# Ideas for RSI eduction



## medicaltransient (Dec 28, 2015)

When we got our Christmas bonus I asked my boss to give me some extra work. He says he wants me to give an RSI class so we can update our protocols. I think we are just going to copy the AEL protocol. Basically I am going to show the ACE SAT video on airway management and then I am going to show a power point and proctor a test. So I need Ideas for the power point. These are the things I am going to include in the test so far. I

The LEMON score. 
The actual protocol 
A slide for every drug
The RASS score 

Does any one know a good reliable online source for pharmacology information? 
Thanks for your help!


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## NomadicMedic (Dec 28, 2015)

Curious, do you have RSI now? 

Cuz, there's a little more to it than a PPT.


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## FiremanMike (Dec 28, 2015)

To build on what DEMedic says, if you don't currently have an RSI or at least "drug assisted intubation" protocol currently in place, try to incorporate some hi-fidelity sim lab training into this process.  RSI is much less about the procedure itself and much more about the decision making process that leads up to the RSI and then the ability to execute the administration of drugs, the intubation, and the ability to decisively move on to a rescue airway in the event that your intubation attempts fail.


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## CANMAN (Dec 28, 2015)

I second all of the above, what is going to be your companies stance on O.R. time for live intubations or procedure for hopefully quarterly, or annual competency? What is your companies current first tube success pass rate? Do you guys have any adjuncts such as VL, bougies, etc? If instituting an RSI program for the first time there is a lot more involved then running a few slides and medics intubating Harry the Half Head half a dozen times for sign off. What is going to be your post RSI plan for sedation, ventilation management, etc? Are you strictly a field EMS program of also doing IFT? Add some more details and I will be happy to provide some more tomorrow on shift. Between the MD's on the forum, Remi, DEmedic, Chaz, FiremanMike, and others we will be able to give you some solid direction.


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## medicaltransient (Dec 28, 2015)

No we don't currently have RSI. I have done it 7 times personally at a previous job. Yes we do plan to have a practical skills training. We only do EMS. We plan on instituting the bougie and king lt-d. I don't know any of our statistics for intubation and I don't know how accessible the local OR is. The protocols are going to be a copy of Air Evac Life Team; 
Premedication:

1. Administer atropine 0.02mg/kg IV prophylactically to prevent bradycardia in all pediatric patients less than 4 years of age. Atropine minimum dose is 0.1 mg to avoid rebound effect.

Use ONE of the following medications: with preference in the order listed.

1. Etomidate 0.3mg/kg IV

2. Ketamine 1mg/kg IV

3. Midazolam 0.1mg/kg IV (only to be used if Etomidate and Ketamine are unavailable or contraindicated)

Neuromuscular Blockade:

Doses are applicable for both adult and pediatric patients. Use ONE of the following medications with preference in the order listed.

1. Succinylcholine 2mg/kg IV (Max single dose 200mg)

2. Rocuronium 1mg/kg IV (Max single dose 2mg/kg of ideal body weight)

POST INTUBATION MANAGEMENT

The goal of post intubation management is to safely provide and monitor adequate sedation of the intubated patient by treating pain and anxiety in the intubated patient. Before sedating the patient:

1. Confirm successful placement of an advanced airway per PRO 007. (ETT, King Airway, LMA, cricothyrotomy)

2. Initiate and continue to monitor ETCO2, SpO2, NIBP values. (arterial lines if available)

3. Establish and maintain patent and working intravenous/intraosseous access.

4. Assess and document initial level of sedation using RASS score.

5. Determine and document target level of sedation using RASS score, typically (-2 to -4)

6. Document RASS score before each time a medication is given, change in patient condition or q10 minutes.

*A RASS score must be documented on every patient. A RASS score must also be documented every time a patient receives sedation.

Is there a need for immediate sedation?

YES

NO.

Reassess RASS score at a

minimum of Q10 minutes. If

patient needs further sedation to attain target RASS score, then…

Is the patient

hemodynamically unstable?

YES NO.

Follow Post

Intubation

Medication list.

A. IV fluids wide open via pressure bag.

B. Ketamine (use with caution in patients with CHF)

ADULT- 0.5mg/kg to 1mg/kg IV. (If needed, repeat with

half of initial dose q5 -15 minute to effect).

PEDIATRIC - 1.5mg/kg to 2.0mg/kg IV. (If needed, repeat with half of initial dose q5 -15 minute to effect).

C. Norepinephrine infusion, titrate SBP>90 (Mix 4mg in

250ml. Starting dose 5-10mcg/minute)

Once patient is hemodynamically stable, then…

Post Intubation Management medication list

A. Fentanyl: 0.5mcg/kg to 1.5mcg/kg IV q2 minutes. (Single max dose of 200mcg)

OR

B. Morphine: 0.05mg/kg to 0.1mg/kg IV q2 minutes. (Single max dose of 10mg)

THEN

C. Midazolam: 0.02mg/kg to 0.05mg/kg IVP q2 minutes. (Single max dose of 5mg). *If unable to obtain targeted RASS score by using multiple doses of fentanyl, morphine and midazolam to sedate the patient, then consider using ketamine.* D. Ketamine:

ADULT- 0.5mg/kg to 1mg/kg IV. (If needed, repeat with half of initial dose q5 -15 minutes to effect)

PEDIATRIC- 1.5mg/kg to 2.0mg/kg

IV. (If needed, repeat with half of initial dose 


Sorry this information is disheveled but I could not get it to copy in an algorithm format.


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## medicaltransient (Dec 28, 2015)

Paralysis: There are very few patients that will need long acting paralytics during post intubation management. The goal of post intubation management is to safely provide and monitor adequate sedation levels by preventing pain and anxiety in the intubated patient. Paralytics do NOT provide sedation and should NEVER be used on any patient that is not properly sedated unless there is an immediate safety concern in flight.

Such as the following:

1. Immediate safety concern in which the patient will cause harm or danger to themselves.

2. Immediate safety concern in which the patient will cause harm or danger to the pilot or aircraft.

3. Immediate safety concern in which the patient will cause harm or danger to the flight crew.

-If long acting paralytics are to be administered, the doses for adult and pediatric patients are as follows:

- Rocuronium 1mg/kg IV.

- Vecuronium 0.1mg/kg IV.


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## CANMAN (Dec 28, 2015)

I personally think taking one programs protocols and trying to implement those as a blanket for your program is a bad idea. I would make a bunch of changes personally to those for many reasons. I think from the sound of things you are missing some real key components and I will be happy to write up a detailed response tomorrow when I have some more time. Thanks for the additional info.


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## Carlos Danger (Dec 28, 2015)

medicaltransient said:


> When we got our Christmas bonus I asked my boss to give me some extra work. *He says he wants me to give an RSI class *so we can update our protocols. *I think we are just going to copy the AEL protocol.* Basically I am going to show the ACE SAT video on airway management and then I am going to show a power point and proctor a test. So I need Ideas for the power point. These are the things I am going to include in the test so far.





medicaltransient said:


> No we don't currently have RSI. *I have done it 7 times personally at a previous job.* Yes we do plan to have a practical skills training. We only do EMS. *We plan on instituting the bougie and king lt-d*. I* don't know any of our statistics for intubation and I don't know how accessible the local OR is*. The protocols are going to be a copy of Air Evac Life Team;



OK, so your program wants to do RSI, but:

Your medical director (apparently) isn't willing or able to design or teach the class.
Your lead educator for this project will be someone who has only done the procedure himself a few times
You don't even know if the paramedics at your service is any good at intubating
You (apparently) aren't already training regularly in an OR, and don't know if you can get hands-on training in an OR
Your paramedics are not already familiar with the basic adjuncts that you recognize are important to have, so they'll have to learn those at the same time that they'll be learning a critical new skill
What could possibly go wrong?


