# Airway Management and Intubating without Drugs



## RocketMedic (Jun 5, 2019)

So as I contemplate a possible CA move, I have a question: I see a lot of folks on the forum seem to intubate fairly frequently (more than I do at least) but not necessarily with traditional RSI protocols. This led me to a follow-on question: how are y’all managing unresponsive, obtunded and respiratory failure patients in terms of airway management. I’ve looked at a lot of the protocols for states like NM, CA, PN, etc, and I see there’s still references to intubation, but how are y’all facilitating and intubating those patients? I’m not thinking so much the completely-unresponsive patient, I’m thinking more along the lines of “unresponsive but (inadequate) breathing” or peri-arrest patients or those with rapidly-progressing respiratory failure or trauma. 

Also, what gear/approach do y’all have?


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## KingCountyMedic (Jun 5, 2019)

I remember the early days where all of us, including ED Physicians did mostly nasal intubations on these patients. I remember lots of vomit, blood, aspiration etc. In the late 80's early 90's Succinylcholine started getting used around here. Usually with no sedatives or pain control. The way we used to manage airways was absolutely barbaric. It's sad that it's still fairly close to this in many communities. Yes you can sedate the **** outta someone and cram a tube in them but it's this practice that keeps our profession from being a respected profession in the medical community. If you are going to pass an endotracheal tube through a persons cords you should have every tool in your tool box to be successful, including all the RSI drugs and rescue devices. AND you should be required to maintain proficiency at the skill by passing at least 12 ET's a year with complete documentation of the procedure including airway grade, number of attempts, ETCO2 etc.

If you don't have ETCO2 and full RSI protocols with the ability to do it A LOT you probably have no business doing it.

My opinion.


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## NPO (Jun 5, 2019)

In my experience, in CA, when I had a patient that required RSI you either called a helicopter or the patient suffered. Those were my options. I distinctly remember a traumatic head injury patient who had snoring respirations and a a significantly reduced GCS. Vomiting was a concern due to the TBI, but he and I had to deal with an OPA and a NRB for about 45 minutes until we got to the hospital. I was not allowed to give any medication to facilitate intubation.


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## DesertMedic66 (Jun 5, 2019)

NPO said:


> In my experience, in CA, when I had a patient that required RSI you either called a helicopter or the patient suffered. Those were my options. I distinctly remember a traumatic head injury patient who had snoring respirations and a a significantly reduced GCS. Vomiting was a concern due to the TBI, but he and I had to deal with an OPA and a NRB for about 45 minutes until we got to the hospital. I was not allowed to give any medication to facilitate intubation.


In CA this is how it works. Either your patient is able to accept a tube because they are extremely unresponsive or you just have to manage BLS until they become that far gone and then you can tube. 

Got a facial burn patient with stridor? Can’t do anything on the ground until they become unresponsive. You either have to get a HEMS unit to you where we can RSI or do a surgical cric or get to your closest ED ask they can RSI and then probably fly the patient to a burn center.


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## StCEMT (Jun 5, 2019)

I don't. Maybe I could get a doc to buy off on Fent/Versed if I felt it was that bad. Usually though I just toe the line on acceptable to CPAP, bag them, or just have the NRB/NC running hard.

Burn patients? Short scene time, drive fast.

Head injuries? Same.

Our higher ups still preach the "you're 7 minutes from a hospital". While I agree with this in surgical interventions and stuff, I think it encourages lazy practice when it comes to treatments we can appropriately do that are right for this patient. They focus in on the 7 minutes to transport and ignore the 5-7 minute response, x minute assessment and extrication, x minute assessment and treatment in the truck, 5-9 minute transport, 5 minutes to turnover and docs start assessing, then however long it may take to finally do the things we could have done.

Although my thoughts on this aren't limited to airway. I wrote a Hyperkalemia protocol a year ago and we still haven't implemented one despite a recent protocol "update" (not a good description of it).


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## GMCmedic (Jun 5, 2019)

KingCountyMedic said:


> If you don't have ETCO2 and full RSI protocols with the ability to do it A LOT you probably have no business doing it.
> 
> My opinion.



Im going to save myself a lot of typing and go with this.


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## RocketMedic (Jun 5, 2019)

California still has needle crimes, right? Is that like the State-endorsed Control-Alt-Delete for these questionable airways?

I mean, I know what I’d like to do and how I’d practice, but if I do move back, I’ve gotta adjust to the ways of the locals. 

Personally, I think all intubation should be done with VL with DL backup, monthly competency trainings and checks and real, effective meds and tools, but that’s not the case everywhere.


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## CANMAN (Jun 5, 2019)

RocketMedic said:


> So as I contemplate a possible CA move, I have a question: I see a lot of folks on the forum seem to intubate fairly frequently (more than I do at least) but not necessarily with traditional RSI protocols. This led me to a follow-on question: how are y’all managing unresponsive, obtunded and respiratory failure patients in terms of airway management. I’ve looked at a lot of the protocols for states like NM, CA, PN, etc, and I see there’s still references to intubation, but how are y’all facilitating and intubating those patients? I’m not thinking so much the completely-unresponsive patient, I’m thinking more along the lines of “unresponsive but (inadequate) breathing” or peri-arrest patients or those with rapidly-progressing respiratory failure or trauma.
> 
> Also, what gear/approach do y’all have?



Is nasal intubation with a trigger tube and BAAM device not a thing there? Not a fan of DAI personally. Either you have the full toolbox or you don't.


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## NPO (Jun 5, 2019)

CANMAN said:


> Is nasal intubation with a trigger tube and BAAM device not a thing there? Not a fan of DAI personally. Either you have the full toolbox or you don't.


Nasal intubation is not a thing in California.

Also keep in mind, as far as DAI, ketamine is still not a thing in most places in California. Sedation is limited to Versed and fentanyl.

Edit: perhaps it's in the state optional scope. It was removed from my scope when I was there.


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## VentMonkey (Jun 5, 2019)

@NPO NTI is still in a handful of CA protocols, IIRC. 

With the advent of CPAP, on the ground in most CA services’ coverage areas, it’s seldom needed. I had at least 5-8 in my pre-CPAP days. When used right, it was efficient. 

That said, I don’t know how often they’re left in due to infection risks. I saw one doc give me accolades, and another scoff and remove it posthaste.

@RocketMedic, in short most ground services here are as described. There is some wiggle room in Kern Co. with regards to post-ETI management in, say, an arrest/ peri-arrested patient and delivery of sedation and pain management. 

But again, we’re talking about a very small population. And considering it seems (to me at least) that most of my ground co-workers refuse to catch up with current practices in prehospital airway management, they’re lucky they’re still allowed the privilege of handling a BVM.


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## RocketMedic (Jun 5, 2019)

VentMonkey said:


> @NPO NTI is still in a handful of CA protocols, IIRC.
> 
> With the advent of CPAP, on the ground in most CA services’ coverage areas, it’s seldom needed. I had at least 5-8 in my pre-CPAP days. When used right, it was efficient.
> 
> ...



Well that's not fantastic. I take it "patient comfort" is pretty far down the list of things cared about in a peri-arrest/unresponsive ETI?


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## VentMonkey (Jun 5, 2019)

RocketMedic said:


> Well that's not fantastic. I take it "patient comfort" is pretty far down the list of things cared about in a peri-arrest/unresponsive ETI?


Depends on the provider. Personally, I could muster up enough to be “within protocols” while still caring for these patients if they’re in front of me sans my flight nurse.


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## RocketMedic (Jun 5, 2019)

VentMonkey said:


> Depends on the provider. Personally, I could muster up enough to be “within protocols” while still caring for these patients if they’re in front of me sans my flight nurse.



It does suck that NTI isn't a thing anymore and that ketamine isn't available. I reckon Versed and Fentanyl work decently well though.

I do think that RSI is a good thing in abstract to have, but keep in mind that I work at a service that is terrible at it and doesn't really have he structure, organization, talent or training desire to improve as a system. My prior system was extremely 'good' at intubating because who was able to do it was very limited to seasoned providers only, but that solution wouldn't work outside of a compact area and had plenty of its own problems.


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## Tigger (Jun 6, 2019)

I think the advent of CPAP has helped tremendously. As I can't RSI/DSI at my full-time place, I am more inclined to stick with CPAP if the patient remains hemodynamically stable with a decent respiratory drive even if they are somewhat more obtunded than perhaps the book teaches as acceptable. We are in at least a 1:1 provider/patient ratio here so I feel that there is adequate "reaction time" to a loss of airway reflexes. 

