# MFI/RSI



## starzolife (Feb 16, 2014)

Now I'm a new ALS provider, but I've been part of the procedure as an ER Tech as well as being my OR rotation "final" (the anesthesiologist's makeshift exam on signing off on my rotation). I've never actually seen it done in field even though I rode with RSI providers.  My question is how much is this used per provider? Is it a once in a while thing or is it like a needle cricothyrotomy where you could go a whole career never having to use it?


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## NightShiftMedic (Feb 16, 2014)

Where I'm at we do a lot of the intubations (RSI and otherwise) in the emergency department.  We are authorized to RSI in the field.  It isn't exactly a once in a career procedure, but it doesn't happen very often at all.  I would imagine there are other places (Sussex, DE for example) where it happens much more often.


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## chaz90 (Feb 16, 2014)

Haha, here in Sussex it is fairly frequent. I've been here slightly over a year and have personally performed ~5 RSIs. Some do more, some do less, but I'd say that the average medic does at least two per year. Waayyy more frequent than any kind of cric for sure.


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## NomadicMedic (Feb 16, 2014)

I'd bet, on average, there is an RSI in our system every other day or so. I haven't seen the numbers for last year, however.


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## Tigger (Feb 16, 2014)

I think we had around 30-35 intubations last year between our ten medics. Half of them were arrests, the other half were almost all RSIs, I think we only had one non-RSI that was not on a cardiac arrest last year.


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## triemal04 (Feb 16, 2014)

It's very dependent on where you work, and in what setting.

In some parts of the country it's standard to be part of a paramedic's skillset, in other parts, not so much.  Some departments have the call volume and mindset that means they use it frequently, others not so much.  A non-transporting paramedic will likely not be doing this, while a transporting paramedic would be more likely to.  Completely variable, but if it's within your scope and protocols, I'd say it's something you can expect to be doing multiple times during your career...just maybe not multiple times in a year, depending on several variables.  Not seeing it done during a limited internship doesn't really mean anything.

This ignores the whole arguement about whether or not paramedics should even be intubating in the first place (a big hell no for most paramedics), let alone doing an elective intubation.


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## TransportJockey (Feb 16, 2014)

Here in NM, a normal ground paramedic doesn't do it at all. But flight medics who respond to scene calls do it on a regular basis (it's one reason a rural provider might call for a rotor in this state). So it all depends on where you're talking about.


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## medicsb (Feb 16, 2014)

With an avg of 20 hours a week of work, I used to take part in 4 per year.  Full-timers would typically take part in 4-8.  There would also be a number of ETIs that would be done with etomidate only or with nothing at all if they were comatose enough.


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## Carlos Danger (Feb 16, 2014)

I never did one as a ground paramedic.

Working the helicopter, I probably averaged around 3-4 a month. Some months I'd do more than that, some months only 1 or occasionally, none at all.


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## blindsideflank (Feb 16, 2014)

Drug assisted intubations- 2 a month
Other tubes (mostly arrests) another 2-4

How do you all define RSI?


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## starzolife (Feb 16, 2014)

I define it as having to use sedation and/or paralytics for a patient to accept intubation.  Where I'm from paralytics are now only part of the process if there is still muscle resistance after sedation.


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## chaz90 (Feb 16, 2014)

blindsideflank said:


> Drug assisted intubations- 2 a month
> Other tubes (mostly arrests) another 2-4
> 
> How do you all define RSI?



Are those your individual numbers or system wide? Consider me surprised if one ground medic is intubating that frequently.


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## blindsideflank (Feb 16, 2014)

1 medic. Tiered system in a metro area.

I would like to know the numbers for a paramedic in surrey bc (Canada). I believe they run one ALS car for 500,000 people (that number seems to stick in my head) and once again, is a tiered system.

And I included calls like a stroke/od/sepsis that takes a little versed before a tube.


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## medicsb (Feb 16, 2014)

blindsideflank said:


> How do you all define RSI?



Basically, a combination of medications that includes a paralytic given in order to facilitate intubation.


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## NomadicMedic (Feb 16, 2014)

We actually call it a DFI here. Word is Ketamine is coming, but right now it's a set cocktail of etomidate> sux >versed> vec. We can, with a Doc's okay, perform an etomidate only DFI.


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## Handsome Robb (Feb 17, 2014)

chaz90 said:


> Are those your individual numbers or system wide? Consider me surprised if one ground medic is intubating that frequently.



Depending on the medic since they started allowing us to tube arrests that's an easily obtainable number here. My girlfriend and her partner had 6 working arrests last week. 

We don't RSI here.


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## usalsfyre (Feb 17, 2014)

Usually did 1-2 a month working rural 911 and air and one every other month or so doing CCT.


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## Carlos Danger (Feb 18, 2014)

blindsideflank said:


> How do you all define RSI?