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## FiremanMike (Dec 28, 2015)

Let me start by saying that AEL's RSI protocol holds a special place in my heart and as an experienced provider, I appreciated it's flexibility.

With that said, I think it's too complicated for the general population of medics, and giving that many choices will quickly lead to frustration.

My current RSI protocol is both strong and simple, able to be quickly understood by all providers and easily drawn up and administered in the heat of the moment.

It goes

Premedication 
2mcg/kg fentanyl
2mg versed

Induction/Paralysis
1mg/kg Ketamine
1mg/kg Rocuronium

Post intubation sedation
2mcg/kg Fentanyl
2mg versed
(if you didn't notice, it's the same regimen as the premedication phase)
(q20min PRN, special training has been given to ensure everyone knows the signs of awareness in a chemically paralyzed patient)

There was quite a bit of heartburn over going to a long acting paralytic for RSI, however our medical director was able to make several points to put guys at ease; 

1.  The idea that giving succs would allow for the patient to start breathing again given a failed airway is based on the false premise that they'll start breathing again.  He points out that we're not in a surgery center, inducing an otherwise healthy 30 year old for shoulder surgery.  We RSI people who are very sick/injured and the likelihood of them resuming spontaneous adequate respirations after being down for 5 mins of succs is extremely low.
2.  Throughout all of the data within the departments covered under our protocol, the incidence of a true failed airway (that is to say, not even a rescue airway could be inserted) was so extraordinarily low that it should be considered a statistical anomaly.  
3.  If, after knowing what we just covered, you're still uncomfortable for giving someone roc and paralyzing them for 30-45 minutes, don't give it.  The fent, versed, and ketamine will likely be enough sedation to intubate them, however he does prefer we give the rocuronium if we're comfortable so as to minimize the risk of aspiration.


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## EMT11KDL (Dec 29, 2015)

I personally like the fact you are using Fentanyl 2 mcg/kg.  Also agree with Ketamine, but I would discuss with some more people and maybe increase your dose to 2mg/kg for induction than 1mg/kg for post intubation sedation. 

Something else I would recommend you doing some research on, is High Flow Nasal Canula for about 5 mins prior to intubation.  N/C Set at 15/L/Min.  there is research going on both sides if it is beneficial or not, just do your own research and come up with your own opinion on the idea. 

Now on another note.  If you agency has not been intubating and not have an RSI protocol in place or even a Drug Assisted, there will need to be a lot of training and continuing education.  Just like anything else, when something new is put on the truck everyone wants to use it, and it can be easily used inappropriately.  RSI is a wonderful tool, but it does have its place. 

Another thing to think about is your transport time and do you guys currently have a vent on the trucks, and do your medics know how to set up and trouble shoot the vent.  Or are you guys going to Bag the patient all the way to the hospital.



FiremanMike said:


> 3. If, after knowing what we just covered, you're still uncomfortable for giving someone roc and paralyzing them for 30-45 minutes, don't give it. The fent, versed, and ketamine will likely be enough sedation to intubate them, however he does prefer we give the rocuronium if we're comfortable so as to minimize the risk of aspiration.



If you are not comfortable using Roc, you should not be doing an RSI.


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## FiremanMike (Dec 29, 2015)

Ah yes, I forgot about the high flow cannula, which we instituted this year.  I don't know why it took so long for that to reach mainstream (that study was in the 60s, I believe) but it works wonderful.  We perform the bulk of our pre and peri-intubation oxygenation with a cannula at 10-15lpm..  Great tool


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## EMT11KDL (Dec 29, 2015)

FiremanMike said:


> Ah yes, I forgot about the high flow cannula, which we instituted this year.  I don't know why it took so long for that to reach mainstream (that study was in the 60s, I believe) but it works wonderful.  We perform the bulk of our pre and peri-intubation oxygenation with a cannula at 10-15lpm..  Great tool



it is required at my agency, and I personally like the idea and research behind it.


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## TXmed (Dec 29, 2015)

There's more to RSI protocols than what is written on paper.

AEL wants to focus on oxygenation during the attempt, if the patients o2sat or SBP drop below 90 during attempt you immediately pull out and re-oxygenate. The goal is to not cause hypoxia while securing the airway. Also as far as premedication prior to induction isn't in the protocol because they found they were just drawing up to much medicine prior to intubating. And they wanted to focus more on oxygenation.

One suggestion if rsi is new to you. Hands on practice. Practice drawing up the medication , practice pushing the medication, practice pre-oxygenation, hands on practice not just talking about it.


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## CANMAN (Dec 29, 2015)

Remi said:


> OK, so your program wants to do RSI, but:
> 
> Your medical director (apparently) isn't willing or able to design or teach the class.
> Your lead educator for this project will be someone who has only done the procedure himself a few times
> ...



Agree 100% with Remi, and he pretty much highlighted all the points that need to be corrected before moving forward with an RSI program and education. Don't take this the wrong way, but chances are if your company doesn't even know some baseline first attempt success rates for it's current provider's, and judging off the information you have provided thus far, I would venture to say they're going to be pretty poor, or certainly not inline with tacking on an RSI program without some leg work. That leg work should be heavy on involvement from your Medical Director, and should establish clear guidelines for O.R. time, and skills assessment on a frequent basis. My program has quarterly requirements for live adult and pediatric intubations, as well as simulator intubations, and has bi-annual education and competency sessions we call WISER days. This past year we had a 96.7% first tube success rate across our entire system.

What are you guys currently using for rescue airways if you do not have training on the King Airway, and use of a bougie? Tossing RSI, along with new devices such as a bougie and King airways in the provider's laps all at one time I think is a terrible idea. That is alot to train everyone up on at one time, and also gives them 0 field time to gain experience with said tools before having to use them in a difficult airway or RSI gone bad scenario.

What is the plan going to be for ventilator management post RSI? Are you hand bagging 5 minutes to most of your ED's, in which case I would question if you even need RSI, or do you have extended transport times where the patient should be getting consistent rate/volume via a mechanical ventilator?

As far as protocols go, there are 10 ways to skin a cat, and maybe other provider's will have their opinions. Based on what has been posted I would make some changes personally. I agree with alot of FiremanMike's points, however would alter the cocktails, or at least give provider's some choices. Choices are great when you have high functioning provider's who are educated and can make solid decisions. I can understand why some places take more of a blanket approach. Based on my experience I am not a fan of Versed for induction. You typically need a hefty dose, and in alot of the population we are performing an RSI on it can put you in a hypotensive situation more often then not. Where I think it works well is in conjunction with Fentanyl for post RSI sedation with stable hemodynamics. Give provider's the option of Etomidate and Ketamine. We also ditched Succs in favor of just carrying Roc and Vec. We used to carry all three. For sedation we have Fentanyl, Versed, Propofol, Ketamine bolus and drip in our protocols. Without having this statement turn into a debate, I think the concept of "waking someone up" in a diffcult airway scenario is only appropriate for an O.R. type setting, where as previously described those patient's have been through pre op screening, and are generally stable for induction. If we make the decision to take someone's airway it's because it's indicated. Waking them up is going to put us in the same S sandwich we started with and put us no better off. If you can mask ventilate you DO NOT have an airway emergency and there is no shame in oxygenating and ventilating with a BVM on the way to the hospital if you cannot successfully intubate or place a rescue airway. If you are in a bad scenario where the patient needs an airway, you cannot establish one via ETT or rescue airway, and you cannot bag and maintain Spo2 of 90 or greater and ventilate then you go to a surgical airway and call it a day. Those are your choices in my opinion.

High flow nasal cannula for apneic oxygenation is a great thing, and I am glad a bunch of people on the board are doing it in the field. We still get crazy looks from MD's and Medics when we show up, RSI, and use that tool. It's our protocol for every RSI situation. Keep in mind it can assist you slightly with pre-oxygenation coupled with a non-rebreather, BVM, or whatever the situation indicates, however it's not going to increase your numbers once drugs are on board. It's designed to prolong your period of desaturation, and I think alot of people miss that concept.