I could also attempt to hurricane spray the crap out of someone, that seems like a bad choice. At the very worst, surgical crics are in the standard scope for every Colorado paramedic. 

I am still happy that we will have a Ketamine/Roc RSI guideline by the end of the year. I was hoping we could carry over the "Ketamine facilitated airway management" guideline from previous/now PRN spot but alas...


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## SandpitMedic (Jun 6, 2019)

As a ground medic in Vegas we always used etomidate/versed via standing order for intubation. Also, fentanyl for pain control. It worked well as I recall. In 2018 ground units got ketamine, but not for induction.

When I got on at a HEMS outfit in Vegas we had the full kit and caboodle of critical care interventions and medications. If they had a pulse, they got a full compliment of RSI drugs.


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## ghost02 (Jun 6, 2019)

VentMonkey said:


> But again, we’re talking about a very small population. And considering it seems (to me at least) that most of my ground co-workers refuse to catch up with current practices in prehospital airway management, they’re lucky they’re still allowed the privilege of handling a BVM.



Not all of us are that bad, but the amount of times I have heard the phrase, "Bougies are for people who can't intubate" or "Why would i ever use suction?" Is pretty high. Curious if we are going to get the DeCanto suction though. That said, there isn't much incentive to improve aside from your own desire to better the patient, and you know how most of our co workers are.

In response to the thread, you basically have two options, be a bad medic and force the tube then sedate, or manage with a BLS airway and advise the hospital to have RSI ready. Had it happen to me earlier in the week, GCS of 7 with strong localization, and it's a choice of either doing something without the right equipment and medication, or manage the airway with an OPA and BVM.

As a side note, in general I feel frustrated more than satisfied in a lot of ways, we had a protocol update a year prior that never went into effect, still no official sepsis protocols, and a disincentive to using EtC02 for anything but pure respiratory reasons. I could list the things that frustrate for a while, but I'm starting to realise that the only thing I can do is improve my own practice as best I  can.


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## RocketMedic (Jun 6, 2019)

Well that’s disappointing.


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## rescue1 (Jun 6, 2019)

In PA we had "sedation assisted intubation", a fancy name for hoping that etomidate alone would be sufficient to intubate a non-unresponsive patient. I've seen it work once, on a burn victim, and fail twice on traumas who eventually got RSIed by the flight crew. It's a ****ty way to intubate. Either have medics trained to RSI or don't intubate alive patients--there are a very small subset of patients who can't be temporized with CPAP/BLS airways but still have airway reflexes, the vast majority of them being traumas--and you need experienced providers who have the yearly numbers and training to do those intubations safely. If you're only doing a small handful of RSIs per year, and/or you're not getting consistent training in the procedure and in pre/post intubation management, you're probably harming more patients than you help.


I'm not 100% convinced that urban areas with consistently short transport times will see any benefit from ground EMS RSI, even if implemented well, but maybe that's just from my experience (bias) working in systems that never had it.


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## RocketMedic (Jun 6, 2019)

rescue1 said:


> In PA we had "sedation assisted intubation", a fancy name for hoping that etomidate alone would be sufficient to intubate a non-unresponsive patient. I've seen it work once, on a burn victim, and fail twice on traumas who eventually got RSIed by the flight crew. It's a ****ty way to intubate. Either have medics trained to RSI or don't intubate alive patients--there are a very small subset of patients who can't be temporized with CPAP/BLS airways but still have airway reflexes, the vast majority of them being traumas--and you need experienced providers who have the yearly numbers and training to do those intubations safely. If you're only doing a small handful of RSIs per year, and/or you're not getting consistent training in the procedure and in pre/post intubation management, you're probably harming more patients than you help.
> 
> 
> I'm not 100% convinced that urban areas with consistently short transport times will see any benefit from ground EMS RSI, even if implemented well, but maybe that's just from my experience (bias) working in systems that never had it.



I don’t think you’re wrong at all.


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## KingCountyMedic (Jun 6, 2019)

rescue1 said:


> I'm not 100% convinced that urban areas with consistently short transport times will see any benefit from ground EMS RSI, even if implemented well, but maybe that's just from my experience (bias) working in systems that never had it.



I agree with you 100% The majority won't see much benefit due large in part to the majority of places doing it wrong! If you don't have total buy in and total program oversight by Physicians that support it you are doomed from the get go. We have some very short transports in parts of King County and some very long ones as well. We RSI every single patient that needs it. Our past and present Medical Directors are all in agreement and have been for the past 50 years. We will occasionally sit on the ramp of an ED and RSI the patient before taking them inside the hospital and our Doctors appreciate it. They know we do it a lot and it typically makes their job a lot easier if we just handle it.


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## FiremanMike (Jun 7, 2019)

ghost02 said:


> Not all of us are that bad, but the amount of times I have heard the phrase, "Bougies are for people who can't intubate" or "Why would i ever use suction?" Is pretty high. Curious if we are going to get the DeCanto suction though. That said, there isn't much incentive to improve aside from your own desire to better the patient, and you know how most of our co workers are.
> 
> In response to the thread, you basically have two options, be a bad medic and force the tube then sedate, or manage with a BLS airway and advise the hospital to have RSI ready. Had it happen to me earlier in the week, GCS of 7 with strong localization, and it's a choice of either doing something without the right equipment and medication, or manage the airway with an OPA and BVM.
> 
> As a side note, in general I feel frustrated more than satisfied in a lot of ways, we had a protocol update a year prior that never went into effect, still no official sepsis protocols, and a disincentive to using EtC02 for anything but pure respiratory reasons. I could list the things that frustrate for a while, but I'm starting to realise that the only thing I can do is improve my own practice as best I  can.



Funny you say that about bougies - I’m phasing our regular stylets for bougies at work.  I’ve always been a fan of the bougie, the study by Driver et al was pretty convincing evidence that it’s time to dump the traditional stylet..

I also recently put DuCanto tips in service..

As for your issues with End-Tidal, what's their motivation for devaluation?  I'm guessing cost, which is unfortunate.  Are they even aware of how widespread EtCO2 is becoming?  Do they understand acid-base balance and WHY end-tidal is an indicator of an anaerobic metabolism (i.e. sepsis, poor perfusion, etc)..  Very frustrating for sure, sounds like you're moving backwards..


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## KingCountyMedic (Jun 7, 2019)

FiremanMike said:


> Funny you say that about bougies - I’m phasing our regular stylets for bougies at work.  I’ve always been a fan of the bougie, the study by Driver et al was pretty convincing evidence that it’s time to dump the traditional stylet..
> 
> I also recently put DuCanto tips in service..
> 
> As for your issues with End-Tidal, what's their motivation for devaluation?  I'm guessing cost, which is unfortunate.  Are they even aware of how widespread EtCO2 is becoming?  Do they understand acid-base balance and WHY end-tidal is an indicator of an anaerobic metabolism (i.e. sepsis, poor perfusion, etc)..  Very frustrating for sure, sounds like you're moving backwards..



I don’t think you should be dumping gear when it comes to airway tools. I think adding equipment that works and makes sense is good. The majority of my tubes are are almost always placed traditionally with a curved blade (Mac 3 or 4) and a cuffed tube with a stylet. I love the Bougie and it gets a lot of use, often it’s the first thing I grab when I see a potential tough airway. I know space on our rigs and kits is limited and valuable but you’ll never see an OR say “what do we need to get rid of so we can have this instead?” When it comes to the airway box I think more tools to increase your chances of success is a good way to go.


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## RocketMedic (Jun 7, 2019)

KingCountyMedic said:


> I don’t think you should be dumping gear when it comes to airway tools. I think adding equipment that works and makes sense is good. The majority of my tubes are are almost always placed traditionally with a curved blade (Mac 3 or 4) and a cuffed tube with a stylet. I love the Bougie and it gets a lot of use, often it’s the first thing I grab when I see a potential tough airway. I know space on our rigs and kits is limited and valuable but you’ll never see an OR say “what do we need to get rid of so we can have this instead?” When it comes to the airway box I think more tools to increase your chances of success is a good way to go.



