# Rapid Sequence Intubation



## Devilz311 (Mar 29, 2008)

I'm just curious to see what the different RSI protocols for various ALS projects... Medical vs Trauma, etc... 

My company started using RSI almost 2 years ago, and the success rate is still in the high 90% range...  Every experience I've had with it turned out pretty well... First RSI was on a severe CHF'er, getting tired pretty quick... could not tolerate the CPAP at all.  Pt was intubated, and ended up walking out of the hospital a few days later.

I've also had a few good experiences with clenched trauma Pts...

Are there any other drugs out there then the usual sequence of Etomidate, defasiculating dose of Vecuronium (sometimes ordered, sometimes not), Succinylcholine, & then post-intubation management, versed & long-acting dose of Vec.


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## VentMedic (Mar 29, 2008)

Devilz311 said:


> Pt was intubated, and ended up walking out of the hospital a few days later.



Depending on the disease process causing the CHF, most CHF pts do walk out of the hospital a few days later.  CHFers' usually require only a few hours to and overnight on the ventilator.  Total time in the hospital averages 3 days in many cases.   Many can be treated with CPAP or BiPAP (trade name).  If they required intubation for extended periods of time like several days, they probably had more going for etiology with CHF being just one symptom.   

Since I have seen the very good and very bad examples of RSI in the field being brought into the ED, I have strong opinions and will let others give you their recipe.  It is a subject where education should be provided and questions such as these should be answered by your medical director.   Too ofter paramedics are given just one piece of information without full knowledge of why it works or why your medical director prefers that way over others.    I know what my options are in my transport and hospital situations for RSI but those may not be applicable to your situations or transport times.


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## Ops Paramedic (Mar 29, 2008)

RSI has only very recently been introduced here on the protocol of those holding the degree qualification (I have not seen this protocol published, but my info is from a reliable source).. 

 Currently we (ALS) have the synergistic  use of Dormicum (Midozolam) and Morphine in patient who might fit the RSI scenario, and sometimes it is only with the experience of the practitioner that the tube will pass, a student/less experienced practitioner might fail.  These meds will not do the trick, and the entire procedure can most likely cause more harm than good.  So as an ALS provider, should you need RSI, you will have to try and get hold of one of the Drs on the road, or you will have to call the heli.

Somehow though, we manage, i just hope the patient does too.


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## tydek07 (Apr 9, 2008)

Heres our protocol:

NOTTA


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## fma08 (Apr 9, 2008)

only PAI at our place, 2.5 Versed... thats about it.


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## firecoins (Apr 9, 2008)

we don't use paralytics here. We get along fine w/o. We can get the tunes w/o the paralytics.


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## Flight-LP (Apr 9, 2008)

Devilz311 said:


> I'm just curious to see what the different RSI protocols for various ALS projects... Medical vs Trauma, etc...
> 
> My company started using RSI almost 2 years ago, and the success rate is still in the high 90% range...  Every experience I've had with it turned out pretty well... First RSI was on a severe CHF'er, getting tired pretty quick... could not tolerate the CPAP at all.  Pt was intubated, and ended up walking out of the hospital a few days later.
> 
> ...



Congratulations on your successes with this procedure, but it is Rapid Sequence Induction, not Intubation. There is nothing rapid about the intubation as this procedure start to finish averages about 5-7 minutes. Sorry for being petty, but it makes me wonder when the procedure isn't even titled correctly........................

I've been using paralytics for over a decade, just as Vent said, i've seen good and bad. Some medics use them just to use them, others are scared to go near them. Our current protocol is Etomidate, Sux (if needed and not contraindicated), intubation, then Versed and Vec as needed. I've used most of the NMBA's out there, personally I prefer Zemeron for induction. None of the Acetylcholine or Potassium issues, it has a rapid onset close to Sux, and it lasts a lot longer so the need for a second paralytic is rarely present.