TXmed, while I agree that focusing on oxygenation is extremely important, and ideally you want to start with the best numbers possible, sometimes clinically that just isn't possible. There are times where intubations occur with less then ideal sats or blood pressure because that is the best you can achieve given what is going on. To say we aren't going to proceed with intubation for a person who might be a trauma patient with a blood pressure of 80 systolic, or stop mid attempt is kinda silly in my opinion. Those number's are certainly going to guide my drug choices, or things we do in the preparation phase such as hyper elevating a morbidly obese person with crappy sats, but they aren't always going to prevent me from pulling the trigger on RSI if that's the best we have seen after some techniques which fail to improve the situation.


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## Carlos Danger (Dec 29, 2015)

The specific protocol means little, IMO. Roc vs sux, ketamine vs. etomidate, fentanyl or not, versed or not, beta blockers or not, apneic oxygenation or not.....none of it matters, really. There are many ways to do an induction correctly, and none of these drugs or techniques has been shown superior to the others except in specific scenarios. If you know what you are doing, you can make pretty much anything work. If you don't know what you are doing, even the "best" protocol is not going to cover for that.

I do have to say I honestly don't see why so many people have decided seemingly overnight that rocuronium is superior to succinylcholine for RSI. I think what annoys me the most about this debate is that the "roc rules" crowd seems to primarily rest their opinion on the fact that "if you can't intubate, sux doesn't wear off fast enough to prevent severe hypoxemia anyway", which of course is true, but is totally a red herring argument because no one who knows what they are talking about has ever argued that that is a reason to use sux.

It's OK to prefer roc, but if you want to convince others that you actually have a reasoned basis for your preference, you really need a better argument than not wanting to remember sux's contraindications, or that "you shouldn't be waking up a patient who you were trying to RSI". You use sux because it is faster and denser and more predictable, not because you think you might change your mind about the patient needing a tube.

Roc clearly has a place in RSI, such as when sux is contraindicated. Both drugs have small (but potentially significant) advantages over the other, but it is important to understand that those advantages really only matter on the margins, and it doesn't make a difference which one you use in 99.9% of cases. It's that 0.1% where you will wish you used the one you didn't. One is not clearly superior to the other. I think those folks who are totally convinced that roc is always a better choice are every bit as wrong as someone who thinks that sux is always a better choice.


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## CANMAN (Dec 29, 2015)

Remi said:


> The specific protocol means little, IMO. Roc vs sux, ketamine vs. etomidate, fentanyl or not, versed or not, beta blockers or not, apneic oxygenation or not.....none of it matters, really. There are many ways to do an induction correctly, and none of these drugs or techniques has been shown superior to the others except in specific scenarios. If you know what you are doing, you can make pretty much anything work. If you don't know what you are doing, even the "best" protocol is not going to cover for that.
> 
> I do have to say I honestly don't see why so many people have decided seemingly overnight that rocuronium is superior to succinylcholine for RSI. I think what annoys me the most about this debate is that the "roc rules" crowd seems to primarily rest their opinion on the fact that "if you can't intubate, sux doesn't wear off fast enough to prevent severe hypoxemia anyway", which of course is true, but is totally a red herring argument because no one who knows what they are talking about has ever argued that that is a reason to use sux.
> 
> ...



I agree with you, I wish we still had Succs personally, however it got pulled from our protocols this last go round and thus is life. We do alot of peds where I work and the peds docs are always so anti-succs for alot of the patient population, certainly under 8 due to possibility for a undeclared neuromuscular disorder. Couple that with watching out for contraindications like a hx of malignant hyperthermia, although rare, hyperkalemia, occular trauma, I think our medical director's just went in favor of carrying less agents. I was always a succs fan, and I also believe that if you can't select the proper medication regiment then you shouldn't be perform the skill, but I enjoy where I work and challenging our medical director over something that means very little to me just isn't worth it.


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## FiremanMike (Dec 29, 2015)

Remi said:


> The specific protocol means little, IMO. Roc vs sux, ketamine vs. etomidate, fentanyl or not, versed or not, beta blockers or not, apneic oxygenation or not.....none of it matters, really. There are many ways to do an induction correctly, and none of these drugs or techniques has been shown superior to the others except in specific scenarios. If you know what you are doing, you can make pretty much anything work. If you don't know what you are doing, even the "best" protocol is not going to cover for that.
> 
> I do have to say I honestly don't see why so many people have decided seemingly overnight that rocuronium is superior to succinylcholine for RSI. I think what annoys me the most about this debate is that the "roc rules" crowd seems to primarily rest their opinion on the fact that "if you can't intubate, sux doesn't wear off fast enough to prevent severe hypoxemia anyway", which of course is true, but is totally a red herring argument because no one who knows what they are talking about has ever argued that that is a reason to use sux.
> 
> ...



I'm not sure if this is directed at me, but if it is, I really don't have much of a preference between roc and succs.  Like you, I like either for specific situations, but also like you, I only function as a paramedic because my medical director says I can, so I use what I'm given.

If your rant is based on my medical directors explanation to our providers as to why it's not a "big deal" to give a paralytic that lasts for 30-45 minutes as opposed to one that lasts for 3-5 (which was the entire point of contention of our cohort and had nothing to do with side effects), I'll be sure to let him know that "Remi from the internet" says his explanation is dumb and that he should have approached it differently.


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## Carlos Danger (Dec 30, 2015)

FiremanMike said:


> I'm not sure if this is directed at me



It wasn't. If it had been, I would have quoted your post. I was just commenting on a current trend.



FiremanMike said:


> If your rant is based on my medical directors explanation to our providers as to why it's not a "big deal" to give a paralytic that lasts for 30-45 minutes as opposed to one that lasts for 3-5 (which was the entire point of contention of our cohort and had nothing to do with side effects), *I'll be sure to let him know that "Remi from the internet" says his explanation is dumb and that he should have approached it differently.*



This is the second time you've threatened that recently. I would suggest that rather than taking anonymous internet posts personally, you instead look at the overall point and take it for whatever it's worth to you.


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## FiremanMike (Dec 30, 2015)

Remi said:


> It wasn't. If it had been, I would have quoted your post. I was just commenting on a current trend.



Fair enough



> This is the second time you've threatened that recently. I would suggest that rather than taking anonymous internet posts personally, you instead look at the overall point and take it for whatever it's worth to you.



I would suggest you do the same?  

Look Remi, you likely have a good amount of experience and points to share to help grow our knowledge base.  Unfortunately, the vast majority of your message is lost because you aggressively assert a "my opinion is the only right one and if you don't agree, you're a bad provider" tone.  This tends to intimidate newer folks and cause them to not want to ask questions to get clarification on things that you are saying that is likely over their head, and it tends to turn off experienced guys like myself who deal with exhausting attitudes like yours at work and don't feel like continuing it on an internet forum.  I certainly hope this attitude doesn't follow you into your professional life, as I find people like that to be dangerous.

I'm not pompous enough to think that my tip will change your posting style around here, but I do hope that I can plant a seed to eventually quell your abrasiveness so that we can all learn from each other. 

On a final note, as for my "threat" of invoking the almighty "Remi from the internet" during my workday, they're jokes meant to lighten the mood.


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## STXmedic (Dec 30, 2015)

Not contributing anything to the topic, but

1) Remi, I really enjoy reading your posts. I don't always agree with what you say, but much of what you post stimulates my urge to research something- much in the same way Veneficus used to.

2) OP, are you still working in S. Texas? If so, which service is trying to add RSI?

Otherwise, I'll echo what others have said. Implementing RSI involves far more than a PowerPoint lecture and flexible protocols. My department implemented it on a small scale (about 20 medics) about a year ago. We had a week of lecture from several different physicians, have monthly lectures from our associate medical directors, and quarterly skills verification. That has felt like just barely enough.


