etomidate, Versed and Fent for sedatives. Thus far I think I like Etomidate better, as I have had a couple of patients burn through Versed stupid quickly.*
> 
> ...



One of the ideas I have been trying to consider is... the decrease in oxygen demand by a provider taking over the work of breathing.


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## MSDeltaFlt (Mar 7, 2011)

M3dicDO said:


> Are you able to pre-medicate with a defasciculating round of either low dose anectine or a non-depolarizing paralytic?



Yes you can. However I've rarely needed to do so.  If you give the full doses of your pre-intubation sedatives and analgesiacs, there's a good chance you won't need a paralytic at all.  If hemodynamics might be an issue, open the fluids up. Even in a head injury on an adult, 1 bag of fluids won't do any harm.

Now as far as lidocaine is concerned, there's not much in the way of any good use listed.


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## M3dicDO (Mar 7, 2011)

the_negro_puppy said:


> Our Intensive Care Paramedics can use Ketamine  as an adjunct to morphine in patients with severe traumatic pain associated with:
> - A. Fracture reduction and splinting
> - B. Multiple or significant fractures requiring facilitated extricatin
> 
> ...



Fascinating! I can see how Ketamine would be a much better anesthetic for severe trauma than other stronger alternatives like Diprivan. Maybe you guys should come here to the U.S. and influence our medical directors to allow Ketamine for pre-hospital use ^_^



n7lxi said:


> That really doesn't make sense to me. Depolarazing agents will cause fasciculations. Why would you give one to stop them?



I totally agree with you *n7lxi*. It didn't make sense to me either, but they've had this defasciculating option for many years as part of their RSI protocol, with much success....

The best explanation I can come up with is that a small dose of Anectine would partially depolarize many but not all Ach receptors. It would cause minor fasciculations (if any) but not as drastic (or complete) as would a full dose of Anectine. Once the NM junction is partially concentrated with the Anectine, giving the full dose would complete occupying the remaining Ach receptors hence causing a negligible fasciculation. So in summary, it's like breaking down the fasciculations into smaller pieces. But it's not going to be half of the complete fasciculation (i.e. it's not 1+1=2) because the NM junction has an exponential physiology rather than linear.



MSDeltaFlt said:


> If you give the full doses of your pre-intubation sedatives and analgesiacs, there's a good chance you won't need a paralytic at all.


Amen! I only used Versed, Etomidate and Fentanyl for RSI, for many years on an ALS ambulance. Our protocols allowed us to stack all three, if needed to achieve proper sedation. And it always worked  Paralytics are indeed a great asset for an RSI, not a requirement.


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## 8jimi8 (Mar 7, 2011)

M3dicDO said:


> the NM junction has an exponential physiology rather than linear.



please elaborate.




I hope that this isnt outdated information.  According to

http://emcongress.org/2007/presentations/18Gibbs.pdf

There is no evidence that succinylcholine worsens outcomes in at risk ICP patients.

Also there is no evidence that defasciculating doses improve outcomes for at risk patients.


Maybe there just needs to be a study.


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## M3dicDO (Mar 7, 2011)

8jimi8 said:


> http://emcongress.org/2007/presentations/18Gibbs.pdf
> 
> There is no evidence that succinylcholine worsens outcomes in at risk ICP patients.
> 
> ...



Thanks for sharing this presentation. It's a really good read!



8jimi8 said:


> please elaborate.



Sorry I tried to cut corners and didn't give a full explanation. Well, consider skeletal muscular depolarization. As you have the wave of depolarization reach the contractile units of the muscle, the translation of the electrical activity into contraction is mediated by the eflux of Ca from the sarcoplasmic reticulum. As you may already know about the nature of Ca in electrochemical activity, increasingly higher concentrations of Ca causes faster and greater release of even more sequestered stores of Ca in the muscle cells. This phenomenon is referred to as "*Calcium induced Calcium release.*" (This similar physiology is seen in pre-synaptic neurons as well, where calcium is used by the neurotransmitter vesicles as a means of "sticking" to the pre-synaptic membrane and mediating neurotransmitter release, to some extent). 