Strong disagreement. You know what you’re doing. The vast majority of us do not. Adding more tools to that doesn’t fix anything and introduces interesting new ways to fail,


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## NPO (Jun 7, 2019)

Removing stylets from our airway bags because all of our tubes come preload of a stylets, and we use the king vision which is incompatible with stylets. They are just one more thing to get in the way and cause confusion during a stressful situation. We still have them in our tubes if we need them, and we have bougies.


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## RocketMedic (Jun 7, 2019)

NPO said:


> Removing stylets from our airway bags because all of our tubes come preload of a stylets, and we use the king vision which is incompatible with stylets. They are just one more thing to get in the way and cause confusion during a stressful situation. We still have them in our tubes if we need them, and we have bougies.



I preload my Kingvision with a tube and bougie. If I don’t need the Bougie, I just advance the tube as normal. If I do, the tube forms a good guide for the bougie in spite of the hyperacute angle of the Kv blade. Combined with good suctioning and the Wilco Way, I’m pretty comfy in intubations.

With that being said, I haven’t DL intubated a real person in a year.


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## NPO (Jun 7, 2019)

Yep. Same. I also do it the WilCo way and I can honestly say I haven't missed a first attempt in I don't know how long. With all of the tools, techniques and training we have, we have made intubating way easier than it used to be.

That said, I did recently have a patient I knew needed to be intubated by a doctor, in an ER, and with support staff and not by me bouncing down the road. So I guess you could claim confirmation bias because I didn't tube the hard one? 

I did need to do a DL recently, first in 2 years. I was surprised how easy the transition was. Muscle memory...


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## RocketMedic (Jun 7, 2019)

NPO said:


> Yep. Same. I also do it the WilCo way and I can honestly say I haven't missed a first attempt in I don't know how long. With all of the tools, techniques and training we have, we have made intubating way easier than it used to be.
> 
> That said, I did recently have a patient I knew needed to be intubated by a doctor, in an ER, and with support staff and not by me bouncing down the road. So I guess you could claim confirmation bias because I didn't tube the hard one?
> 
> I did need to do a DL recently, first in 2 years. I was surprised how easy the transition was. Muscle memory...



Nothing wrong with delaying at all. Walls is pretty clear about that- don’t do it if you aren’t confident of success and you can maintain via alternative measures.


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## NPO (Jun 7, 2019)

RocketMedic said:


> Nothing wrong with delaying at all. Walls is pretty clear about that- don’t do it if you aren’t confident of success and you can maintain via alternative measures.


This particular one was a gentalman, lethargic, shocky and in and out of consciousness. He was spewing copious amounts of blood from his mouth. My first thought was esophageal varicies. A quick history from his wife and I learned he had esophageal cancer, and it appeared that a tumor had begun bleeding.

Not knowing what his anatomy was going to be like, I wasn't confident paralysing him and he was maintaining his airway. So a quick ride to the ER was what he got.


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## FiremanMike (Jun 7, 2019)

KingCountyMedic said:


> I don’t think you should be dumping gear when it comes to airway tools. I think adding equipment that works and makes sense is good. The majority of my tubes are are almost always placed traditionally with a curved blade (Mac 3 or 4) and a cuffed tube with a stylet. I love the Bougie and it gets a lot of use, often it’s the first thing I grab when I see a potential tough airway. I know space on our rigs and kits is limited and valuable but you’ll never see an OR say “what do we need to get rid of so we can have this instead?” When it comes to the airway box I think more tools to increase your chances of success is a good way to go.



The bougie is just better than a stylet.  I pulled the stats at my department for the last 3 years and found (over the 3 year query) an average of 3 intubations, with an outlier of 11, a handful in the 4-6 range, and a mode of 1, meaning the majority of my folks have only intimated 1 time in 3 years (yes, I know, but that’s another topic entirely).

In those intubation attempts, the majority of the time, folks were using the king vision, which means traditional intubation is almost never done here.  When it’s done, it needs to be done with the tool proven to have a better first pass success rate.

Not attacking you - but I did find it curious that you grab the bougie first when you “know” it’s going to be a difficult airway.  Personally I treat and teach to expect every airway to be a disaster and then you can be pleasantly surprised when it’s easy..


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## GMCmedic (Jun 7, 2019)

I consider myself to be average to below average while intubatingwith tradional DL and stylette. I had 100% first pass success last year with DL and bougie on 7 intubations. September to now using the Mcgrath with 50/50 stylette/bougie im sitting at 90% on 10 intubations (the one miss i never attempted to pass a tube, cruddy anatomy). 

Anecdotal, but bougie and VL are full of win.


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## StCEMT (Jun 7, 2019)

My only thing with the KV is that it took me a lot of practice to get used to how it's different. I liked it alright enough, but I didn't find it to be as intuitive. However, I can't argue with results and I did eventually get the hang of it. I'd like to use it on a live intubation some day to see how I feel about it when actually put to use.


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## NPO (Jun 7, 2019)

StCEMT said:


> My only thing with the KV is that it took me a lot of practice to get used to how it's different. I liked it alright enough, but I didn't find it to be as intuitive. However, I can't argue with results and I did eventually get the hang of it. I'd like to use it on a live intubation some day to see how I feel about it when actually put to use.


Look up the WilCo in service on it. It changes everything.


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## ghost02 (Jun 7, 2019)

NPO said:


> Look up the WilCo in service on it. It changes everything.



Thanks for suggesting that, I've actually never seen it and it was an eye opener. I'm willing to bet that there would be no need to remove intubation should this become standard practice. As per normal though, it's a choice between improvement, which is costly and requires effort, verses removal.


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## NPO (Jun 7, 2019)

Why VL isn't standard of care is beyond me. It should be. There is no excuse.


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## ghost02 (Jun 7, 2019)

NPO said:


> Why VL isn't standard of care is beyond me. It should be. There is no excuse.


It costs money my friend. Hell I want IV zofran and the auto tamponade IVs.


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## NPO (Jun 7, 2019)

ghost02 said:


> It costs money my friend. Hell I want IV zofran and the auto tamponade IVs.


Again, not a valid excuse. They aren't THAT expensive anymore. Some things we need to work out the money.


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## ghost02 (Jun 7, 2019)

NPO said:


> Again, not a valid excuse. They aren't THAT expensive anymore. Some things we need to work out the money.



I don't disagree. You've galvanized me to try and work this out actually. If there is one thing that I feel its worth fighting for it is this, and complaining about it isnt going to get me anywhere.


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## DesertMedic66 (Jun 7, 2019)

NPO said:


> Again, not a valid excuse. They aren't THAT expensive anymore. Some things we need to work out the money.


It may not be a valid excuse but when you work for a private company that mainly focuses on profitability then any increased cost is not good. Why pay for VL when the equipment for DL is much cheaper. Until areas start mandating VL there are a lot of companies that will not switch.


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## StCEMT (Jun 7, 2019)

NPO said:


> Look up the WilCo in service on it. It changes everything.


I actually have watched all the stuff on it. But seeing something done and doing it are very different, especially when some finesse is involved. I was able to get it, just not quite as quickly as McGraths and similar devices. 

Although some of the concepts seem pretty universal whether or not it is a track system or not.


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## KingCountyMedic (Jun 7, 2019)

FiremanMike said:


> The bougie is just better than a stylet.  I pulled the stats at my department for the last 3 years and found (over the 3 year query) an average of 3 intubations, with an outlier of 11, a handful in the 4-6 range, and a mode of 1, meaning the majority of my folks have only intimated 1 time in 3 years (yes, I know, but that’s another topic entirely).
> 
> In those intubation attempts, the majority of the time, folks were using the king vision, which means traditional intubation is almost never done here.  When it’s done, it needs to be done with the tool proven to have a better first pass success rate.
> 
> Not attacking you - but I did find it curious that you grab the bougie first when you “know” it’s going to be a difficult airway.  Personally I treat and teach to expect every airway to be a disaster and then you can be pleasantly surprised when it’s easy..



No worries bro 🙂 

Just different systems, our folks get 2-3 tubes a shift on average.


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## FiremanMike (Jun 8, 2019)

KingCountyMedic said:


> No worries bro 🙂
> 
> Just different systems, our folks get 2-3 tubes a shift on average.



Definitely would have loved to work in a system like KC..

That said -  you should look up the Driver et al study on the Bougie, 10-12% first pass success rate increase between styles and Bougie, and that’s in a well lit ER with plenty of hands, I think you guys would see a similar increase.