As far as success rates go, the paralytic should have no bearing on decreasing the overall tube placement rate. If it does, then you have issues that need to be addressed with your QI/QA program. The key when using these drugs isn't are we successful in placing the tube, rather did we instigate any adverse effects, i.e. malignant hyperthermia, transient hypoxia, and hyperkalemia. You must know these drugs inside and out right down to their action at the cellular level. Anything less and you have no business even touching the vial.

Also, do you have a 100% chart review on every intubation? Nothing improves skills and education better than in depth peer review and critique. A quality QI/QA program does wonders for a professional EMS agency................


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## Flight-LP (Apr 9, 2008)

fma08 said:


> only PAI at our place, 2.5 Versed... thats about it.



That sux (no pun intended!).....................

Half as@!ng it does little for your patient or your sanity. You should inquire with your medical director as to why he/she believes a low dose of Versed will remotely afford you a secured airway in the conscious patient. My opinion is "all or nothing"................


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## Jon (Apr 9, 2008)

CPAP is amazing.

Around here, Etomidate is approved, but not everyone is carrying it. PA is afraid of RSI after Dr. Wang's study showed how bad most medics are at airway manegment.


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## firecoins (Apr 10, 2008)

NYC now allows for etomidate.


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## Ridryder911 (Apr 10, 2008)

Flight-LP said:


> Congratulations on your successes with this procedure, but it is Rapid Sequence Induction, not Intubation. There is nothing rapid about the intubation as this procedure start to finish averages about 5-7 minutes. Sorry for being petty, but it makes me wonder when the procedure isn't even titled correctly........................



Actually, Flight it is now commonly referred to as Rapid Sequence Intubation in lieu of Rapid Sequence Induction, a few years ago it was formally changed due to we do not really induce or have a license to induce anesthesia. Even physicians prefer intubation over induction; indicating speciality of anesthesia. I believe it came from pressure of CRNA/Anesthesia groups as well as liability/litigation cases. 

R/r 911


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## Ops Paramedic (Apr 10, 2008)

We don't have them this currently on ALS protocol.  As ALS you will have to make do with Morphine & Midazolam concurrently.  There is a new qualification, the B-Tech/Degree paramedic, which appareantly RSI is on their protocol.  I havent' seen it published yet, as well as that register only opened last year for them.

Besides, we also recently got Lorazepam (Ativan) on protocol, which is great, but i don't think our services or practitioners are 100% equippped for the fridge drugs yet, but we are working on it!!!


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## Ridryder911 (Apr 10, 2008)

Ops Paramedic said:


> We don't have them this currently on ALS protocol.  As ALS you will have to make do with Morphine & Midazolam concurrently.  There is a new qualification, the B-Tech/Degree paramedic, which appareantly RSI is on their protocol.  I havent' seen it published yet, as well as that register only opened last year for them.
> 
> Besides, we also recently got Lorazepam (Ativan) on protocol, which is great, but i don't think our services or practitioners are 100% equippped for the fridge drugs yet, but we are working on it!!!



There is a new form of Ativan, that does not require refig.; although you have to mix it. We used cold/frozen blocks that one would use to keep beverages cold, it kept the med.'s cold enough. 

R/r 911


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## Flight-LP (Apr 10, 2008)

Ridryder911 said:


> Actually, Flight it is now commonly referred to as Rapid Sequence Intubation in lieu of Rapid Sequence Induction, a few years ago it was formally changed due to we do not really induce or have a license to induce anesthesia. Even physicians prefer intubation over induction; indicating speciality of anesthesia. I believe it came from pressure of CRNA/Anesthesia groups as well as liability/litigation cases.
> 
> R/r 911



I guess that trend hasn't worked its way south yet...............  

Everyone around here still refers to it as induction. Interesting to know though!


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## Ridryder911 (Apr 10, 2008)

Flight-LP said:


> I guess that trend hasn't worked its way south yet...............
> 
> Everyone around here still refers to it as induction. Interesting to know though!



Yeah, I called it that for years until I was clarrified that it was a "legal issue", and seen some texts and posters describing that we were not really "placing people under for true induction"; in which I guess we would have to monitor the stage of anesthesia, etc.. 