RSI only has 1 definition:

Induction of anesthesia in order to optimize intubating conditions by rapid-sequence (or simultaneous) administration of both a potent sedative and a neuromuscular blocking drug. 

Or something closely along those lines.


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## blindsideflank (Feb 18, 2014)

Halothane said:


> RSI only has 1 definition:
> 
> Induction of anesthesia in order to optimize intubating conditions by rapid-sequence (or simultaneous) administration of both a potent sedative and a neuromuscular blocking drug.
> 
> Or something closely along those lines.



Right, but I think he was asking more about drug assisted intubations than only those with nmba use. (Maybe I'm wrong, sorry if I'm putting words in OP's mouth)

Edit: just read the original post again and I don't know why I felt he didn't strictly mean RSI. In that case, we don't have it and I know guys here that say they have had long careers and have never needed paralytics. But they don't take into account that paralytics generally improve your view by one grade in direct laryngoscopy. (Make your first try your best try).


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## Carlos Danger (Feb 18, 2014)

blindsideflank said:


> Right, but I think he was asking more about drug assisted intubations than only those with nmba use. (Maybe I'm wrong, sorry if I'm putting words in OP's mouth)
> 
> Edit: just read the original post again and I don't know why I felt he didn't strictly mean RSI. In that case, we don't have it and I know guys here that say they have had long careers and have never needed paralytics. But they don't take into account that paralytics generally improve your view by one grade in direct laryngoscopy. (Make your first try your best try).



No I think you were right - in the title he put "MFI/RSI", and I assume MFI = medication facilitated intubation, which would mean any sort of drug to help you out, not necessarily a NMB.

It's just a stupid peeve of mine when people say "RSI" when all they really did is use some sedation and Brutane. It wasn't directed towards you, just at the thought that some people have very different definitions for RSI  

And you are right about paralytics - they make intubating much easier. I've never thought it made much sense to give a large dose of a sedative that causes apnea and blunts airway reflexes but does not guarantee good intubating conditions, yet be afraid of giving a NMB that causes apnea and abolishes airway reflexes, but guarantees optimal intubating conditions.


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## abuan (Feb 19, 2014)

Happens pretty frequently here on Oahu especially in the rural areas.


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## DPM (Feb 23, 2016)

Does anyone know if RSI is allowed anywhere in California?


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## DesertMedic66 (Feb 23, 2016)

DPM said:


> Does anyone know if RSI is allowed anywhere in California?


It is not in the CA paramedic scope (at least none of the proper medications aside from versed and Fentanyl are in the scope). The way around this is with flight crews and CCTs with a RN on board. The RN is able to give the medications and the paramedic is able to intubate.


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## DPM (Feb 23, 2016)

DesertMedic66 said:


> It is not in the CA paramedic scope (at least none of the proper medications aside from versed and Fentanyl are in the scope). The way around this is with flight crews and CCTs with a RN on board. The RN is able to give the medications and the paramedic is able to intubate.



Thanks for the quick answer. I'm having a hard time on my phone, but can you steer me towards an online Cali Scope?


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## DesertMedic66 (Feb 23, 2016)

DPM said:


> Thanks for the quick answer. I'm having a hard time on my phone, but can you steer me towards an online Cali Scope?


This was the only thing I could find right now:
http://www.emsa.ca.gov/media/default/word/ch4_emtp.doc

It looks like San Diego did a trial study in 1996 with RSI and from the trial they decided not to add in RSI to the paramedic protocols.


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## DPM (Feb 23, 2016)

DesertMedic66 said:


> This was the only thing I could find right now:
> http://www.emsa.ca.gov/media/default/word/ch4_emtp.doc
> 
> It looks like San Diego did a trial study in 1996 with RSI and from the trial they decided not to add in RSI to the paramedic protocols.



Thanks! It's a shame about the San Diego trial. From what I can see, it wasn't very well constructed.


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## DesertMedic66 (Feb 23, 2016)

DPM said:


> Thanks! It's a shame about the San Diego trial. From what I can see, it wasn't very well constructed.


It's CA. The only things well constructed are our gun laws and vehicle emission laws


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## Akulahawk (Feb 23, 2016)

DPM said:


> Does anyone know if RSI is allowed anywhere in California?


For Paramedics, the answer is no, not outside a trial and there aren't any currently running RSI trials in California right now that I know of. For nurses, the answer is "it depends." RN/RN flight teams allow for the RN to do RSI and I've seen it also written in CCT-RN protocol. Technically, my job as an ED RN _could_ have me perform the procedure but I'd have to be specifically credentialed for it. I'd be PICC certified before I would be allowed to intubate in my ED.


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## DPM (Feb 23, 2016)

Looking at the Ca Paramedic scope and optional scope, it shows that some agencies are using "Drug Facilitated intubation", which as far as I know is RSI without paralytics.  