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## Carlos Danger (Jun 8, 2019)

KingCountyMedic said:


> No worries bro 🙂
> 
> Just different systems, our folks get 2-3 tubes a shift on average.


2-3 tubes a shift? 

X how many paramedics?


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## KingCountyMedic (Jun 8, 2019)

Remi said:


> 2-3 tubes a shift?
> 
> X how many paramedics?



18 + 1 MSO per shift I think we’re around 76-80 Medics including day time MSO’s


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## rescue1 (Jun 8, 2019)

Are you saying every medic unit is getting 2-3 tubes a shift, or that among all 9 units there are 2-3 per shift? Because one of those seems very....aggressive haha


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## KingCountyMedic (Jun 8, 2019)

Remi said:


> 2-3 tubes a shift?
> 
> X how many paramedics?



18 + 1 MSO per shift I think we’re around 76 


rescue1 said:


> Are you saying every medic unit is getting 2-3 tubes a shift, or that among all 9 units there are 2-3 per shift? Because one of those seems very....aggressive haha


 

My bad, that’s 2-3 per Medic unit during the busy months. Some units are super busy, a couple are fairly slow. We run dual Medics in every rig so usually each Medic will get one or two depending on the location and what the system is doing. Our busiest Medic unit last year had more intubations than all of Shoreline Medic One units combined. Between CPR, shootings and car crashes in the summer our number of intubations skyrocket.


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## Carlos Danger (Jun 8, 2019)

KingCountyMedic said:


> 18 + 1 MSO per shift I think we’re around 76
> 
> 
> 
> My bad, that’s 2-3 per Medic unit during the busy months. Some units are super busy, a couple are fairly slow. We run dual Medics in every rig so usually each Medic will get one or two depending on the location and what the system is doing. Our busiest Medic unit last year had more intubations than all of Shoreline Medic One units combined. Between CPR, shootings and car crashes in the summer our number of intubations skyrocket.


I’d love to see a study on the outcomes there vs. other comparable cities. No other study has ever defended such aggressiveness in prehospital airway management.


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## rescue1 (Jun 8, 2019)

In defense of Seattle/KCM1, there are some (OK, just one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/) studies that show that they have better outcomes for GCS<8 trauma patients when compared to other cities in the ROC database (cities like Portland, Pittsburgh, Toronto, etc). I need to dig through the study more, but basically places that intubated more aggressively had better overall outcomes for these patients, however among all cities/systems, intubated patients did worse even when controlled for injury severity. Kind of a strange conclusion, and I'm not sure how much useful data we can actually take from it. 


@KingCountyMedic , I thought I remember reading in some JEMS article written by the Medic One folks that the average KCM1/Seattle medic had between 13-16 tubes a year. By your numbers, the average medic is pushing 100 tubes a year, which seems extraordinarily high in a system that only runs like 60,000 ALS calls a year (in fact, that would mean that almost 15% of your patients get intubated).


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## FiremanMike (Jun 8, 2019)

rescue1 said:


> In defense of Seattle/KCM1, there are some (OK, just one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/) studies that show that they have better outcomes for GCS<8 trauma patients when compared to other cities in the ROC database (cities like Portland, Pittsburgh, Toronto, etc). I need to dig through the study more, but basically places that intubated more aggressively had better overall outcomes for these patients, however among all cities/systems, intubated patients did worse even when controlled for injury severity. Kind of a strange conclusion, and I'm not sure how much useful data we can actually take from it.
> 
> 
> @KingCountyMedic , I thought I remember reading in some JEMS article written by the Medic One folks that the average KCM1/Seattle medic had between 13-16 tubes a year. By your numbers, the average medic is pushing 100 tubes a year, which seems extraordinarily high in a system that only runs like 60,000 ALS calls a year (in fact, that would mean that almost 15% of your patients get intubated).



It’s possible, given their reportedly highly functioning tiered systems.  The impression they give is that their paramedics truly treat and transport sick als patients, and the rest are taken by FD staffed BLS ambulances..


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## KingCountyMedic (Jun 8, 2019)

rescue1 said:


> In defense of Seattle/KCM1, there are some (OK, just one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/) studies that show that they have better outcomes for GCS<8 trauma patients when compared to other cities in the ROC database (cities like Portland, Pittsburgh, Toronto, etc). I need to dig through the study more, but basically places that intubated more aggressively had better overall outcomes for these patients, however among all cities/systems, intubated patients did worse even when controlled for injury severity. Kind of a strange conclusion, and I'm not sure how much useful data we can actually take from it.
> 
> 
> @KingCountyMedic , I thought I remember reading in some JEMS article written by the Medic One folks that the average KCM1/Seattle medic had between 13-16 tubes a year. By your numbers, the average medic is pushing 100 tubes a year, which seems extraordinarily high in a system that only runs like 60,000 ALS calls a year (in fact, that would mean that almost 15% of your patients get intubated).




I'm looking for some of our more recent data, I agree I think I'm off on my numbers a bit. A lot of our data that gets released is a combination of all King County and Seattle at times. In South King County where we are a true third service (not firefighters) we staff 9 Medic Units, 1 BC MSO that is 24hrs and a Paramedic, and 4 day time MSO positions that are all Paramedics. We do more intubations than Seattle and the north ends of King County, quite a bit more. We have the lowest income, most gangs, drugs and such so we see a lot more sick folks than the rest of our area. Our average is well above 16 a year but no where near 100 per year I think it's probably around 25 or so. We also have a large amount of overtime always available so it's not uncommon for our heavy OT workers tube numbers to really blow up. Personally I think the most I've ever done in 24 hours was 4-5 and that was on some crazy days. If you want to intubate a lot we are looking at huge numbers of retirements in the next 3 years. We are required 12 a year per Medic or you get to go to Harborview's OR to get up to the magic 12. No field Medics ever have to do this, just the day shift folks. (In our Zone, the rest of Seattle and North King County do have to send folks to the OR for tubes)


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## rescue1 (Jun 8, 2019)

KingCountyMedic said:


> I'm looking for some of our more recent data, I agree I think I'm off on my numbers a bit. A lot of our data that gets released is a combination of all King County and Seattle at times. In South King County where we are a true third service (not firefighters) we staff 9 Medic Units, 1 BC MSO that is 24hrs and a Paramedic, and 4 day time MSO positions that are all Paramedics. We do more intubations than Seattle and the north ends of King County, quite a bit more. We have the lowest income, most gangs, drugs and such so we see a lot more sick folks than the rest of our area. Our average is well above 16 a year but no where near 100 per year I think it's probably around 25 or so. We also have a large amount of overtime always available so it's not uncommon for our heavy OT workers tube numbers to really blow up. Personally I think the most I've ever done in 24 hours was 4-5 and that was on some crazy days. If you want to intubate a lot we are looking at huge numbers of retirements in the next 3 years. We are required 12 a year per Medic or you get to go to Harborview's OR to get up to the magic 12. No field Medics ever have to do this, just the day shift folks. (In our Zone, the rest of Seattle and North King County do have to send folks to the OR for tubes)



Got it, that makes a lot more sense. 

I'm not really qualified anymore to apply to EMS jobs, but I was looking at your EMS fellowship down the road, depending on how my training goes.


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## KingCountyMedic (Jun 8, 2019)

rescue1 said:


> Got it, that makes a lot more sense.
> 
> I'm not really qualified anymore to apply to EMS jobs, but I was looking at your EMS fellowship down the road, depending on how my training goes.



You mean the UW Medical Program? It’s a pretty good one. You’d get to ride with us a lot. The ED Fellows have to ride Seattle Aid Cars, Medic One rigs, and I think they end up doing fixed wing and helicopter time with Airlift NW


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## MackTheKnife (Jun 10, 2019)

KingCountyMedic said:


> I remember the early days where all of us, including ED Physicians did mostly nasal intubations on these patients. I remember lots of vomit, blood, aspiration etc. In the late 80's early 90's Succinylcholine started getting used around here. Usually with no sedatives or pain control. The way we used to manage airways was absolutely barbaric. It's sad that it's still fairly close to this in many communities. Yes you can sedate the **** outta someone and cram a tube in them but it's this practice that keeps our profession from being a respected profession in the medical community. If you are going to pass an endotracheal tube through a persons cords you should have every tool in your tool box to be successful, including all the RSI drugs and rescue devices. AND you should be required to maintain proficiency at the skill by passing at least 12 ET's a year with complete documentation of the procedure including airway grade, number of attempts, ETCO2 etc.
> 
> If you don't have ETCO2 and full RSI protocols with the ability to do it A LOT you probably have no business doing it.
> 
> My opinion.