What I mean by this is that small doses of Anectine translates to small release of Ca from the sacroplasmic reticulum and hence less Ca to interact with troponin, and so on. If on the other hand a large dose of Anectine is given, the Ca release is so huge (due to a large wave of incoming depolarization) that the a large storm of the ion causes fasciculations.  But you can achieve occupying Ach receptors without inducing the "Calcium induced Calcium release," by giving a small dose of Anectine as a premedicating defasciculator,  and so the upcoming full dose will not cause the fasciculations normally expected.......since many of the Ach receptors are already occupied. I guess, you can make two 0.5 mg/kg doses suffice (in theory), but giving the full 1-1.5 mg/kg doses as the second dose is a way of being certain you've achieved a definite paralyzation.

Oh, I forgot to address the "exponential" vs. "linear" physiology. If you were to graph the Ca release (and thus muscle contraction) vs. Ach stimulation, you would expect to see a steeper curve as more and more Ach receptors are recruited.

Please let me know if I missed anything....


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## 8jimi8 (Mar 7, 2011)

M3dicDO said:


> Thanks for sharing this presentation. It's a really good read!
> 
> 
> 
> ...



Thanks!


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## 8jimi8 (Mar 7, 2011)

MSDeltaFlt said:


> Yes you can. However I've rarely needed to do so.  If you give the full doses of your pre-intubation sedatives and analgesiacs, there's a good chance you won't need a paralytic at all.  If hemodynamics might be an issue, open the fluids up. Even in a head injury on an adult, 1 bag of fluids won't do any harm.
> 
> Now as far as lidocaine is concerned, there's not much in the way of any good use listed.




You didn't mention the nitrogen washout, i'm curious if in the most critically emergent patient's you take time to bag them for 3 minutes.


Also,

Do you disagree with this statement below from ACEP?
Focus On: Rapid Sequence Intubation Pharmacology
http://www.acep.org/Content.aspx?id=49401

When used as a pretreatment agent, lidocaine is dosed at 1.5 mg/kg intravenously, and the duration of action is approximately 10-20 minutes.1 Lidocaine offers protection in two clinical scenarios: 1) prevention of increase in ICP caused by RSRL, and 2) bronchodilation in reactive airway disease


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## MSDeltaFlt (Mar 7, 2011)

8jimi8 said:


> You didn't mention the nitrogen washout, i'm curious if in the most critically emergent patient's you take time to bag them for 3 minutes.
> 
> 
> Also,
> ...


 
As stated in my quote, "not much..."

"Robinson and Clancy in the _Emergency Medicine Journal_ published a literature review showing that although this agent does blunt the RSRL-caused ICP increase, *there is no evidence of improved neurologic outcome when using lidocaine in head-injured patients*"

Besides, there is a difference here that some don't seem to realize. And it's a phylosophy as well that depends on one's medical control. And that, my friend is Rapid "Sequence" Intubation vs Drug "Assisted" Intubation.

The operative words here (depending on you OLMC) is "sequence' in RSI: once you start the sequence, you complete the sequence, and "assisted" in DAI: if your pt stops breathing and loses a gag before you've given your paralytic, go ahead and pass the tube.

This is where the true nature of the original title of this thread lies: critical thinking.

Look at your patient.  Assess and reassess.  Never say never.  Never say always.


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## usalsfyre (Mar 7, 2011)

8jimi8 said:


> You didn't mention the nitrogen washout, i'm curious if in the most critically emergent patient's you take time to bag them for 3 minutes.



If at all possible I absolutely denitrogenate a patient prior to making any attempt to pass a tube, drug assisted or not. The only times I haven't (since I stopped  tubing arrest) are the two times I've used a paralytic with no sedative as I noted in another thread (bradycardiac hypoxic patient we couldn't BVM and a head injury with trismus who had puke coming through his teeth, manual airway maneuvers wouldn't work on either one).