Can anyone from the EMT life brain trust give me s good answer as to why? DFI is more dangerous, with higher failure and more likelihood of aspiration etc, so why are they allowing it over RSI?


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## Carlos Danger (Feb 23, 2016)

DPM said:


> Looking at the Ca Paramedic scope and optional scope, it shows that some agencies are using "Drug Facilitated intubation", which as far as I know is RSI without paralytics.
> 
> Can anyone from the EMT life brain trust give me s good answer as to why? DFI is more dangerous, with higher failure and more likelihood of aspiration etc, so why are they allowing it over RSI?



Because the people who make that decision don't know what they are dealing with.

Edit: I'm sure they have their reasons. Certainly there are very good arguments against prehospital RSI. But as you note, there are even stronger arguments against sedation-facilitated intubation.


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## DPM (Feb 23, 2016)

If anyone can help me, I'm trying to find an example of a DAI / DFI / fake-RSI protocol, but I'm having a tough time!


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## chaz90 (Feb 23, 2016)

DPM said:


> If anyone can help me, I'm trying to find an example of a DAI / DFI / fake-RSI protocol, but I'm having a tough time!


Our statewide protocols used to give an option for sedation only intubation for agencies not utilizing paralytics. I don't know for sure, but I believe it specified 0.3 mg/kg Etomidate. It's garbage, and I never used it. Our most recent protocol update seems to have eliminated that verbiage completely.


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## nater (Feb 23, 2016)

The urban service I rode with in school did not allow RSI, they only have Versed to facilitate intubation. The rural service I started with had RSI protocol and the majority of my intubations were RSI.

In my setting now, we have very open protocols. Most intubations still use our RSI protocol, but with proper ventilator settings, sedation and pain control we don't need to use long term paralytics as often. Having BiPAP available has reduced the need for emergent intubations as well.


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## DPM (Feb 23, 2016)

Can you direct me to their versed facilitated intubation protocol?


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## nater (Feb 23, 2016)

DPM said:


> Can you direct me to their versed facilitated intubation protocol?



It isn't the best: up to 5mg Versed IV for sedation to facilitate endotracheal intubation before or after the procedure. Repeat up to 10 mg before calling for orders for more.

We have been using Ketamine more over the past few years and I have grown to like it. It is also a brochodilator which is great for certain respiratory cases.


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## DPM (Feb 23, 2016)

nater said:


> It isn't the best: up to 5mg Versed IV for sedation to facilitate endotracheal intubation before or after the procedure. Repeat up to 10 mg before calling for orders for more.



Yeah 5mg isn't great at all! What's the name of the service? Trying to see the whole thing laid out if possible.


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## nater (Feb 23, 2016)

They are regional protocols, not available online to link to.


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## DPM (Feb 23, 2016)

Can you name the region at least? Maybe I can call them and find a way to have a look


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## Carlos Danger (Feb 23, 2016)

DPM said:


> Can you name the region at least? Maybe I can call them and find a way to have a look


There's really not much to look at. 

Versed or ketamine --> tube.


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## nater (Feb 23, 2016)

I just copied the protocol. You give versed then intubate.  There is no need to call anyone, and personally I don't think it would be a good one to copy anyway. What more do you need to know?


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## DPM (Feb 23, 2016)

I know someone who is gobsmacked that this is a thing offered at all, he wanted to have a look at the protocol. (Definitely not to copy!)


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## NomadicMedic (Feb 23, 2016)

Savannah apparently has a "sedation facilitated intubation" protocol. It's etomidate -> tube. I haven't seen it, but that's what I hear. 
Sounds like a 100% bad idea.


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## E tank (Feb 23, 2016)

New here. Hi. "RSI" is a casually tossed about term that has taken on many meanings so as to become meaningless.

It is an anesthesia term meaning that acceptable intubating conditions are brought about after a period of pre oxygenation by way of rapid sequential blouses of a hypnotic followed by an adequate dose of muscle relaxant. These conditions are induced in 60 seconds or less and should not be accompanied by positive pressure mask ventilation before laryngoscopy.

Any ongoing administration of any cocktail of sedation prior to hypnosis is not RSI. The point is to maintain native airway reflexes until a very brief period of paralysis and unconsciousness is induced, after which a definitive airway is immediately placed.


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## nater (Feb 23, 2016)

We use protocols based off the Difficult Airway course and book by Dr. Ron Walls.  Here is good primer, but keep in mind it is written for the ICU and our environment has different concerns as well: http://www.medscape.org/viewarticle/443567

For our purposes, RSI always involves sedation and paralysis. If I give report to an ER doc or intensivist, they will expect I followed those guidelines as often as possible. Our preferred agents are etomidate or ketamine with sux or norcuron. Long term paralysis should be avoided if possible. We don't stock it, but can get propofol for most interfacility runs.