I sure as hell wish we would have had RSI and capnography back in my day (80's)! We never got around to Sux although it was talked about.


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## MackTheKnife (Jun 10, 2019)

Tigger said:


> I think the advent of CPAP has helped tremendously. As I can't RSI/DSI at my full-time place, I am more inclined to stick with CPAP if the patient remains hemodynamically stable with a decent respiratory drive even if they are somewhat more obtunded than perhaps the book teaches as acceptable. We are in at least a 1:1 provider/patient ratio here so I feel that there is adequate "reaction time" to a loss of airway reflexes.
> 
> I could also attempt to hurricane spray the crap out of someone, that seems like a bad choice. At the very worst, surgical crics are in the standard scope for every Colorado paramedic.
> 
> I am still happy that we will have a Ketamine/Roc RSI guideline by the end of the year. I was hoping we could carry over the "Ketamine facilitated airway management" guideline from previous/now PRN spot but alas...


How frequently are crics being done in CO?


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## KingCountyMedic (Jun 10, 2019)

MackTheKnife said:


> How frequently are crics being done in CO?



I can't speak for CO but I know here WA  they went down after the Eschmann Bougie was added many years ago by most agencies and then they dropped even further once we added the iGel. I think the majority of surgical airways we end up doing in the last few years have mostly been burn patients. I have actually been able to slip a bougie into the airway using the iGel.


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## Tigger (Jun 12, 2019)

SandpitMedic said:


> When I got on at a HEMS outfit in Vegas we had the full kit and caboodle of critical care interventions and medications. If they had a pulse, they got a full compliment of RSI drugs.


If the patient has not intact gag reflex, why the RSI medications? Hopefully the dosing was at least lessened for the difficult to resuscitate patients.


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## RocketMedic (Jun 12, 2019)

Tigger said:


> If the patient has not intact gag reflex, why the RSI medications? Hopefully the dosing was at least lessened for the difficult to resuscitate patients.



A lot of medics out there think anything that isn’t a full arrest needs the full suite of RSI drugs because protocol. It’s not good medicine.


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## FiremanMike (Jun 12, 2019)

RocketMedic said:


> A lot of medics out there think anything that isn’t a full arrest needs the full suite of RSI drugs because protocol. It’s not good medicine.



Then again, there is at least one study out there that says emergent intubation without NMB correlates to an increase in complications as well as morbidity/mortality..


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## Tigger (Jun 12, 2019)

FiremanMike said:


> Then again, there is at least one study out there that says emergent intubation without NMB correlates to an increase in complications as well as morbidity/mortality..


Could you post? I'd be interested in reading that.

A good primer regarding RSI in shocked patients: https://litfl.com/intubation-hypotension-and-shock/
More specific to Ketamine: https://rebelem.com/dosing-sedatives-low-and-paralytics-high-in-shock-patients-requiring-rsi/


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## Tigger (Jun 12, 2019)

MackTheKnife said:


> How frequently are crics being done in CO?


I have no idea what the state numbers are. Our system (which is the largest "combined" in the state) probably only does at most five per year over 650k total population.


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## FiremanMike (Jun 12, 2019)

Tigger said:


> Could you post? I'd be interested in reading that.
> 
> A good primer regarding RSI in shocked patients: https://litfl.com/intubation-hypotension-and-shock/
> More specific to Ketamine: https://rebelem.com/dosing-sedatives-low-and-paralytics-high-in-shock-patients-requiring-rsi/



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

It is admittedly a small study, but this is the first one I came across


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## Carlos Danger (Jun 12, 2019)

FiremanMike said:


> Then again, there is at least one study out there that says emergent intubation without NMB correlates to an increase in complications as well as morbidity/mortality..


If you are really comparing apples to apples, I don't see how that could be true.

I mean, if you are talking about slipping a tube into a patient who is perfectly relaxed after getting some sux vs. one of those scenarios where one person is holding the patient's arms down and another is holding their chest and head down and they are biting your blade as you try repeatedly to ram a tube into their trachea, then sure, I can certainly see how the former would probably end up with fewer complications, and likely doing better.

But assuming the patient is relaxed enough to DL without NMB, I can't see any advantage to giving NMB just for the heck of it.


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## FiremanMike (Jun 12, 2019)

Remi said:


> If you are really comparing apples to apples, I don't see how that could be true.
> 
> I mean, if you are talking about slipping a tube into a patient who is perfectly relaxed after getting some sux vs. one of those scenarios where one person is holding the patient's arms down and another is holding their chest and head down and they are biting your blade as you try repeatedly to ram a tube into their trachea, then sure, I can certainly see how the former would probably end up with fewer complications, and likely doing better.
> 
> But assuming the patient is relaxed enough to DL without NMB, I can't see any advantage to giving NMB just for the heck of it.



My feeling is that it has to do with our ability to truly assess how deeply sedated they are.. "Hey, they seem to accept an oral airway, lets cram a laryngoscope in there" only to find that the deeper stimulation led to gagging, spasms, vomiting, aspiration, etc etc.. 

This is echoed in that study that showed a 15% increased incidence of aspiration in the sedation only cohort and does make logical sense when I run it through my brain..  The study is admittedly small, but 15% is still 10 patients out of 67 who aspirated which would have likely been prevented with NMB..

I'm a bit fried from microbio right now, I'll do some more google searching tomorrow to see if I can find a larger study supporting NMB in emergent airways..


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## DesertMedic66 (Jun 12, 2019)

My flight company also has the viewpoint that sedation only RSI comes with an increased risk of vomiting and aspiration.


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## Tigger (Jun 13, 2019)

DesertMedic66 said:


> My flight company also has the viewpoint that sedation only RSI comes with an increased risk of vomiting and aspiration.


Which is I suppose conceivable (and likely makes for more difficult intubating conditions due to potential residual muscle tone), but does the near-apneic, peri-arrest patient with a GCS of three need sedation?


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## StCEMT (Jun 13, 2019)

Tigger said:


> Which is I suppose conceivable (and likely makes for more difficult intubating conditions due to potential residual muscle tone), but does the near-apneic, peri-arrest patient with a GCS of three need sedation?


How often are we realistically intubating people that we need to do an abbreviated method for though? The last Roc only intubation I saw I honestly don't agree with, but less so because of sedation and more because I think there should have been a more aggressive resus first.


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## Carlos Danger (Jun 13, 2019)

FiremanMike said:


> My feeling is that it has to do with our ability to truly assess how deeply sedated they are.. "Hey, they seem to accept an oral airway, lets cram a laryngoscope in there" only to find that the deeper stimulation led to gagging, spasms, vomiting, aspiration, etc etc..
> 
> This is echoed in that study that showed a 15% increased incidence of aspiration in the sedation only cohort and does make logical sense when I run it through my brain..  The study is admittedly small, but 15% is still 10 patients out of 67 who aspirated which would have likely been prevented with NMB..
> 
> I'm a bit fried from microbio right now, I'll do some more google searching tomorrow to see if I can find a larger study supporting NMB in emergent airways..



There have actually been quite a few studies showing that using NMB increases success rates and minimizes complications with intubation. 

You certainly can get NMB-like intubating conditions with sedation alone. I assure you that with enough propofol and fentanyl, you would never be to able to tell clinically whether someone was just well-sedated or paralyzed.  

In actual practice however, there's usually nothing to be gained from avoiding NMB, because if you use enough sedation, you have abolished airway reflexes and induced apnea anyway. So we use sux or roc and less sedation for what they refer to in anesthesia circles as a "balanced anesthetic", and it's usually the best approach in an emergent scenario.  

So it's really an academic debate: clinically, 99% of the time, just use the NMB (unless you are doing an awake intubation, which is a whole other discussion). But technically, no you don't need NMB, and if these studies were truly comparing apples to apples (meaning an ADEQUATELY sedated patient vs. one who got NMB), I think you'd see similar outcomes.


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## Tigger (Jun 13, 2019)

StCEMT said:


> How often are we realistically intubating people that we need to do an abbreviated method for though? The last Roc only intubation I saw I honestly don't agree with, but less so because of sedation and more because I think there should have been a more aggressive resus first.


That also have a pulse? Probably not often, but I'm not sure that "if they have a pulse they get RSIed" is good practice either.