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## gotbeerz001 (Dec 30, 2015)

Hi @STXmedic


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## STXmedic (Dec 30, 2015)

gotshirtz001 said:


> Hi @STXmedic


Missed you too, @gotshirtz001


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## Carlos Danger (Dec 30, 2015)

@STXmedic, I appreciate that. I think the quality of discussion on here is really good also, and I learn new things here all the time.

@FiremanMike, I'm not sure what it was about my comments in this thread that so offended you - I was just participating in the discussion on RSI protocols. I didn't even disagree with anyone. I don't know why my opinion would be less valid than anyone else's. And I don't know what to tell you about the "tone" of my posts.


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## TXmed (Dec 31, 2015)

CANMAN said:


> TXmed, while I agree that focusing on oxygenation is extremely important, and ideally you want to start with the best numbers possible, sometimes clinically that just isn't possible. There are times where intubations occur with less then ideal sats or blood pressure because that is the best you can achieve given what is going on. To say we aren't going to proceed with intubation for a person who might be a trauma patient with a blood pressure of 80 systolic, or stop mid attempt is kinda silly in my opinion. Those number's are certainly going to guide my drug choices, or things we do in the preparation phase such as hyper elevating a morbidly obese person with crappy sats, but they aren't always going to prevent me from pulling the trigger on RSI if that's the best we have seen after some techniques which fail to improve the situation.



I understand and agree with you to an extent you also have to understand why you are choosing to RSI. Is it V/Q mismatch ? Airway protection? There are many scenarios. You can't continue down that road just to get the tube. If you have that trauma patient with a systolic below 90 refractory to fluid bolus why continue jackin around with the airway ?, place a king tube to assist in airway protection and move on. In the pre-hospital setting Intubation is more of a protective measure than a treatment.


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## CANMAN (Dec 31, 2015)

TXmed said:


> I understand and agree with you to an extent you also have to understand why you are choosing to RSI. Is it V/Q mismatch ? Airway protection? There are many scenarios. You can't continue down that road just to get the tube. If you have that trauma patient with a systolic below 90 refractory to fluid bolus why continue jackin around with the airway ?, place a king tube to assist in airway protection and move on. In the pre-hospital setting Intubation is more of a protective measure than a treatment.


 
Are you suggesting giving RSI drugs and placing a King Airway in those scenarios, or are you saying just placing a King Airway if the patient has more then one thing going on to manage? Under my protocols at work we place our King's with a laryngoscope to aid with tongue displacement and proper positioning. That being said there isn't a significant time difference in my system between time to ETT placement or King. Airway still comes before circulation in my book, and I can also work on more thing at once time using my partner and delegation. In the setting of a trauma or medical patient who needs an airway and remains hypotensive I will pick other drugs for the intubation/or king placement, and then proceed on to treat the hypotension with additional fluid, blood, vasopressors, whatever the situation might dictate, however just because the patient needs multiple interventions doesn't mean I am going to drop a King, if an ETT is predicted to be easy placement and will not result in additional delay. To be fair I am also working with a RN partner for all missions, so protocols and approach are different then if I were in a field 911 unit as a solo provider. If that were the case I could certainly get on board with your suggestion.

This topic has gotten a little off track, and we haven't heard alot back from the OP.


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## FiremanMike (Dec 31, 2015)

TXmed said:


> I understand and agree with you to an extent you also have to understand why you are choosing to RSI. Is it V/Q mismatch ? Airway protection? There are many scenarios. You can't continue down that road just to get the tube. If you have that trauma patient with a systolic below 90 refractory to fluid bolus why continue jackin around with the airway ?, place a king tube to assist in airway protection and move on. In the pre-hospital setting Intubation is more of a protective measure than a treatment.



I don't necessarily agree with this line of thinking.  An obtunded trauma patient who is showing signs of decompensation should have aggressive airway management, with preference going to a secured ETT over a king airway.  Now, if you're saying that you should be ready to move to the king in the event of a failed airway, I would agree, but I'd also say you should be ready to do that no matter what the circumstances.

@Remi - I've said what needed said, brother.  If you don't see your tone, then I don't know what else to tell you.  I'll concede that I should have done so in a private message instead of out in public.  You and I are after the same thing here, which is to help the community learn and grow.


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## TXmed (Dec 31, 2015)

Sorry let me clarify. If you go in for the attempt and have yet to get to a point where you advance the tube then just stick the king. Obviously if you see the cords just stick the ET tube in. But the point I'm trying to make is people will brag about being successful on the first attempt but they didn't keep the patient oxygenated and delayed other treatment/transport for a procedure that is a protective measure. 

Great thing using a larygescope to place the king.


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## medicaltransient (Dec 31, 2015)

Thanks for the input and thanks for your positive attitude Remi. We do have stats but I am a street medic and I don't deal with those things. Our coverage area is a 2 county area almost 3000 square miles and we do not have an ER. Also we do not have a helicopter in our coverage area. We use helicopters about half the time we need it due to availability and logistics. Our country does not have a lot of money so vents are definitely out. I've been really busy lately so I will answer more questions later. Thanks again.


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## FiremanMike (Dec 31, 2015)

TXmed said:


> Sorry let me clarify. If you go in for the attempt and have yet to get to a point where you advance the tube then just stick the king. Obviously if you see the cords just stick the ET tube in. But the point I'm trying to make is people will brag about being successful on the first attempt but they didn't keep the patient oxygenated and delayed other treatment/transport for a procedure that is a protective measure.
> 
> Great thing using a larygescope to place the king.



I don't delay transport for intubation, I do it en route, and I keep a high flow cannula on during the peri intubation phase.


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## Carlos Danger (Dec 31, 2015)

medicaltransient said:


> Thanks for the input and thanks for your positive attitude Remi. We do have stats but I am a street medic and I don't deal with those things. Our coverage area is a 2 county area almost 3000 square miles and we do not have an ER. Also we do not have a helicopter in our coverage area. We use helicopters about half the time we need it due to availability and logistics. Our country does not have a lot of money so vents are definitely out. I've been really busy lately so I will answer more questions later. Thanks again.



Im sorry, but by your description, I just don't think it sounds like you guys have the resources to have a good RSI program. 

The didactic aspect is easy - there are tons of resources online. The specific protocol is not important, either. Probably the best single resource is Manual of Emergency Airway Management by Ron Walls. 

What matters is that you are able to provide good, frequent hands-on training and close monitoring of performance and related patient outcomes. In order to do that, I think at a minimum you need close medical director involvement, training done by someone with a lot of experience, and access to both an OR and simulator for frequent practice.


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## Doczilla (Dec 31, 2015)

If I can sidebar: 

Why are people using ketamine for induction but not for maintenence sedation? Ketamine is excellent for that also (well, it's excellent for pretty much everything).


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## TXmed (Dec 31, 2015)

I use it alot for maintenance. Works great with propofol, I can give a big dose before movement and if you push it slow it doesn't have a great effect on the respiratory drive which I think will lead to the patient being extubated sooner.


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## Doczilla (Dec 31, 2015)

I see a lot of versed/Fenanyl  protocols, that seems pretty popular. I'm just not sold on it, because the old mantra "anesthesia AND analgesia" isn't being met. Versed simply isn't an anesthetic (at least not at the pitiful doses it's given at). 

Ketamine does both in one drug; with the caveat of having to add a small dose of a benzo, which is no big deal. I used to keep people down for hours with a ketamine/versed/vecuronium infusion for hours. Simple, easy, and resource-saving. 

Then again, maybe we're just easing into it as a culture still. When I got out and started preaching about ketamine to people in 2013, having used it for a variety of things (PSA for chest tubes and fracture reductions, induction/maintenence, dental work, etc) people looked at me like I was crazy. It's only recently started to catch on it seems.