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## Chimpie (Feb 25, 2016)

*Moderator's Note: Several posts have been removed. Please keep it on topic and civil. Thanks!*


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## SeeNoMore (Mar 8, 2016)

I do anywhere from 1-2 a month on average between ALS service and flight service. That does not include OR tubes.


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## Bullets (Mar 8, 2016)

Our two county ALS project uses RSI pretty regularly. But its a highly populated high call volume region. One of the few good things about NJ EMS, there are plenty of calls and plenty of opportunity for medics to tube and RSI


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## SixEightWhiskey (Mar 30, 2016)

I work for a non-transporting service, 3 trucks during the day (either 1 or 2 at night depending on staffing), providing ALS tiered/dual-response with BLS for several municipalities (a population of roughly 250,000). Full-time paramedics are expected to have between 20-25 intubations per year (mix of cardiac arrests and RSIs). The annual average for the service as a whole is 300+ intubations overall, and the arrest/RSI numbers are about 50/50.


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## chaz90 (Mar 30, 2016)

SixEightWhiskey said:


> I work for a non-transporting service, 3 trucks during the day (either 1 or 2 at night depending on staffing), providing ALS tiered/dual-response with BLS for several municipalities (a population of roughly 250,000). Full-time paramedics are expected to have between 20-25 intubations per year (mix of cardiac arrests and RSIs). The annual average for the service as a whole is 300+ intubations overall, and the arrest/RSI numbers are about 50/50.



Sounds pretty busy for your number of trucks. You staff one ALS truck for a population of 250k at night? That's impressive.


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## cruiseforever (Mar 30, 2016)

chaz90 said:


> Sounds pretty busy for your number of trucks. You staff one ALS truck for a population of 250k at night? That's impressive.



I was thinking the same thing.  I also wonder about when you have a set number of intubations  to be done.  Is there pressure to RSI someone who may not need to be tubed?  I am pretty conservative when it comes to RSI.  When I work with a newer medic I am amazed at the number they claim they to have done over the year.


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## jcroteau (Apr 5, 2016)

Seems like a pretty aggressive RSI protocol if you're RSI'ing one person for every code you tube.


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## DPM (Apr 7, 2016)

I didn't catch the "one RSI per code" post, but most of my codes get an advanced airway, and it's the tube placement that's the hard part (as opposed to pushing the drugs). 

A lack of technical proficiency, either real or perceived, is what (IMO) prevents any decent advances in airway management for us


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## perimeter (Apr 17, 2016)

DEmedic said:


> Savannah apparently has a "sedation facilitated intubation" protocol. It's etomidate -> tube. I haven't seen it, but that's what I hear.
> Sounds like a 100% bad idea.



Do you have any sources to cite that it's a bad idea?  Any studies that show it isn't as effective or safe as RSI?


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## TXmed (Apr 17, 2016)

perimeter said:


> Do you have any sources to cite that it's a bad idea?  Any studies that show it isn't as effective or safe as RSI?


http://www.ncbi.nlm.nih.gov/pubmed/10102312

medication facilitated intubation will always have complications. what are you protecting by not adding a paralytic?  if we are doing this their airway is not working for them so we need to be all in on taking it. versed and etomidate doesnt always take away the gag reflex, stop vocal cord spasm, or keep the patients airway from tensing up when you put the larygescope in their mouth. plus succs and roc constrict the esophageal sphincter helping in that matter.


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## perimeter (Apr 17, 2016)

Thank you for that.  Any other out there that you know of that cite specifically which drugs were used?


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## TXmed (Apr 17, 2016)

http://www.ncbi.nlm.nih.gov/pubmed/16418085


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## Carlos Danger (Apr 17, 2016)

perimeter said:


> Do you have any sources to cite that it's a bad idea?  Any studies that show it isn't as effective or safe as RSI?



It's such a bad idea that there isn't much research on it.

Can it work? Sure. Is it a good idea? Not at all. The deletion of a NMB adds nothing, but the addition of it reduces the chances of several potentially catastrophic complications.

Edit: there certainly are times that it is desirable to keep the patient breathing throughout the airway management sequence. There are several recipes out there for "awake" fiberoptic intubation, for instance. But this is very different than just giving a massive slug of etomidate and hoping for the best.


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## Tigger (Apr 18, 2016)

TXmed said:


> http://www.ncbi.nlm.nih.gov/pubmed/10102312
> 
> medication facilitated intubation will always have complications. what are you protecting by not adding a paralytic?  if we are doing this their airway is not working for them so we need to be all in on taking it. versed and etomidate doesnt always take away the gag reflex, stop vocal cord spasm, or keep the patients airway from tensing up when you put the larygescope in their mouth. plus succs and roc constrict the esophageal sphincter helping in that matter.


A versed only regimen sounds even worse than an etomidate only...


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