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## NomadicMedic (Jun 13, 2019)

Somebody should share these studies with the PA medical advisory committee. We still have sedation only intubation in our protocol. 

We (our agency) doesn't allow it
.


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## FiremanMike (Jun 13, 2019)

NomadicMedic said:


> Somebody should share these studies with the PA medical advisory committee. We still have sedation only intubation in our protocol.
> 
> We (our agency) doesn't allow it
> .



I remember the days of Etomidate and Versed.. Etomidate at 0.3mg/kg but with a max dose of 20mg, half our people clamped down almost immediately.  The fix, at the time, was doubling the Etomidate dose (it worked)..


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## RocketMedic (Jun 13, 2019)

What affect does NMB have on periarrest patients though? Since we’re paralyzing everything, wouldn’t any remaining vascular tone also be obliterated by nmb?


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## StCEMT (Jun 13, 2019)

Tigger said:


> That also have a pulse? Probably not often, but I'm not sure that "if they have a pulse they get RSIed" is good practice either.


What kind of concerns did you have in mind? Or are you thinking more of the poor hemodynamic patient being given the same dose of sedation as the relatively healthy person?


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## Carlos Danger (Jun 13, 2019)

RocketMedic said:


> What affect does NMB have on periarrest patients though? Since we’re paralyzing everything, wouldn’t any remaining vascular tone also be obliterated by nmb?


No. NMB does not affect smooth muscle.


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## NPO (Jun 13, 2019)

Remi said:


> No. NMB does not affect smooth muscle.


Thank God.


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## Peak (Jun 13, 2019)

Remi said:


> No. NMB does not affect smooth muscle.



Technically some NMBDs do have a very small effect on muscarinic receptors in smooth muscle. That being said they effect is so small it shouldn't present any appreciable change in vascular tone.


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## Carlos Danger (Jun 13, 2019)

Peak said:


> Technically some NMBDs do have a very small effect on muscarinic receptors in smooth muscle. That being said they effect is so small it shouldn't present any appreciable change in vascular tone.


Only succinylcholine has muscarinic effects, but it does not cause any vasodilation because not enough of it reaches the M3 receptors to have a clinical effect, and M3 stimulation does not reliably cause vasodilation....it also causes vasoconstriction.


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## KingCountyMedic (Jun 14, 2019)

Those of you that have RSI drugs, what do you use on your CPR patients when they're fresh? (pulseless but still agonal, trismus etc.)

We just use Succinylcholine, never had a problem but we are looking at going to mostly Rocuronium.


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## StCEMT (Jun 14, 2019)

KingCountyMedic said:


> Those of you that have RSI drugs, what do you use on your CPR patients when they're fresh? (pulseless but still agonal, trismus etc.)
> 
> We just use Succinylcholine, never had a problem but we are looking at going to mostly Rocuronium.


I've never gone straight to ETI in an arrest that quickly and usually they've been down for a while by the time I get there. The most recent arrest that occurred in front of me probably would have had no issue taking a tube right away.


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## Carlos Danger (Jun 14, 2019)

KingCountyMedic said:


> Those of you that have RSI drugs, what do you use on your CPR patients when they're fresh? (pulseless but still agonal, trismus etc.)
> 
> We just use Succinylcholine, never had a problem but we are looking at going to mostly Rocuronium.


“Never had a problem with our current routine but can’t resist fixing what ain’t broke”.


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## rescue1 (Jun 14, 2019)

What exactly are people's concerns with "over RSI-ing" patients who have ambiguously intact airway reflexes? Is it hypotension? Oversedation? 


Regardless of what meds, if any, you are pushing in an alive patient, you should be extremely cognizant of the patients blood pressure and resuscitate them (fluids, push dose pressors) up above 90-100 systolic at the absolute minimum before even thinking about intubation, because just the act of passing the tube and ventilating is going to drop their pressure from the vagal response and potentially a preload drop from the ventilation itself. I don't think trying to avoid sedation or paralysis for fear of this is going to fix the issue, plus its pretty inhumane to not at least sedate alive patients who are getting plastic shoved down their throat. You can always give them more epi to bring them back up after the RSI meds go in.


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## KingCountyMedic (Jun 14, 2019)

Remi said:


> “Never had a problem with our current routine but can’t resist fixing what ain’t broke”.




The Thomas Splint from WWI was still in use in King County up until a few years ago! Lol

We currently carry Sux & Roc but a few departments are dropping Anectine and only carrying Rocuronium. We’re going through a lot of changes, when our Mentor Dr. C left it created a weird new world. Lots of non M1 out of state Doctors coming into our system. Could be good, could be not so good.


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## StCEMT (Jun 14, 2019)

rescue1 said:


> What exactly are people's concerns with "over RSI-ing" patients who have ambiguously intact airway reflexes? Is it hypotension? Oversedation?
> 
> 
> Regardless of what meds, if any, you are pushing in an alive patient, you should be extremely cognizant of the patients blood pressure and resuscitate them (fluids, push dose pressors) up above 90-100 systolic at the absolute minimum before even thinking about intubation, because just the act of passing the tube and ventilating is going to drop their pressure from the vagal response and potentially a preload drop from the ventilation itself. I don't think trying to avoid sedation or paralysis for fear of this is going to fix the issue, plus its pretty inhumane to not at least sedate alive patients who are getting plastic shoved down their throat. You can always give them more epi to bring them back up after the RSI meds go in.


Take this for what it's worth since I can't RSI, but my main issues are what you outlined. I think the laryngoscope as a murder weapon series (or at least the concepts) should be something drilled into our heads (both in training and medic school), because I've seen post intubation arrests multiple times in the ED due to those things not being addressed. At least on the RSI's and crics I've seen, I can't think of very many where a easy paced resus then induction would have been inappropriate.


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## RocketMedic (Jun 14, 2019)

StCEMT said:


> Take this for what it's worth since I can't RSI, but my main issues are what you outlined. I think the laryngoscope as a murder weapon series (or at least the concepts) should be something drilled into our heads (both in training and medic school), because I've seen post intubation arrests multiple times in the ED due to those things not being addressed. At least on the RSI's and crics I've seen, I can't think of very many where a easy paced resus then induction would have been inappropriate.



Pretty much this. Although ketamine for sedation blunts the hypotension potential, I have seen multiple hypotensive RSIs that got worse with etomidate or *terrible medicine choice* versed + succs, and I was sort of reckoning that there must be a better way for those patients.


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## KingCountyMedic (Jun 15, 2019)

RocketMedic said:


> Pretty much this. Although ketamine for sedation blunts the hypotension potential, I have seen multiple hypotensive RSIs that got worse with etomidate or *terrible medicine choice* versed + succs, and I was sort of reckoning that there must be a better way for those patients.



We don’t RSI unstable patients anymore. If your patient is hypotensive you address that  first, the same with O2 sats. Get their pressure & sats up before RSI. 

Anyone remember 3 stacked shocks? Lol


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## Carlos Danger (Jun 15, 2019)

RocketMedic said:


> Pretty much this. Although ketamine for sedation blunts the hypotension potential, I have seen multiple hypotensive RSIs that got worse with etomidate or **terrible medicine choice* versed + succs,* and I was sort of reckoning that there must be a better way for those patients.



Why is versed and succinylcholine a terrible choice?

I think the vast majority of people who do this routinely would agree that generally, versed is inferior to the other commonly used options. But it definitely has a place in some scenarios.


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## VFlutter (Jun 15, 2019)

Providers commonly intubate patients with impending circulatory collapse without adequate resuscitation and then blame the RSI medications when they crash. Like said, versed is not ideal but is more than adequate along with paralytics for RSI.


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## RocketMedic (Jun 15, 2019)

Remi said:


> Why is versed and succinylcholine a terrible choice?
> 
> I think the vast majority of people who do this routinely would agree that generally, versed is inferior to the other commonly used options. But it definitely has a place in some scenarios.



Versed isn't/wasn't a great go-to in a hypotensive CHF patient with secondary sepsis, particularly when there is no effort at resuscitation made. I don't blame the versed alone, but I think that sedation could have been better-achieved with an alternative like etomidate or ketamine.


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## Carlos Danger (Jun 15, 2019)

People don't always need to be fully anesthetized in order for intubation to happen. If you are committed to using a full induction dose of any sedative, then yeah, you might have a bad time if they are sick and you don't take the time to resuscitate first. 