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## chaz90 (Dec 31, 2015)

We've been trying desperately to get Ketamine added to our protocols here in Delaware. So far the state and county medical directors haven't bit. We continue to utilize Versed, Fentanyl, and vecuronium as our only options for post RSI sedation and paralysis. I think the fact that we haven't really reported any problems as a system with that combo is making our MDs reluctant to "fix" what they see as not being broken in the first place. I'd love to have Ketamine as an option for procedural sedation, chemical restraint, and RSI, but we just haven't quite managed to pull the trigger.


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## STXmedic (Dec 31, 2015)

In reference to doczilla's last post:

I've read that adding benzos is great for staving off emergence reaction, but is there another reason to add versed to ketamine during post-intubation sedation? 

We have the option for either ketamine or fent/versed for maintenance sedation, but they aren't too keen on us adding versed to ketamine in the absence of agitation.


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## Doczilla (Dec 31, 2015)

STXmedic said:


> In reference to doczilla's last post:
> 
> I've read that adding benzos is great for staving off emergence reaction, but is there another reason to add versed to ketamine during post-intubation sedation?
> 
> We have the option for either ketamine or fent/versed for maintenance sedation, but they aren't too keen on us adding versed to ketamine in the absence of agitation.



In theory, no; if you're infusing enough ketamine they shouldn't break the k-hole. However, while I was searching for just the right "cocktail" after running out of narcs one night in what basically was the EMS equivalent of an MCI, every cocktail involving ketamine also had versed involved. I chose the 10vec/10versed/100 ketamine in a 500 bag at 30ml/hr, which worked fine. No spikes in the waveform, or vital sign fluctuations (well, outside of teetering through various stages of shock).

It was probably recommended as a safeguard in case they momentarily started to come down from dreaming in algebra, due to the fact that they were still paralyzed and we would be none the wiser.

Mind you the addition of versed is also helpful for severe TBI's, and while benzos aren't recommended for seizure prophylaxis, it's nice to have some GABA action if you RSI one of em. In fact, the GABA action is the very reason they add propofol to ketamine infusions; so think of versed as propofol's distant, ugly cousin. 

Unfortunately, I didn't have access to an I.V pump, so propofol was off the table. Shame, because propofol Is very cerebroprotective.


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## STXmedic (Dec 31, 2015)

Doczilla said:


> In theory, no; if you're infusing enough ketamine they shouldn't break the k-hole. However, while I was searching for just the right "cocktail" after running out of narcs one night in what basically was the EMS equivalent of an MCI, every cocktail involving ketamine also had versed involved. I chose the 10vec/10versed/100 ketamine in a 500 bag at 30ml/hr, which worked fine. No spikes in the waveform, or vital sign fluctuations (well, outside of teetering through various stages of shock).
> 
> It was probably recommended as a safeguard in case they momentarily started to come down from dreaming in algebra, due to the fact that they were still paralyzed and we would be none the wiser.
> 
> ...


Thanks for that. I'll have to look up the role of versed in TBIs (though I would assume it has to do with seizure prophylaxis and cerebral hypoxia)


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## Doczilla (Dec 31, 2015)

STXmedic said:


> Thanks for that. I'll have to look up the role of versed in TBIs (though I would assume it has to do with seizure prophylaxis and cerebral hypoxia)



Well, it's just that if you RSI a herniating or seizing TBI, you still have to terminate the seizure on the cellular level. Paralyzing them doesn't really help much, (aside from preventing spikes in ICP and rhabdo) cause theyll go brain dead after about 7 minutes of continuous seizure activity. 

That's why I mentioned the GABA action being a plus; it's not really "on-label" for prophylactic reasons, but seeing as how that's kind of a blanket cocktail, every little bit helps in situations like that.


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## Merck (Dec 31, 2015)

Do you guys have AIME education in the states?  Might just be Canadian:

http://aimeairway.ca/

Anyway, all of our practitioners go through it, one for ALS and one for BLS.  Teaches principles, not protocols generally.  I'm not associated with them in any way, and have my own critiques of the program, but it is a good approach.

On the original topic, I firmly believe that RSI for paramedics has to be handled cautiously.  Our ALS medics (ACPs here) do not RSI, and there are arguments both for and against that.  When I was one I certainly had more 'against' arguments in an attempt to support my desire to have the skill available.  However, with more training and education I have to say I'm not sure.  People treat RSI like some sort of prehospital holy grail.  It's not the RSI that's important, as has been mentioned in other posts, but rather everything around it.  What are the right drugs?  Depends.  What is the right paralytic?  Depends.  If people give you a strict dogmatic answer to those, then they need to reflect on their own practice.

Our critical care program addresses anesthesia, not intubation.  Otherwise it's like focusing on starting an IV rather than learning to run a cardiac arrest.  Planning, executing, and maintaining someone on sedation/paralysis has to be well-considered and pt-specific.  I think we always have to be aware of stating absolutes.  I only say this because I was sure I was doing the right things eight years ago on the street as ALS.  Now I think, "man, I was an idiot".

Briefly, on the above, midazolam is an acceptable sedation tool following intubation, but maybe not the best.  Pre-hospital - don't sweat the emergence reaction.  Are you planning on waking them up?  Not really.  My concern with polypharmacy is always hypotension.  In a TBI people often give a lot of drugs because of the delay in onset.  Do people really wait for the onset of a drug before giving more?  I've seen people give lots of drug in an attempt to bring about rapid unconsciousness only to have a whole lot of no blood pressure ten minutes later. 

Last note, yep, propofol is awesome, but I'm not sure I can agree with "very cerebroprotective".


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## Doczilla (Dec 31, 2015)

Merck said:


> Do you guys have AIME education in the states?  Might just be Canadian:
> 
> http://aimeairway.ca/
> 
> ...



Greetings from the US, bud. Cheers! Thanks for the insight!

Can you share your thoughts on propofol? Why don't you feel that it's "very" cerebroprotective?

Also, I don't think versed should ever be in mass quantities, especially in the anesthesia topic. I think there's a reason that it isn't commonly used for induction anymore, because the dose you need is outright rediculous. 

I feel that using versed in this case is proactive, not reactive. The only caveat to that is if you actually witness a seizure (talking about head injuries here) and you're forced to RSI. It's still a consideration. 

I believe that the combination of versed and ketamine is far less likely to cause hypotension than versed and fentanyl.


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## Carlos Danger (Dec 31, 2015)

Ketamine is a great drug because of its impressive versatility. However, as with any "jack of all trades", while it may be _good_ at pretty much everything, it's probably not _the best _choice in most scenarios. It's a great tool to have in the box but it's rarely the first thing I reach for, unless I'm intubating someone in the early stages of hemodynamic instability or volume depletion. Or doing a deep sedation with someone whose airway I'm concerned about.



Doczilla said:


> I see a lot of versed/Fenanyl  protocols, that seems pretty popular. I'm just not sold on it, because the old mantra "anesthesia AND analgesia" isn't being met. Versed simply isn't an anesthetic (at least not at the pitiful doses it's given at).



Versed and fentanyl is actually a great combo - probably the best, in fact - at least in the very early phases where hemodynamics may be an issue and you aren't yet thinking about extubation. You don't need a general anesthetic depth of anesthesia to keep an intubated patient comfortable. A few mg's an hour of versed plus a hundred or so mcg's of fentanyl will often do a nice job. More during transport of course, because of the greater sensory stimulus.



Doczilla said:


> Mind you the addition of versed is also helpful for severe TBI's, and while benzos aren't recommended for seizure prophylaxis, it's nice to have some GABA action if you RSI one of em. *In fact, the GABA action is the very reason they add propofol to ketamine infusions*; so think of versed as propofol's distant, ugly cousin.



Actually, it is the other way around. Ketamine is sometimes added to propofol so that less propofol can be used to achieve a given level of sedation. And ketamine actually does agonize GABA receptors on its own (as well as opioid, serotonin, and adrenergic ones).