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## NomadicMedic (Mar 7, 2011)

This has been one of the most fascinating threads on EMTlife. 

Thanks to everyone who's taken part.


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## M3dicDO (Mar 7, 2011)

usalsfyre said:


> I've used a paralytic with no sedative.....



Interesting approach. Does your protocol allow you to skip sedation? :glare: Or did a physician approve this method via OLMC? Can you share with us "the two times" you did this?


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## usalsfyre (Mar 7, 2011)

M3dicDO said:


> Interesting approach. Does your protocol allow you to skip sedation? :glare: Or did a physician approve this method via OLMC? Can you share with us "the two times" you did this?



I shared the two times in the same post, immediately after the line you quoted.  Yes it was based on guideline, if you'll look up the National Emergency Airway Algorithms(Dr. Walls guidelines) this is an accepted technique called crash airway. Both of these patients were deeply unconscious and both had midazolam administered with in a minute or two post-intubation for sedation/retrograde amnesia. Both of these cases were headed rapidly for a bad outcome, and waiting the extra minute or so to draw up and administer the Etomidate wasn't in the cards. This would be absoloutely idiotic technique to place under OLMC as it's intended for situations where you don't have time for a sedative, as by that time I a doc on the phone here I could sedate 20 times. I've never worked in a system where RSI has been online anyway.

No, it's not a technique I think is appropriate on 99.99% of patients, it's something where critical thinking applies. I sedate first always, excepting these two specific cases. So there's no need to glare .


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## usafmedic45 (Mar 7, 2011)

> You would have thought the cramping sensation in the wrist would give 'em a clue they're going wayyy to fast



As someone who bagged a patient all the way from Pensacola to Ft. Smith, Arkansas after we had out ventilator start acting up just as we reached cruising altitude, I would agree with that.



> Are you able to pre-medicate with a defasciculating round of either low dose anectine or a non-depolarizing paralytic?



Why would you waste time doing that when faced with any of the scenarios that would be amenable to RSI?


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## M3dicDO (Mar 8, 2011)

usafmedic45 said:


> Why would you waste time doing that when faced with any of the
> 
> scenarios that would be amenable to RSI?



Just like there are varying opinions on the benefits of using Lidocaine on head trauma patients, there are many practitioners out there that are firm believers in using a defasciculating round of paralytics before intubating a patient suspected of increased ICP. 

I agree with you on the fact that we would "waste time doing that when faced with any of the scenarios that would be amenable to RSI" but there are many transport programs out there that either a) require a defasciculating dose as one of their pre-medications in RSI or b) strongly urge transport personnel to consider it. Defasciculating pre-medication may be an old-school (and by some, considered possibly controversial) practice but I've noticed many medical directors feel indifferent in removing therapies that prove no harm. 



usalsfyre said:


> I shared the two times in the same post, immediately after the line you quoted.



Yes, I read it, but I was hoping you wouldn't mind doing a short case presentation on it, so we would get a more complete picture....



usalsfyre said:


> Yes it was based on guideline, if you'll look up the National Emergency Airway Algorithms(Dr. Walls guidelines) this is an accepted technique called crash airway.



I agree, it is a great algorithm for difficult airways. I understand that in the field, critical thinking is important in the matters of life and death, but I was asking you if you had the ability to skip sedation based on established protocols for your program. I have never heard of such leniency for any non-physician provider. I worked with a few medics and nurses that thought whatever happened behind closed doors of the aircraft stayed in the aircraft, and got away with a lot (as long as it was "properly documented.") Reminds me of the two "cowboy" flight nurses from CALSTAR in February 2008 that got nailed to the cross.....



usalsfyre said:


> Both of these patients were deeply unconscious and both had midazolam administered with in a minute or two post-intubation for sedation/retrograde amnesia