But if it's a scenario where you really need the tube in now and you don't have time to resuscitate (or mechanical ventilation IS the resuscitation), then a small amnestic dose of something is perfectly acceptable, and in that case versed is generally a good option.


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## rescue1 (Jun 15, 2019)

I think barring some fairly rare situations (airway burns, laryngospasm, some sort of traumatic airway disaster), you always have enough time to take a few minutes to beef up the pressure and maximize your oxygenation/CO2 before you drop the tube, even if you have to bag for a short amount of time first. You're always going to drop the pressure regardless of what you do, so I don't think the choice of sedation is super important, as long as its dosed appropriately. Like in @RocketMedic 's example, I don't think the Versed is to blame, I think it's trying to rapidly intubate a hilariously unstable patient with a very fragile blood pressure.

I know intubation is puffed up to be the coolest and most lifesaving thing a healthcare provider can do, but it's rare that tubing a patient actually fixes their underlying problem--most patients are tubed for some form of cardiac or respiratory failure that still needs to be addressed, all you're doing is buying more time to fix it. Sometimes it's best to just try and stabilize them as best you can and then let them get tubed down the road once they're a little more stable.


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## FiremanMike (Jun 15, 2019)

rescue1 said:


> I think barring some fairly rare situations (airway burns, laryngospasm, some sort of traumatic airway disaster), you always have enough time to take a few minutes to beef up the pressure and maximize your oxygenation/CO2 before you drop the tube, even if you have to bag for a short amount of time first. You're always going to drop the pressure regardless of what you do, so I don't think the choice of sedation is super important, as long as its dosed appropriately. Like in @RocketMedic 's example, I don't think the Versed is to blame, I think it's trying to rapidly intubate a hilariously unstable patient with a very fragile blood pressure.



Versed is vasoactive, as is etomidate, the two of them together can drop pressure.. 

Funny you mention bolstering the oxygenation.  One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).


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## Carlos Danger (Jun 15, 2019)

In most scenarios, resuscitation before intubation probably makes sense. Especially if you are bound by protocol or tradition to use an induction agent or a dose of induction agent that is inappropriate given the shocked state. 

But if you deal with enough sick patients - especially trauma patients - you will definitely come across scenarios where even though the vitals are crap and even though intubation isn't going to fix the underlying problem, the first priority in the resuscitation is still definitive airway control.


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## KingCountyMedic (Jun 15, 2019)

FiremanMike said:


> Versed is vasoactive, as is etomidate, the two of them together can drop pressure..
> 
> Funny you mention bolstering the oxygenation.  One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).



This has been a big push in our neck of the woods too. Spokane Fire in Eastern Washington even put out a study in 2018 and published it in Prehospital Emergency Care. We are using O2 sat, ETCO2, and BP as indicators and if they are low we work to fluid resuscitate, and BVM until we have a "stable" patient to initiate RSI. It's a big change for a lot of us that have just been dropping ET's as soon as possible. If the patient is super sick we will go straight to intubation, but if you can manage to make things a bit better prior to RSI it's a good thing to do


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## rescue1 (Jun 15, 2019)

FiremanMike said:


> Versed is vasoactive, as is etomidate, the two of them together can drop pressure..
> 
> Funny you mention bolstering the oxygenation.  One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).



Yeah, sorry, my point was "you're likely going to drop the pressure regardless of what you do, so don't think that using ketamine is going to save your patient who is hypotensive". Like you said, some drugs will drop it more than others, but you should always anticipate the hypotension.


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## NomadicMedic (Jun 15, 2019)

... double post_


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## FiremanMike (Jun 15, 2019)

Remi said:


> In most scenarios, resuscitation before intubation probably makes sense. Especially if you are bound by protocol or tradition to use an induction agent or a dose of induction agent that is inappropriate given the shocked state.
> 
> But if you deal with enough sick patients - especially trauma patients - you will definitely come across scenarios where even though the vitals are crap and even though intubation isn't going to fix the underlying problem, the first priority in the resuscitation is still definitive airway control.



Yeah that was my first reaction with the oxygenation criteria as well..


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## GMCmedic (Jun 15, 2019)

FiremanMike said:


> Versed is vasoactive, as is etomidate, the two of them together can drop pressure..
> 
> Funny you mention bolstering the oxygenation. One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).



I feel like this one comes up at eagles every year. This has been our local practice with passive oxygenation for a few years now.


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## KingCountyMedic (Jun 15, 2019)

NomadicMedic said:


> This will change everything.
> 
> 
> 
> ...



Possibly.... Seattle is already undergoing all kinds of changes, there is talk up north of transport vents and some bizarre witch doctor devices called CRAP or CCRAP or something? Scary times indeed. As long as my checking account stays well fed I'm good with whatever!


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## RocketMedic (Jun 15, 2019)

KingCountyMedic said:


> Possibly.... Seattle is already undergoing all kinds of changes, there is talk up north of transport vents and some bizarre witch doctor devices called CRAP or CCRAP or something? Scary times indeed. As long as my checking account stays well fed I'm good with whatever!




You....you don't have CPAP or transport vents?


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## Tigger (Jun 16, 2019)

KingCountyMedic said:


> Possibly.... Seattle is already undergoing all kinds of changes, there is talk up north of transport vents and some bizarre witch doctor devices called CRAP or CCRAP or something? Scary times indeed. As long as my checking account stays well fed I'm good with whatever!


Wait, so you guys RSI and intubate a high number of patients...and then BVM them to the hospital? Is there at least a PEEP valve?


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## StCEMT (Jun 16, 2019)

Tigger said:


> Wait, so you guys RSI and intubate a high number of patients...and then BVM them to the hospital? Is there at least a PEEP valve?


We dont have vents, but I'm also not electively RSIing....not that I find that to be a good reason.


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## KingCountyMedic (Jun 16, 2019)

RocketMedic said:


> You....you don't have CPAP or transport vents?



Nope! 🙂

A study is getting ready to kick off using both transport vents and CPAP. ALNW has it on their choppers, we use them for the long distance stuff.


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## DesertMedic66 (Jun 16, 2019)

KingCountyMedic said:


> Nope! 🙂
> 
> A study is getting ready to kick off using both transport vents and CPAP. ALNW has it on their choppers, we use them for the long distance stuff.


How on earth do you not have CPAP? Even the super crappy systems in CA have CPAP haha


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## KingCountyMedic (Jun 16, 2019)

DesertMedic66 said:


> How on earth do you not have CPAP? Even the super crappy systems in CA have CPAP haha



We know how to take care of sick people. I’d wager we have more Physician involvement than just about any other system in the country, especially California! Our Docs haven’t seen a need for it in our first 50 years of our program but we are going to start a study and see if it’s worth adding it to our rigs. One of our main medical directors is a world renowned pulmonary critical care Doc and he hasn’t felt a need for us to use transport vents so that’s good enough for me.


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## Peak (Jun 16, 2019)

I don't think a 911 system needs a transport vent, but I'm surprised you don't have flow inflating bags or those cheap disposable CPAPs. The local 911 service rarely has transports over 10 minutes and they carry them, and have definitely kept patients from getting tubed, and they pride themselves on being a bit of the EMS cowboys.


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## Tigger (Jun 17, 2019)

KingCountyMedic said:


> Nope! 🙂
> 
> A study is getting ready to kick off using both transport vents and CPAP. ALNW has it on their choppers, we use them for the long distance stuff.


What do you need to study? Pretty sure that Washington state is not a vortex in which evidence based practice does not apply somehow.


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## FiremanMike (Jun 17, 2019)

KingCountyMedic said:


> Nope! 🙂
> 
> A study is getting ready to kick off using both transport vents and CPAP. ALNW has it on their choppers, we use them for the long distance stuff.



Holy cow..  that honesty surprises me..

I’m guessing you guys still regularly RSI your CHF patients then?  That probably explains why your system has so many intubations these days..


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## rescue1 (Jun 17, 2019)

KingCountyMedic said:


> We know how to take care of sick people. I’d wager we have more Physician involvement than just about any other system in the country, especially California! Our Docs haven’t seen a need for it in our first 50 years of our program but we are going to start a study and see if it’s worth adding it to our rigs. One of our main medical directors is a world renowned pulmonary critical care Doc and he hasn’t felt a need for us to use transport vents so that’s good enough for me.