R/r 911


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## Short Bus (Apr 10, 2008)

Flight-LP said:


> That sux (no pun intended!).....................
> 
> Half as@!ng it does little for your patient or your sanity. You should inquire with your medical director as to why he/she believes a low dose of Versed will remotely afford you a secured airway in the conscious patient. My opinion is "all or nothing"................



I agree with ya here 100%.  We use the Lido, Atropine, Etomidate, Sux, and the vec.  Versed or more Etomidate as needed.  Sooner is much better than later.


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## fma08 (Apr 10, 2008)

i've talked to people about it, and it seems the feeling is that while RSI is a great tool in the right hands, it is a potentially dangerous tool not to be overused, and while they wouldnt admit it, many medics would be too... excited? if thats the word... about using it, especially in a situation where it isn't warrented, or where sedation itself would be fine. He, pretty much feels that in a position where the pt. truly would even need intubation, they would be unresponsive already or in a state where it would only take minimal sedation to achieve the same results. He, and some staff feel it is better to assist ventillations rather than knock the pt's resp. drive out and need to focus our effort on breathing for him. We work pretty much only 2 man crews, Medic-Medic or Medic-Basic, so if pt's resp. drive is gone, then the man in back is stuck doing that when other tasks may need to be performed. I'm all for adding an RSI protocal, but I can completely see where the medical director is coming from. We work hard on school at learning how to properly manage an airway BLS style (bag and OPA or NPA), so we can do that effectively before even considering intubating. Plus, the vast majority of our call volume is within a 10min transport time to a hospital...


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## Ridryder911 (Apr 11, 2008)

The point of RSI is for those patients that are worn out or to secure an airway to prevent aspiration. Assisting them will definitely, increase teh risk as well as those such in exacrebated COPD/CHF is desparately attempting to maintain, but is slowly loosing all drive. 

If one is able to RSI as well, they should have acess to transport vents. Why not? This free's up the Paramedic as well as a lot better ventilation if done properly. 

R/r 911


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## Devilz311 (Apr 11, 2008)

Flight-LP said:


> Congratulations on your successes with this procedure, but it is Rapid Sequence Induction, not Intubation. There is nothing rapid about the intubation as this procedure start to finish averages about 5-7 minutes. Sorry for being petty, but it makes me wonder when the procedure isn't even titled correctly.......................



Everywhere in our policy and procedure manual, as well as every memo titles it Rapid Sequence Intubation.



Flight-LP said:


> Also, do you have a 100% chart review on every intubation? Nothing improves skills and education better than in depth peer review and critique. A quality QI/QA program does wonders for a professional EMS agency................



Our Clinical program has 100% QA on every single chart, not just RSI... ALS, BLS, SCTU, Non-Emergent BLS, everything is QA'd.  For every RSI we do, it requires a special form to fill out, as well as every case is reviewed in depth...


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## firecoins (Apr 11, 2008)

Devilz311 said:


> Everywhere in our policy and procedure manual, as well as every memo titles it Rapid Sequence Intubation.


Your policy and procedure policy is also incorrect. This just how EMS refers to the procedure. The correct medical name of the procedure is Rapid Sequence Induction. It is about the medication.  Not the actual intubation.


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## Flight-LP (Apr 11, 2008)

fma08 said:


> i've talked to people about it, and it seems the feeling is that while RSI is a great tool in the right hands, it is a potentially dangerous tool not to be overused, and while they wouldnt admit it, many medics would be too... excited? if thats the word... about using it, especially in a situation where it isn't warrented, or where sedation itself would be fine. He, pretty much feels that in a position where the pt. truly would even need intubation, they would be unresponsive already or in a state where it would only take minimal sedation to achieve the same results. He, and some staff feel it is better to assist ventillations rather than knock the pt's resp. drive out and need to focus our effort on breathing for him. We work pretty much only 2 man crews, Medic-Medic or Medic-Basic, so if pt's resp. drive is gone, then the man in back is stuck doing that when other tasks may need to be performed. I'm all for adding an RSI protocal, but I can completely see where the medical director is coming from. We work hard on school at learning how to properly manage an airway BLS style (bag and OPA or NPA), so we can do that effectively before even considering intubating. Plus, the vast majority of our call volume is within a 10min transport time to a hospital...