Deeply unconcious as in code blue? :blink: I don't mean to be picky but Midazolam has not been proven to produce effective retrograde amnesia in any patient population (1,2,3,4). I hope neither of those patients remember being gagged by the cold laryngoscope blade. 



usalsfyre said:


> This would be absoloutely idiotic technique to place under OLMC as it's intended for situations where you don't have time for a sedative, as by that time I a doc on the phone here I could sedate 20 times



I guess it all depends on how much you would want to put your license on the line. If :censored::censored::censored::censored: hits the fan, any medical director would cover their own butt first. Seen it happen, it's not pretty.

(1) Hupp JR, Becker LE. Intensity and duration of amnesia from intravenous midazolam given for sedation, Conn St Dent Assoc J 1988;62:80-5.
(2) Oboyle CA. Benzodiazepine-induced amnesia and anaesthetic practice: a review. Psychopharmacol Ser 1988;6:146-65. 
(3) Twersky RS, Hartung J, Berger BJ, et al. Midazolam enhances anterograde but not retrograde amnesia in pediatric patients. Anesthesiology 1993;78:51-5.
(4) Antoun K, Janet IM. Does Midazolam cause retrograde amnesia, and can flumazenil reverse that amnesia? Anesth Analg 1997;85:211-2.


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## MrBrown (Mar 8, 2011)

M3dicDO said:


> Just curious, does anyone know of transport programs (w/o a physician) that use Ketamine? If so, what kind of dosage and provisions do they have?



We use ketamine for analgesia and anaesthesia (RSI).

Ketamine
• Indicated in severe pain, particularly musculoskeletal or burn pain.
Is preferably used in combination with morphine.
• Contraindicated if:
a. Age less than one year or
b. Unable to obey commands or
c. Has active psychosis or
d. Has cardiac chest pain or
e. Midazolam has already been given.
• Give oxygen via nasal prongs or acute (ordinary) mask.
• In adults:
a. If morphine or IM ketamine already given, give 5-10 mg
ketamine IV every 3-5 min.
b. If morphine or IM ketamine has not been given, give 10-20 mg
ketamine IV every 3-5 min.
c. If unable to gain IV access, give 1 mg/kg ketamine (rounded off
to nearest 10 kg) IM or oral, up to a maximum of 100 mg. This
may be repeated after 20 minutes if required. Do not use IM
route if shocked and avoid IM use in children if possible.
d. Reduce the dose if the patient is elderly, small or
physiologically unstable.
• For children, see paediatric drug dose table.
• Ketamine must be diluted to 2 mg/ml for IV use. Place 200 mg
(2 ml) of ketamine in a 100 ml bag of 5% glucose (shake well and
label).


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## Aidey (Mar 8, 2011)

Nasal prongs? lol


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## Shishkabob (Mar 8, 2011)

RSI scares the absolute bejeezus out of me.


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## usalsfyre (Mar 8, 2011)

M3dicDO said:


> Yes, I read it, but I was hoping you wouldn't mind doing a short case presentation on it, so we would get a more complete picture....


(Please keep in mind I may be wrong on some details, the cases in question happened about two years ago, six months apart. I haven't run into a case that's needed a crash airway since)