One of the reasons ketamine is still controversial as a routine induction agent is because of it's pro-seizure properties. It's probably not a good choice in someone at high risk for seizures (SAH), and I'm not sure a few mg's of versed would have much impact on that risk. The last I knew (it's been a while since I looked at the guidelines), the Brain Trauma Foundation still recommended propofol for sedation of TBI patients because of its ability to maintain CBF in relatively low-flow states, but acknowledges that there is really no research showing that it leads to superior outcomes as compared to the other drugs that are commonly used for that purpose.


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## Carlos Danger (Dec 31, 2015)

Merck said:


> On the original topic, I firmly believe that RSI for paramedics has to be handled cautiously.  Our ALS medics (ACPs here) do not RSI, and there are arguments both for and against that.  When I was one I certainly had more 'against' arguments in an attempt to support my desire to have the skill available.  However, with more training and education I have to say I'm not sure.  People treat RSI like some sort of prehospital holy grail.  It's not the RSI that's important, as has been mentioned in other posts, but rather everything around it.  What are the right drugs?  Depends.  What is the right paralytic?  Depends.  If people give you a strict dogmatic answer to those, then they need to reflect on their own practice.
> 
> Our critical care program addresses anesthesia, not intubation.  Otherwise it's like focusing on starting an IV rather than learning to run a cardiac arrest.  Planning, executing, and maintaining someone on sedation/paralysis has to be well-considered and pt-specific.  I think we always have to be aware of stating absolutes.  *I only say this because I was sure I was doing the right things eight years ago on the street as ALS.  Now I think, "man, I was an idiot".*



Great points. The more you learn, the more you realize you don't know anything.


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## Merck (Dec 31, 2015)

Doczilla said:


> Greetings from the US, bud. Cheers! Thanks for the insight!
> 
> Can you share your thoughts on propofol? Why don't you feel that it's "very" cerebroprotective?
> 
> ...



Hiya,

I only question the effectiveness of propofol because my admittedly brief research shows the claims are made primarily using animal (murine) models.  Not great evidence.  My other concern there is that, well, you know how it goes, all of a sudden - "have to use propofol, it's neuroprotective!" happens with a pressure in a TBI of 91/50.

I agree that versed/ketamine is better than versed/opioid, but even there at least fentanyl is a good choice.  Ketamine is good for continued sedation, I've just anecdotally had a harder time getting a stable RASS in the short-term.

As well, no question that benzos are 1st line for seizure.  Considering a seizure 'treated' because a pt is roc'd would get you strung up around here.

Oh, and Happy New Year all.


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## Doczilla (Dec 31, 2015)

Remi said:


> Ketamine is a great drug because of its impressive versatility. However, as with any "jack of all trades", while it may be _good_ at pretty much everything, it's probably not _the best _choice in most scenarios. It's a great tool to have in the box but it's rarely the first thing I reach for, unless I'm intubating someone in the early stages of hemodynamic instability or volume depletion. Or doing a deep sedation with someone whose airway I'm concerned about.
> 
> 
> 
> ...



Interesting. I knew that ketamine has actions beyond NMDA agonism, but none of what I've read was concrete enough to try to share here to be fair though, i havent looked in a while. Can you share where you found that please ? It seems kind of counterintuitive that ketamine would have GABA action, while still being pro-seizure. I wonder what the proposed mechanism behind a medicine that allegedly supresses neuronal transmission through GABA, while also predisposing you to seizures is.

On the topic of "Ketafol", ketamine is mixed with propofol because propofol has zero analgesic properties whatsoever--- and therefore, no meeting the "two A's" that you need.

The amount of propofol needed for its cerebroprotective effects (again, GABA), is likely still under the threshold that would cause hypotension in TBI patients, (as opposed to barbiturates and sodium channel blockers), which is probably why it's reccomended.

I don't think there is a "one size fits all" drug, and I also don't believe that infusing 10mg of versed (for maintenance) will cut it when it comes to seizures. I just suggested that it may be favorable given the situation.

Sorry for the late response, working tonight.


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## Doczilla (Dec 31, 2015)

Merck said:


> Hiya,
> 
> I only question the effectiveness of propofol because my admittedly brief research shows the claims are made primarily using animal (murine) models.  Not great evidence.  My other concern there is that, well, you know how it goes, all of a sudden - "have to use propofol, it's neuroprotective!" happens with a pressure in a TBI of 91/50.
> 
> ...



I suppose it depends on how the propofol is initiated, (example: 40mg bonuses titrate to coma, versus a straight IV in fusion of mcg/kg/min).


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## TXmed (Dec 31, 2015)

Speaking on sedation. I am lucky enough to use a fairly sophisticated ventilator. And I see that if I focus on proper vent settings then I can use alot less sedation, as it is more comfortable for the patient.


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## Doczilla (Dec 31, 2015)

One more thing, (since it's not letting me edit), I'm a huge fan of combining benzos and opiates. You use less of each, they're synergistic, and overall safer as opposed to snowing someone with either one alone. 

Ive talked to people who have been "kept down" with versed and fentanyl, and between their personal testimony and my gut as a provider, I just don't feel like it's enough to attenuate the traumatic experience of having a tube jammed down your throat for any intermediate or extended period of time.


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## Merck (Dec 31, 2015)

+1 for the vent.  You can mitigate the need for drugs with a little bit of care for your strategy.


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## RocketMedic (Jan 1, 2016)

Medicaltransient, let me be blunt. You and your system are not ready for RSI. You lack the funds, it sounds like you lack the intellectual and informational support and you lack the really relevant material support and the realistic prospect of gaining those.


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## SeeNoMore (Jan 1, 2016)

OP I think it's great you took the initiative at work , and to look for some insight from this community. Perhaps you can speak to your medical director and find out whether some of the concerns raised here can be addressed? It may not be a reality to purchase specific equipment (like vents), but at a minimum you certainly need a robust and organized approach to implementing RSI that is far beyond the scope of hosting a class by a provider who is fairly inexperienced in airway management. That's not meant to offend you in any way or demean your practice, I am only saying it because of the small number of RSIs you have performed. Best,


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## TXmed (Jan 1, 2016)

Just because your not ready today doesn't mean you'll never be ready. That's what education is for. I encourage you to keep working towards it. The majority of RSI systems in Texas don't have all the resources named here but they find different ways to make it work. 

Also if you're gonna use AEL protocols you can ask them for help with education. They will be more than happy to come out to your service and assist you with this.


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## Carlos Danger (Jan 1, 2016)

Doczilla said:


> Interesting. I knew that ketamine has actions beyond NMDA agonism, but none of what I've read was concrete enough to try to share here to be fair though, i havent looked in a while. Can you share where you found that please?



Ketamine does not bind to GABAa receptors, but enhances GABA transmission indirectly via the glutamate-GABA interaction. The thing to understand about ketamine is that it is not a "clean" drug - it has very complex effects on virtually all of the major CNS neurotransmitter pathways, as well as peripherally. This is touched on in both Miller's Anesthesia and Stoelting's Pharmacology & Physiology in Anesthetic Practice, and explained in more depth in one of the big pharm texts (Evers Anesthetic Pharmacology, I think?).



Doczilla said:


> On the topic of "Ketafol", ketamine is mixed with propofol because propofol has zero analgesic properties whatsoever--- and therefore, no meeting the "two A's" that you need.



Well yeah, for a painful procedure, propofol alone isn't ideal. What I disagreed with before was your statement that "the GABA action is the very reason they add propofol to ketamine infusions".