Sorry, but that is a horrible excuse from your MD. If the airway can be managed by simple BLS interventions, then fine, but you show me a conscious pt. in distress that will allow you to lay him flat to ventilate with a BVM. Or an OD pt. with vomitus that is barely conscious, but has an intact gag reflex. Or the status seizure pt. that has now seized for over 10 minutes most of which without spontaneous respirations. These are the folks that need a Paramedic to take over their respiratory system. That is done through sedation and paralysis. It sounds like to me that your MD doesn't trust his medics if he is that concerned about "taking away a respiratory drive". After all, Anectine only lasts about 4-6 minutes, even if you don't get a tube, you can bag the pt without an issue.

If you wait until a pt. is "bad enough" to intubate, then you are way behind the 8 ball. This is when mistakes are made as you now have to race against time to save your patients life.
 For the record, the last three pts. that I intubated have all been conscious upon our arrival and all three without a shadow of a doubt, required immediate intubation. There was no other safe or effective way to manage their airway.

I've heard a lot of excuses as to why RSI is not needed, usually it is the old myth that a naso-intubation would work just fine. I've never heard one like this before......................


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## VentMedic (Apr 11, 2008)

firecoins said:


> Your policy and procedure policy is also incorrect. This just how EMS refers to the procedure. The correct medical name of the procedure is Rapid Sequence Induction. It is about the medication.  Not the actual intubation.



The term rapid sequence intubation is preferred over rapid sequence induction because the latter denotes the technique used by anesthesiologists for rapid airway control coincident with the initiation of *anesthesia.*  The Anesthesiologist has many meds that can be given different routes for different types of surgeries that require rapid induction.  In emergency settings, RSI should be seen not "as the initiation of anesthesia" but rather as the use of deep sedation and paralysis to facilitate endotracheal intubation.  


NAEMSP is also considering the use of DAI - Drug Assisted Intubation as a catch all term.  

*Recommended Uniform Guidelines for Uniform Reporting of Data from Out-of-Hospital Airway Management*
NAEMSP Annual Meeting  (The National Association of EMS Physicians)
January 18, 2003, Panama City, Florida

http://www.naemsp.org/pdf/wangforum.pdf

http://www.naemsp.org/pdf/Recommended_Guidelines_for_Uniform_Reporting_of_Data.pdf



> *Should we use the term “Rapid Sequence Intubation” or “Neuromuscular Blockade Intubation?”*
> 
> We prefer “Rapid-Sequence Intubation” or “RSI.” The rationale for using this term is that in the development of a prior position paper (Prehospital Rapid-Sequence Intubation), there were long debates regarding potential alternative terms to describe this technique. In fact, “Neuromuscular Blockade Assisted Intubation” (NMBI) was used as the working term throughout the position development process. However, in the end, there was clear consensus that RSI was already a widely used term with clear connotations, and that we should not try to introduce another new term.
> 
> ...


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## Street Dancer (Apr 11, 2008)

Our RSI protocol.

1.0mg/kg Lidocaine
.5 Atropine for 

-Hypoxia with decreased SAO2 and Increased CO2
-Peds <12 @ 0.01mg/kg
-HR <100
Etomidate 0.3mg/kg max 20mg
Succinylcholine 1.5 mg/kg, max of 200 mg single dose

If suspected increased ICP give 10% wait a minute give other 90%
Intubate - Verified with CO2 waveform, maintained @ 35-45mm/hg.

Long term Paralysis

Versed 2.5-10mg prn
Vecuronium 0.1mg/kg

Missing a tube on RSI buys you a day of OR time.:sad:


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## firecoins (Apr 12, 2008)

Street Dancer said:


> Missing a tube on RSI buys you a day of OR time.:sad:



Which is why I am not big fan of RSI, not that I have any problems with the OR.