Case 1. 60ish year old male found in the ditch by ground EMS (no info further than that, the homeowner had literally walked out and found a strange, half nude man in the ditch) they had attempted intubation and were unable to as the patient had bitten the blade(no RSI). Narcan admionistered and found to be ineffective BVM was ineffective, only about every third or fourth ventilation was effective, as the patient was edentulous, bearded and had sunken cheeks. No signs of trauma were noted, patient was cold to touch and pale, unconscious and completely unresponsive, pupils were a 1 and fixed. Breath sounds were initially diminished to absent, abdomen was soft. Extrimities were intact. Pt was satting in the low 80s and headed downward, HR was in the 60s and headed down with the Sp02, but was hypotensive, systolic pressure in the 70s, per EMS this was the case from time of arrival. Were drawing up meds to intubate, when the SpO2 got to 75% and the HR 40 or so we aborted the full attempt, pushed 150mgs of succs and intubated quickly, lowest observed Sp02 was I believe 68% and lowest HR was 64. Sp02 and HR rose quickly after intubation, maintained in the high 90s and tachycardic respectively. Sedated with fent and a little bit of midz. In flight the patient received a liter of fluid and had dopamine started. Patient coded on arrival, CPR started, one shock delivered, and ROSC achieved. Was never able to follow up further than this as we were in a bit off a tiff with the receiving at the time, but I can't imagine him living.  

Case 2. 19 YOM unrestrained driver ejected in a high speed MVC. Ground EMS packaged and was drawing up drugs to RSI on our arrival. Pt was unconscious, unrseponsive, trismus was noted, patient had vomit coming out from between his teeth, EMS was attempting to suction, but the trismus prevented it. Ground EMS had succs already drawn up, directed them to give it, achieved relaxation, suctioned appx 50-70mls of thick emisis out of his airway, passed a tube and ventilated. Pt sats remained in the 90s throughout this, pt had been on a NRB mask prior to our arrival so he was adequately prexoygenated. Sedated again with fent and midaz and passed an OG. Enroute patient remained adequately sedated and oxygenated. Was treated for a head bleed (don't remember the exact nature) and discharged to rehab a month or so later. 



M3dicDO said:


> I agree, it is a great algorithm for difficult airways. I understand that in the field, critical thinking is important in the matters of life and death, but I was asking you if you had the ability to skip sedation based on established protocols for your program. I have never heard of such leniency for any non-physician provider.


My last job (HEMS) and my current job (regular ground EMS) both pretty much have photocopies of Dr. Walls guidelines (RSI, Crash, and Difficult and Failed) in their protocol books, the only change is that my current provider uses rocc instead of succs. I like options in airway managment, solely having an "RSI" protocol is why EMS fails at difficult airways. I also don't think every, or even the majority of EMS providers need to be doing RSI. 



M3dicDO said:


> I worked with a few medics and nurses that thought whatever happened behind closed doors of the aircraft stayed in the aircraft, and got away with a lot (as long as it was "properly documented.")


I've worked with some of these, I assure I'm not one of them. What I do at any point affects what's down the road. I'll also say I've never actually had a medical director have a problem with treatments I've provided, it's always been their underlings. I have a reason for every treatment I provide. Most medical directors are very understanding of this, even if they suggest a different course the next time. The people I've seen get really hammered are the ones that do things "just because". 



M3dicDO said:


> Reminds me of the two "cowboy" flight nurses from CALSTAR in February 2008 that got nailed to the cross.....


These two were actually cleared on any wrong doing by the state nursing board. You look at the minutes, and it seems to boil down to 1).a paramedic who lied multiple times 2.) the medical director's underling as above and 3.)an inaccurate coroner's report (I have no idea what this guy's motivation was, but he charted a jagged laceration well below the cricothyroid membrane as the cut for the cric). Several experts testified on the two nurses behalf. 



M3dicDO said:


> Deeply unconcious as in code blue? :blink: I don't mean to be picky but Midazolam has not been proven to produce effective retrograde amnesia in any patient population (1,2,3,4). I hope neither of those patients remember being gagged by the cold laryngoscope blade.


I hope they didn't either. But as you can see, my partner and I truly believed in both cases it was a life-threatening situation. 



M3dicDO said:


> I guess it all depends on how much you would want to put your license on the line. If :censored::censored::censored::censored: hits the fan, any medical director would cover their own butt first. Seen it happen, it's not pretty.


I was backed up by protocols and standard of care in both cases.

Sorry if this is disjointed, it was written over the course of 7 hours due to run volume :wacko:


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