In anesthesia, ketafol could be used for all types of things, but is typically used alone for brief, relatively painless procedures like colonoscopies, or in conjunction with a local anesthetic for small painful procedures like a a carpal tunnel release, or with a nerve block for something bigger like a distal radius ORIF. In these case, because you have good local anesthesia, you don't really need a lot of IV analgesia (if any), and in fact propofol is very commonly used all by itself for these things. So when ketamine is added, it isn't usually being used for it's analgesic effects per se, but more for its propofol-sparing effect. Meaning that propofol depresses pharyngeal tone, which is fairly easily managed in most patients, but in some can result in difficulty maintaining a patent airway. Opioids would just worsen the airway problem, so you add some ketamine to your prop (or just bolus the ketamine separately, which is what I prefer to do - I really don't see the point in mixing them), and then you can reach a given level of sedation with less total dose of propofol and correspondingly less pharyngeal relaxation.




Doczilla said:


> Ive talked to people who have been "kept down" with versed and fentanyl, and between their personal testimony and my gut as a provider, *I just don't feel like it's enough* to attenuate the traumatic experience of having a tube jammed down your throat for any intermediate or extended period of time.



Oh, it it definitely enough. Providing an adequate dose is being used, of course.

If you can do major surgery under just versed/fentanyl anesthesia - and you certainly could - you can definitely maintain comfort during mechanical ventilation with the same drugs.


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## Doczilla (Jan 1, 2016)

Remi said:


> Ketamine does not bind to GABAa receptors, but enhances GABA transmission indirectly via the glutamate-GABA interaction. The thing to understand about ketamine is that it is not a "clean" drug - it has very complex effects on virtually all of the major CNS neurotransmitter pathways, as well as peripherally. This is touched on in both Miller's Anesthesia and Stoelting's Pharmacology & Physiology in Anesthetic Practice, and explained in more depth in one of the big pharm texts (Evers Anesthetic Pharmacology, I think?).
> 
> 
> 
> ...



Well, I use the term "mix" very loosely; I meant given simultaneously. I don't think I've ever seen propofol directly mixed with anything actually.

I also realize that ketamine is a complex beast--- too complex in fact, to go in depth about here (especially since I've started this sidebar). The point I wanted our colleagues to glean here is that adding some type of GABA agonist to ketamine is benificial (but not required in some cases), and isn't crystallized into the "emergence phenomenon prophylaxis".

In the case of RSI, and the subsequent maintenance sedation, I'm a firm believer that considering the other options that the prehospital realm has, ketamine has the most utility.


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## Carlos Danger (Jan 1, 2016)

Doczilla said:


> Well, I use the term "mix" very loosely; I meant given simultaneously. I don't think I've ever seen propofol directly mixed with anything actually.



Yep, many people like to actually mix the ketamine into their syringe of propofol, that's where the term "ketafol" came from. I think it's easier to just give a bolus of ketamine and then start your propofol at half the dose that you would if you were using it alone.


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## Doczilla (Jan 1, 2016)

Remi said:


> Yep, many people like to actually mix the ketamine into their syringe of propofol, that's where the term "ketafol" came from. I think it's easier to just give a bolus of ketamine and then start your propofol at half the dose that you would if you were using it alone.



Yeah, I don't think I would ever use a mixed dose personally. I value ketamine for it's dissociative effects (and long-term analgesia following the anesthesia phase), and it would probably be difficult to determine if they're fully disassociated if you're bolusing the propofol at the same time. 

The infusion afterwards, sure.


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## medicaltransient (Jan 3, 2016)

Thanks for the input, I definitely learned a lot from the dialogue and I know I have some work cut out for me. You guys made a lot of good points that I will explore. The pharmacology I will be getting from the Hospira website and I will be using the Manual of Emergency Airway Management by Ron Walls for the rest. I have no word on the practical portion yet and I suggested getting a new more involved medical director eventually and it was not received well. We don't have much money but we do have a problem working airways for long periods of time so hopefully the program is a success.


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## medicaltransient (Jan 3, 2016)

Do you guys use RASS score regularly? Anyone have problems with it?


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## FiremanMike (Jan 3, 2016)

Our transport time is 5-10 minutes at the most and before we used Roc, we would follow up our tube confirmation with Vec, in both cases we'd use a good amount of fent and versed.  Short answer, no, we do not use RASS score.

IMHO (and I'm sure some will disagree), RASS is more appropriate for longer IFT transports of somewhat stabilized patients and not the emergent patients that we have RSI'd because they were really sick.


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## Doczilla (Jan 3, 2016)

FiremanMike said:


> Our transport time is 5-10 minutes at the most and before we used Roc, we would follow up our tube confirmation with Vec, in both cases we'd use a good amount of fent and versed.  Short answer, no, we do not use RASS score.
> 
> IMHO (and I'm sure some will disagree), RASS is more appropriate for longer IFT transports of somewhat stabilized patients and not the emergent patients that we have RSI'd because they were really sick.



Yeah, especially since you're likely being, as you said, generous with the drugs to keep em down. I think the RASS is more to see if the long term stuff is adequate.


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## Carlos Danger (Jan 3, 2016)

The RASS is intended for the ICU, where you are trying to use as little sedation as possible while still keeping the patient comfortable, because you are hoping to extubate as soon as possible and are trying to minimize delirium. Not a good tool for field use, I don't think.


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## Doczilla (Jan 3, 2016)

I mean look at the components of the score also. Not useful if they're paralyzed.


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## medicaltransient (Jan 3, 2016)

I don't think AEL parallelizes everyone they RSI. No it's not intended for the paralyzed pt.


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## RocketMedic (Jan 3, 2016)

This entire venture seems to be steeped in failure. Medicaltransient, what area are you discussing here? To be honest, it sounds like you're trying to justify what's already being done, and it sounds sketchy as heck.


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## medicaltransient (Jan 4, 2016)

RocketMedic said:


> This entire venture seems to be steeped in failure. Medicaltransient, what area are you discussing here? To be honest, it sounds like you're trying to justify what's already being done, and it sounds sketchy as heck.


Thanks for your encouragement RocketMedic and I will cease the project immediately.


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## medicaltransient (Jan 4, 2016)

How do you guys prepare and administer Ketamine?


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## EMSComeLately (Jan 4, 2016)

medicaltransient said:


> How do you guys prepare and administer Ketamine?


For us, it's diluted with 9ml NS before ivp.


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## SeeNoMore (Jan 4, 2016)

I'm not sure if people really understand the RASS. In any event OP, if you do go ahead with this without OR time and a doc involved, I'd suggest you all work to support each other.  I'd use scenario training with no hand holding. Make sure people are able to explain why they want to RSI , what med doses  (and draw them up), verbalize a checklist, perform the intubation several times  (different blAdes, video, bougie) and manage the patient afterwards. Go over pre and post RSI hypotension and other management issues. Good luck.


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## TXmed (Jan 4, 2016)

I don't believe OR time is a must for this type of education, RSI has alot more components then just ET success rates.


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## chaz90 (Jan 4, 2016)

TXmed said:


> I don't believe OR time is a must for this type of education, RSI has alot more components then just ET success rates.


I don't think anyone would argue that ETI itself is the only important part of RSI. I think you'd be hard pressed to argue it isn't vital though. The best decision making processes, appropriate medication administration, and pre-oxygenation doesn't mean much if your successful first pass intubation rate is only 50%...


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## TXmed (Jan 4, 2016)

But there are other ways to increase ET success without OR time. VL, bougie, practice on manikens, and some cadaver training. If you can get OR time that is great but Its not a must.


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## chaz90 (Jan 4, 2016)

Real, live (or dead in some cases) intubations on human beings with varying anatomy and physical characteristics matters much more than intubations on Fred the Head. Mannequin practice has its place, but it doesn't replace real intubations or skill competency check off by an expert in the OR. 