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## Vizior (Apr 12, 2008)

firecoins said:


> Which is why I am not big fan of RSI, not that I have any problems with the OR.



Because you're afraid of a medic missing a tube, you don't like RSI?  Why would you dislike a treatment option just b/c of the possibility of a poor outcome?  Would the result be any worse than without trying to introduce a tube?


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## firecoins (Apr 12, 2008)

Vizior said:


> Because you're afraid of a medic missing a tube, you don't like RSI?  Why would you dislike a treatment option just b/c of the possibility of a poor outcome?  Would the result be any worse than without trying to introduce a tube?



My problem is the paralytic. Not the tube. If you intorduce a paralytic, you must be able to get the tube.


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## Ridryder911 (Apr 12, 2008)

firecoins said:


> My problem is the paralytic. Not the tube. If you intorduce a paralytic, you must be able to get the tube.



or..... you can bag them, and place an alternative airway in (Combitube, LMA, etc) and if need be, crich them.. 

Really, if you are truly competent in intubations and airway skills, having the patient RSI and paralyzed is much easier and safer for both you & the patient to intubate, than those have "gag" or performing a nasal intubation. 

R/r 911


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## fma08 (Apr 12, 2008)

all of those situations you just mentioned can be managed without RSI, ex. Conscious pt. in resp. distress, we have CPAP now, works wonders, if it doesnt, thats where the versed comes into play, giving enough to knock em, down, then tubing, ex. OD pt, whats the one thing you always have while tubing? suction. takes care of the vomit, and again, versed to knock em down the rest of the way. ex. seizure pt, versed again, especially if they have been seizing for 10 min. not one of those scenerios did the pt. need to be paralyzed.


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## firecoins (Apr 13, 2008)

Sedation does wonders.  Paralytics are overkill.  I don't feel endangered after usind sedatives nor do I drawbacks for the patient.  I can do it safely and quickly without paralytics.  We now have etomidate.   Just my opinion.


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## fma08 (Apr 13, 2008)

i agree completely, sedation works just fine for the field, in my opinion, it is not a controlled enough environment to make paralytics a common practice, the hospital and OR's are a completely different story. and again, i'm not saying paralytics should never be used, the flight service here does field work/scene flights where they RSI, but they are specially  trained people. for you're average street medic, i'd tend to lean to just sedation. it works just fine.


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## Ridryder911 (Apr 13, 2008)

firecoins said:


> Sedation does wonders.  Paralytics are overkill.  I don't feel endangered after usind sedatives nor do I drawbacks for the patient.  I can do it safely and quickly without paralytics.  We now have etomidate.   Just my opinion.



Okay, exactly how much experience do you have with either? Have you ever seen laryngospasm occur? Have you ever had to treat and deal with an airway that this occurs in?  Do you realize the risks and percentages of sedation without paralytics? Do you understand the risks of vagal stimulation, increasing ICP with intubation without paralytics? 

Again, there is really a reason this is performed to begin with! This is not a matter that was devised to make it easier. It is again for the patient's sake. 

Entomidate is a great medication but does not ensure prevention of gag reflex, laryngospasm, "bucking the tube". Since it is a short acting medication, to maintain level of grade of anesthesia needed for deep sedation has to be considered, the risks is hogh. Paralytic along with deep sedation is more beneficial to the patient. 

Laryngospasm is a very common event, even with deep sedation. Having laryngospasm can of course has its complications. 

Again, this procedure was to assure intubation to be sucessful. Extubation and reintubations of patents can only lead to problems and possibility increase of morbidity. 

R/r 911


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## Flight-LP (Apr 13, 2008)

Ridryder911 said:


> Okay, exactly how much experience do you have with either?



With the posted responses and the fact that they are Paramedic students, I'd say little.....

I had a lengthy post rebutting every single word that you both wrote, but unfortunately my computer closed IE as I was posting it...............

Here's the deal...........