As much as the actual act of intubating a few patients an hour in the OR is worth your time, having an anesthesiologist or CRNA who manages airways for a living critique your technique is invaluable. I'd go so far as to say that if your program doesn't have access to an OR for initial skills verification and retesting/practice as needed, you shouldn't establish a RSI program. One of the scariest things about some paramedics having access to RSI is the prospect of people who may not have intubated a real patient in two or three years pulling the trigger on an RSI and realizing they're over their head when it comes to a live patient.


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## TXmed (Jan 4, 2016)

Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI


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## jwk (Jan 4, 2016)

TXmed said:


> Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI


Intubating the same mannequin 50 times does absolutely nothing to teach you about varying airway anatomy.  Getting one-on-one training on real patients in the OR from someone with expertise is invaluable.  Mannequins are a poor substitute.  I've been involved with EMS airway training off and on for years - invariably, the medics and students I've had in the OR would agree there is no comparison.


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## TXmed (Jan 4, 2016)

I'm not saying OR time isn't great to have. But in my opinion it is not a must have for a successful education program.


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## CANMAN (Jan 4, 2016)

TXmed said:


> Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI



You're missing the point. Intubating Fred the Head will develop the same technique and the same muscle memory each and every time is what we are saying. Obviously in real life every airways isn't the same, so why would you train that way? There is also a lot more to benefit from OR time then just sinking a tube. I guarantee if you went to an OR regularly your technique would improve 10 fold and you will realize that your technique probably wasn't that great to start with.... I certainly did, and I felt like I was fairly strong in airway management when I first started hitting the OR compared to some of my coworkers in both knowledge, number of live intubations, etc.

12 intubations a year to maintain a 90% success rate, where you are still missing 10% of your tubes. Most field medics now a days are lucky to get half of that. RSI service or not. Dedicated OR time for an RSI program is an invaluable resource.


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## Carlos Danger (Jan 4, 2016)

I can see both sides of this.

On one hand, I think the only way to get REALLY good at something is to do it frequently for a long period of time, under different conditions and with different challenges. And the only place you can reliably practice airway management multiple times a day, on any day, is the OR. Manikins are good for practicing the gross procedure of intubation and the entire sequence of doing an RSI - and that stuff is important - but they simply aren't realistic enough to provide the type of practice you get on real patients. In the OR you can drop LMA after LMA and ET tube after ET tube in patients of all shapes, sizes, and ages. You can see how different drugs and combinations of drugs and dosages effect the patient. You can practice different ways of positioning. Masking a fat face is different from a skinny face, and someone with teeth is different than someone without. You just can't replicate masking a bearded 350#er with sleep apnea or intubating a 70 year old diabetic with a stiff, brittle cervical spine.

On the other hand though......while I think there are a lot of glaring weaknesses in prehospital airway management and I do not think RSI should be a standard paramedic skill, the fact is that success rates for intubation are actually really high with prehospital RSI, and I don't know that the amount of time paramedics spend in the OR has ever been shown to have much bearing on that. Most paramedics who do go to the OR only go once or twice a year and might get a handful of tubes each time. But that's not nearly enough time to develop the type of skill and comfort level with airway _management_ (not just airway intubation) that I think we would ideally have if we are going to be paralyzing sick people out in the field with little or no backup.

So I think OR practice is critically important in order to learn how to be a really skilled and confident all-around airway manager. But when it just comes to pushing some sux (or roc ) and then dropping a tube, I honestly don't know that it really matters that much.


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## RocketMedic (Jan 5, 2016)

"Waaaaa I wanna RSI people on an organizational level despite lacking literally all of the prerequisite support for it!"


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## Tigger (Jan 5, 2016)

TXmed said:


> Manikins are important for developing technique and muscle memory. If it was required to have OR time as a skills check off then 90% of the programs in Texas wouldn't have RSI


So how do you decide someone is competent then? Most of the skills that EMS provides are practiced in a clinical setting prior to the provider being cut loose. While there are some exceptions (crichs among others), this is an elective procedure. There is no excuse not to test for competency and that is done on live patients in a controlled setting.


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## RocketMedic (Jan 5, 2016)

Do you even have an organizational culture that would take the training seriously?


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## medicaltransient (Jan 5, 2016)

There will be a test for competency and not every one will be clear to do RSI. We have a great bunch of guys and most of us are older guys. Thanks again for the input.


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## medicaltransient (Jan 5, 2016)

RocketMedic said:


> "Waaaaa I wanna RSI people on an organizational level despite lacking literally all of the prerequisite support for it!"


RocketMedic; you are so immature. If you worked at my service you would not be clear to RSI just based off your attitude.


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## RocketMedic (Jan 6, 2016)

medicaltransient said:


> RocketMedic; you are so immature. If you worked at my service you would not be clear to RSI just based off your attitude.



I like how he's super-vague on where he works, makes claims that the organization can handle it despite multiple levels of obstacles, and then goes on to start putting perceptions of attitude and maturity into the equation when someone gives a blunt opinion. He wants to make a few hours of "training" that will somehow confer good RSI skills. It's a horrible idea. But I'm arrogant and immature for not supporting it...

I'm just throwing this out there, but an ex-Acadian washout medic who couldn't get hired most anywhere as of last year is probably not the fountain of knowledge and instruction that he thinks he is, particularly if he is already trying to incite change in the management of his new agency to allow ventures into dangerous territory. Maybe, just maybe, you should sideline your ego for a bit and look at what you're really trying to do and what it means to your patients.


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## RocketMedic (Jan 6, 2016)

As far as the procedure itself goes, medicaltransient, it seems as if your agency is ignoring most of the long-term implications and challenges posed by RSI to add a few more drugs (if you don't have it already). What numbers are we talking about here? Is there a population that you find yourself intubating frequently that would benefit from RSI? Do you have less invasive alternatives? Is your service going to buy video laryngyscopes and capnography if you don't already have it? Is your service going to reconsider a ventilator? 

As for the personal insults, well, I'd greatly enjoy the chance to work a shift with you, simply in order to crush your pompous little soul into many little pieces. This is a profession where your ego and decisions can literally kill someone, and you don't get a free pass from me when you pull the self-righteous act and namedrop AEL when you're trying to suck up to your boss and get a high-risk, high-acuity cool guy skill authorized for your service without the proper supporting mechanisms. If you want to actually be an agent of positive change, open up, be willing to establish the proper groundwork first, THEN start worrying about training and minutia. 

I'm disappointed that so few other posters have mentioned this. It's really not terribly important as to exactly how the procedure itself is performed when you have someone wanting to boil the whole thing down into an afternoon inservice. It's like trying to put an eighth grader into the NFL.


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## Carlos Danger (Jan 6, 2016)

Look, let's give the OP a bit of a break. I'll give him the benefit of the doubt that this wasn't even necessarily his idea and that this project would simply be given to someone else - perhaps someone even less qualified than him - if he declined to do it.

The reality is there are lots of resource limited services doing stuff like this. There are lots of places doing RSI with little more than an afternoon lecture and a handful of manikin scenarios. We would probably all agree that that is far from ideal and in a perfect world would never happen, but I'm sure we'd also all agree that we don't live in a perfect world.

I have some ideas on how I'd structure this program that I'll outline later on when I have more time.


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## SeeNoMore (Jan 19, 2016)

Rocketmedic , while you make some good points I question your delivery. The OP has been respectful and willing to listen to questions, concerns and criticisms. Frankly, I think you are the one who is coming off as self righteous. Your approach is more likely to shut down conversation than educate. Everyone else was able to voice criticism in a civil manner. 

I don't personally think that Paramedic RSI is a good idea outside of select services with extensive education / training, but the OP can't bear the whole burden of the failures of the US EMS system. Many services RSI who have no business doing so. At least he/she is taking the implementation of an RSI program seriously. I think what is showing here is general lack of experience clouded by enthusiasm.  I hope that the concerns raised in this discussion will be taken seriously and that the medical director(s) will do more than rubber stamp this process.


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## RocketMedic (Jan 20, 2016)

It's mostly because I personally detest him.


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