RSI has been STATISTICALLY PROVEN to increase probability of successful intubation vs. sedation alone. "Snowing" a pt. does nothing more than alter them with possible significant hemodynamic effects. In the aforementioned example, despite your ignorant assertation that you could have done better without RSI'ing the pt., allow me to expand on why the RSI was needed (not that a justification to you is warranted or the fact that neither of you will open your ears and actually listen to others that may know a HELL of a lot more than you)

1. CPAP was used and not tolerated, therefore you have one option left (unless you want to wait for them to go into respiratory arrest)

2. The OD just happened to be from a benzodiazepine agent, so why on earth would I want to give my pt. VERSED????????? Suction for the vomiting, that's a good one. Do you just tape the suction tip down like you would an ET tube. Why not just secure the airway?? Remember the KISS prinicple, it will save you everytime!

3. Think about this one for a moment, if the Versed isn't stopping the seizure, do you really think it is going to make intubating any easier? Why give something when it has already shown it will not work. Status seizure patients need oxygenation. These patients need airway protection that they cannot offer themselves. These patients need to stop their excessive ATP and energy utilization due to the "seizure workout". Out of all three of these, this one would probably need it most.

Right now, you should be focusing on your Paramedic education and learning to be the best that you can be. RSI is not something you should even be thinking about, especially with your current train of thought. Get your certification and some experience and when you actually start inducing (or whatever PC word is to be used these days) paralysis with these medicines, then come back and talk with us.........................


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## fma08 (Apr 13, 2008)

ok, next time though, give a full scenerio for each, then maybe i can make a better decision, not just OD, he's puking, status seizure of 10 min, pt. in resp. distress, and i do listen to those that know more than me, unless they are giving me attitude while doing it


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## Ridryder911 (Apr 13, 2008)

I do worry about such forums as these that may give the impression of those that are not even licensed/certified to give opinions on procedures, methodologies in which they are not able to perform or have very little exposure to. 

Again, this would be similar for me to criticize a surgical approach, that I have never performed or have seen a few times, even though I am not licensed to perform. 

Opinions are nice and insightful, only if they can be validated from experience and education. 

Maybe opinions should be limited or definitely clarified either as having clinical experience and expertise in a particular procedure or anecdotal thinking. Since we are attempting to inform, educate and present truthful information.

R/r 911


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## eggshen (Apr 18, 2008)

Our answer to lack of RSI? BNTI followed by a dose of Versed. I don't know a lot about RSI so I will not speak on the subject. I do know that the State does not allow it and the waiver process is a ******* to get through. Over the last lot of years I have had great success with BNTI. Such that I feel more comfortable there than I do with a Miller in my L hand. That being said, we pasturize milk now right?

Egg


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## VentMedic (Apr 20, 2008)

Saw this posted on another forum:

*High-risk EMS procedure gets a low level of oversight*

http://www.star-telegram.com/state_news/story/593026.html

By DANNY ROBBINS
Star-Telegram staff writer



> Not long after complaining of shortness of breath at her Quinlan home, Patricia Cannon was in a Hunt County ambulance heading north toward Greenville with a drug dripping into her veins capable of paralyzing every muscle in her body.
> 
> The drug, succinylcholine, was administered by a paramedic. The intent was for Cannon, thought to be suffering from a blood clot in the lung, to be immobilized while a breathing tube was placed in her windpipe.
> 
> But something happened along the way that prevented the tube from being inserted correctly. The job wasn't done until the ambulance delivered Cannon, 41, to the emergency room at Greenville's Presbyterian Hospital. By then, her condition had worsened considerably.






> An examination by the Star-Telegram found that at least two people in Texas have died and another has become permanently disabled after being deprived of oxygen during the procedure, known as Rapid Sequence Intubation.





> The situation also raises larger questions about EMS in Texas, illustrating what some believe is a state system that allows paramedics with minimal training to engage in increasingly invasive procedures.
> 
> "The elephant in the room is prehospital personnel have a difficult time managing airways," said Robert Simonson, director of emergency services at Methodist Dallas Medical Center and the medical director for CareFlite and six North Texas ground EMS providers. "And they get into particular problems when they paralyze patients. That is a very unforgiving thing."





> "You can become a paramedic in Texas with less than 700 contact hours, but it takes between 1,000 and 1,500 [to get a license] to cut hair," said Jay Cloud, an EMS instructor at San Jacinto College in Pasadena. "What's wrong with this picture?"
> 
> The bigger problem with intubations, according to many in EMS, is staying proficient, mainly because liability issues have made it increasingly difficult for most paramedics to work in hospital settings.



*much more at:*

http://www.star-telegram.com/state_news/story/593026.html


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## fma08 (Jul 8, 2008)

... wow, we are doing so much better now with our protocols. We are allowed a whole 10mg of Versed if need be to assist with intubation now. :angry: (note the sarcasm)


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## mo-firemedic (Jul 9, 2008)

"You can become a paramedic in Texas with less than 700 contact hours, but it takes between 1,000 and 1,500 [to get a license] to cut hair," said Jay Cloud, an EMS instructor at San Jacinto College in Pasadena. "What's wrong with this picture?"

you actually have to have an IQ to get into medic school!!! well at least for the most part.

the thing with this whole argument is the way it turned into a pi$$!ng match between two or three people instead of a simple response to a question. all of the whining and moaning made me want to pull my hair out of my head. if you are old enough to be in the field than please for the sanity of the rest of us, freaking act like it.

 in missouri it is called rapid sequence intubation, not that it really matters what you call it. if you are uncomfortable with your skills to control an airway, then dont rsi the patient or you can still paralyze the patient and secure with a combitube, king airway or LMA. we have this thing called a paramedic's discretion. it is up to the medic in charge of the patient at that time who has been trained in rsi to make that decision!!! follow your protocols and when in doubt call your med control doc. thats what your service pays him for!


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## rhan101277 (Jan 27, 2010)

Well many med control doctors allow paramedics to use this drug and some don't.  I think it could help people who have gag reflex to get a secure airway.

If you don't get the tube, then just bag them and monitor SpO2 and waveform capnography to ensure proper respirations, it isn't that hard.

If you have to put in a rescue airway.


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## rhan101277 (Jan 27, 2010)

Article previously discussed doesn't show up now, but I found a new one.

http://www.jems.com/news_and_articl..._Procedure_Gets_a_Low_Level_of_Oversight.html


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## firecoins (Jan 27, 2010)

This thread is a long time dead.  I actually cut hair in Texas now after pushing paralytics.


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## ExpatMedic0 (Jan 28, 2010)

haha agreed



mo-firemedic said:


> "You can become a paramedic in Texas with less than 700 contact hours, but it takes between 1,000 and 1,500 [to get a license] to cut hair," said Jay Cloud, an EMS instructor at San Jacinto College in Pasadena. "What's wrong with this picture?"
> 
> you actually have to have an IQ to get into medic school!!! well at least for the most part.
> 
> ...


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## MrBrown (Jan 28, 2010)

For an international perspective we first trialled RSI for select Intensive Care Paramedics (ALS) in Auckland during 2005-2006.  The success rate was very high at about ~97% and for the last few years it has been an Auckland only skill because of the high volume of calls they recieve.

We expanded the trial during 2008 to two other areas which while not recieving as high call volume as Auckland they are very large and have the potential for long transport times, up to an hour to hospital.

This trial showed again around 97% success in over 500 patients.

RSI is now being rolled out nationwide for certian officers at Intensive Care level.

Our drugs of choice are suxamethonium and vecuronium, fentanyl and either midazolam for TBI or nuerogenic causes w/ GCS <= 10 (e.g. stroke) or ketamine for everybody else.


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## bmc911 (Feb 3, 2010)

I work in 2 different services, one inner city commercial and the other rural tarnsport/ALS intercept. no RSi in the city and RSI in the woods. 

where i use RSI we have very progressive med-con that QAs everything from psychs to critical patients. easy for them to do as they only sponsor like 75 or so paramedics. in 2008 we had 37 RSIs with 100% success rate. we have access to OR time anytime we feel it needed a we gives long as week or so heads up. depending on how a call is documented we actually get questioned for not using RSI on certain calls. we use sux and etomidate, with versed afterwards, no maintenance paralytic (which we have been fighting for) and have recently taken out lidocaine for ICP due to lack of evidence that it actually blunts ICP. we also have the airtrach for difficult intubations, LMA for backup and CPAP to hopefully avoid intuabtion. 

in the city where i work for a well known evil empire, RSI wont even be considered for many reasons. one being short transports, a few poor paramedics, very poor QA by med-con and the company and..... we have some ED docs at one hospital that dont believe in prehospital medicine. these docs think we should go back to being a fast response meat wagon. in their defense we have had some very poor medics that dont make a good a name for prehospital medicine, but in those medics defense, QA has really only been used for punishment and not corrective action. in this area i have yet to hear of any incidents where medics were sat down and taught what and why something was wrong. its either yelling, termination, med con suspension or more often, no action taken. with that being said, i also dont know if i would want to see RSI available to all medics in this area. what 2 cities have out here have done is allow chosen medics to use RSI after an interview process with MDs and senior medics. this isnt a horrible idea but creates an inconsistent standard of care in those areas because these werent fly car intercept medics but medics in transport rigs who were usually schleppin a fer and not available during potential calls. 
i have criched a trismus patient who was assesed as a potentially easy RSI/ intubation and sao2 imediately improved and airway became much more manageable however still ended up in a state i like to refer to as feed and weed. I have also had several successful nasal intubations on patients that i would have performed RSI had i had the option. 

I am a believer that if you are going to do something do it all the way. i do not agree with etomidate only intubations for sveral reasons. very rarely does it provide adequit relaxation unless the pt is already obtunded and very tired. there is several documented cases of it also causing periods of trismus after administration by itself, (ill see if i can find those studies and post em here). and there is the already mentioned laryngospam

there was 1 or 2 studies done about 5 or 6 years ago that did not make a good case for field RSI by paramedics. i believe the success rate was only 85% and a lot of documented cases of dropping 02 sats druing these studies. now, i have personally witnessed some very poor RSIs in several different EDs by both seasoned attendings and residents, of small hospitals and of trauma centers some of which resulting in multiple attempts, low o2 sats, severe bradycardia and arrest. from my veiw point, few would have been considered difficult(always easy to say when the scope is not my hand) but seem to have been more due to poor skill and poor overall airway management.


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## phildo (Feb 9, 2010)

I've been doing RSII for almost 14 years.  We first used versed and vecuronium.  It worked, but it was a pain to have to reconstitute the vec, and it took as long as 3 minutes to work.  I currently use etomidate and sux. (vec for a renal or burn patient)  Onset of effects is almost instantaneous.  tones...more later


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## phildo (Feb 9, 2010)

part2.  Now, at the service where I work we are busy, and intubate frequently enough that we are good at it.  I feel confident in our ability to use paralytics because we ventilate adequately and we are not too embarrassed to roll into the ED with an OPA/BVM or LMA in  place if we were unable to place the tube.  I have done this more than once.  I wish we had CPAP or BIPAP here.  I'm told the hospitals here would not be prepared to handle it if we did, so it's on a back burner for now.  I really like having the option of RSII in CVAs and head trauma.  I have twice needed it to intubate burn patients and barely got the tube in due to swelling.  IMHO, having RSII is better than not having it.


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## MrBrown (Feb 9, 2010)

I think RSI is a very useful tool in the right hands.  This is why we're only expanding it to select Intensive Care Paramedics as to create a better degree of skill retention per officer.

Now I do agree that it is inconsistent with say one ambo being able to RSI and another not but this is not like when we introduced ondansteron; these are not simple drugs and skills being dealt with.

Five years ago it was "never" going to be seen as standard but rather only for "selected" Paramedics (ILS) to have adrenaline, morphine and naloxone but that is being given to every officer now over the next few years.

With that in mind, in five years RSI might change too.


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