I would argue that knowing how to take care of sick people includes the ability to put people on CPAP, which has been standard of care for quite some time and can avoid a significant amount of intubations. It’s been a BLS skill in most places since like 2014.


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## CANMAN (Jun 17, 2019)

rescue1 said:


> Yeah, sorry, my point was "you're likely going to drop the pressure regardless of what you do, so don't think that using ketamine is going to save your patient who is hypotensive". Like you said, some drugs will drop it more than others, but you should always anticipate the hypotension.



Glad someone gets it... While Ketamine has been all the rave lately in many organizations, it certainly isn't a fix all medication like some believe. We implemented it pretty heavily a few years ago and you will get plenty of hypotension in very sick and/or catecholamine depleted patients. I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.


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## FiremanMike (Jun 17, 2019)

CANMAN said:


> Glad someone gets it... While Ketamine has been all the rave lately in many organizations, it certainly isn't a fix all medication like some believe. We implemented it pretty heavily a few years ago and you will get plenty of hypotension in very sick and/or catecholamine depleted patients. I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.



Even at lower doses (1mg/kg)?  I'm not doubting you, I just haven't seen it myself..


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## CANMAN (Jun 17, 2019)

FiremanMike said:


> Even at lower doses (1mg/kg)?  I'm not doubting you, I just haven't seen it myself..



Have never administered a 1mg/kg dose for RSI so I'm not sure if you would get the same effect Our protocol was 1.5mg/kg and that was plenty to see hypotension in certain patient populations.


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## FiremanMike (Jun 17, 2019)

CANMAN said:


> Have never administered a 1mg/kg dose for RSI so I'm not sure if you would get the same effect Our protocol was 1.5mg/kg and that was plenty to see hypotension in certain patient populations.



Our RSI protocol right now is 1mg/kg ketamine and 1mg/kg rocuronium.. Works well and we've not seen any hemodynamic issues with it


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## CANMAN (Jun 17, 2019)

FiremanMike said:


> Our RSI protocol right now is 1mg/kg ketamine and 1mg/kg rocuronium.. Works well and we've not seen any hemodynamic issues with it



911 or IFT service?


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## FiremanMike (Jun 17, 2019)

CANMAN said:


> 911 or IFT service?



Municipal 911, will do local ER to ER IFT in an emergency and no privates available, but it's extremely rare..


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## GMCmedic (Jun 17, 2019)

CANMAN said:


> Have never administered a 1mg/kg dose for RSI so I'm not sure if you would get the same effect Our protocol was 1.5mg/kg and that was plenty to see hypotension in certain patient populations.


We regularly cut the dose in half to 1mg/kg in really sick patients. We still see hypotension in some patients but achieve adeqaute sedation.


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## KingCountyMedic (Jun 17, 2019)

FiremanMike said:


> Holy cow..  that honesty surprises me..
> 
> I’m guessing you guys still regularly RSI your CHF patients then?  That probably explains why your system has so many intubations these days..



Nope, we don't RSI many CHF patients at all. We use Nitro and good BVM "Firefighter CPAP" you could say. Love us or hate us we have never done anything without running studies first to see if it is something we need to do as a county wide system. Our Medical Directors make the decisions with input from the field Paramedics and local ED Physicians. Major changes have to be agreed upon by all Directors and then we also implement it into our Paramedic Training Program at Harborview. Our system has so many intubations due to the fact that we have a small amount of Paramedics seeing a large volume of sick people and our Doctors support and encourage us to be aggressive in airway management.


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## SandpitMedic (Jun 17, 2019)

Tigger said:


> If the patient has not intact gag reflex, why the RSI medications? Hopefully the dosing was at least lessened for the difficult to resuscitate patients.


As in if the pt needs to be sedated/paralyzed.
Yes, if they are obtunded and they have no gag the full RSI is unwarranted.


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## FiremanMike (Jun 17, 2019)

KingCountyMedic said:


> Nope, we don't RSI many CHF patients at all. We use Nitro and good BVM "Firefighter CPAP" you could say. Love us or hate us we have never done anything without running studies first to see if it is something we need to do as a county wide system. Our Medical Directors make the decisions with input from the field Paramedics and local ED Physicians. Major changes have to be agreed upon by all Directors and then we also implement it into our Paramedic Training Program at Harborview. Our system has so many intubations due to the fact that we have a small amount of Paramedics seeing a large volume of sick people and our Doctors support and encourage us to be aggressive in airway management.



I don’t mean to direct any hate towards you, but king county is considered to be a Mecca for paramedics.. To think that you need to go through some extensive T&E before implementing a BLS procedure that is the standard of care across the  nation for at least 5 years now just floors me.

I mean, CPAP isn’t some obscure treatment that _may _help, it fixes CHF exacerbations nearly every time and it works in under 60 seconds..


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## Tigger (Jun 17, 2019)

KingCountyMedic said:


> Nope, we don't RSI many CHF patients at all. We use Nitro and good BVM "Firefighter CPAP" you could say. Love us or hate us we have never done anything without running studies first to see if it is something we need to do as a county wide system. Our Medical Directors make the decisions with input from the field Paramedics and local ED Physicians. Major changes have to be agreed upon by all Directors and then we also implement it into our Paramedic Training Program at Harborview. Our system has so many intubations due to the fact that we have a small amount of Paramedics seeing a large volume of sick people and our Doctors support and encourage us to be aggressive in airway management.


It’s not above loving or hating the system, it’s about doing what’s right for the patient. C/BiPAP prevents intubation in a variety of settings, both in and out of the hospital. I’d rather be intubated in an ED than an ambulance but most of all I’d like to avoid intubation unless there isn’t another option.

It seems exceptionally likely to me that many of the system’s intubated patients buy a tube because that’s one of the few tools available to provide positive pressure. “Firefighter CPAP?” This isn’t the 80s anymore. You might be getting by, but improvements have actually occurred in the last two decades. Perhaps firefighter CPAP and/or intubation adequately manages the patient, but why must the patient receive a higher risk intervention when we know that lower risk interventions are equally, if not more effective?

Something about if your only tool is a hammer...


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## KingCountyMedic (Jun 17, 2019)

Tigger said:


> It’s not above loving or hating the system, it’s about doing what’s right for the patient. C/BiPAP prevents intubation in a variety of settings, both in and out of the hospital. I’d rather be intubated in an ED than an ambulance but most of all I’d like to avoid intubation unless there isn’t another option.
> 
> It seems exceptionally likely to me that many of the system’s intubated patients buy a tube because that’s one of the few tools available to provide positive pressure. “Firefighter CPAP?” This isn’t the 80s anymore. You might be
> 
> ...


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## VentMonkey (Jun 17, 2019)

CANMAN said:


> I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.


I’d be interested to know how this pans out for you and your program. It’s such a simple calculation, and I think it’d help keep things like resuscitation prior to induction and it’s ok to take a minute if it will save you several post-induction in the back of the providers minds.


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## Tigger (Jun 17, 2019)

CANMAN said:


> Glad someone gets it... While Ketamine has been all the rave lately in many organizations, it certainly isn't a fix all medication like some believe. We implemented it pretty heavily a few years ago and you will get plenty of hypotension in very sick and/or catecholamine depleted patients. I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.


That was a huge part of our RSI/DSI update this year, I think it's going to make a big difference. That along with the new but not new adage of "resuscitate before you intubate" which mostly just re-emphasized the utility of push dose pressors and a really solid pre-ox regimen.


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## FiremanMike (Jun 18, 2019)

@KingCountyMedic I read your response before you deleted it, it was good

I don't mean to take anything away from KCM1, from an outsiders perspective you guys have an awesome job for EMS and you've done great things in EMS research.  You rewrote (or at least significantly refined) the playbook on resuscitation and your methods are used across the nation (including my department).  Although for full disclosure, I've always felt it a bit disingenuous to make it appear that your Utstein survival rates are your overall survival rates.

I guess the point of my post about CPAP is twofold.  First off, to reiterate what many of us are thinking which is that this really is a great tool and it's surprising that a department of your quality and reputation still hasn't implemented..  Secondly, it's a good reminder that even the best appearing jobs from the outside (who doesn't want to come in to work and do ONLY ALS??)  still have their quirks which some would find quite frustrating..


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## TRSpeed (Jun 18, 2019)

VentMonkey said:


> I’d be interested to know how this pans out for you and your program. It’s such a simple calculation, and I think it’d help keep things like resuscitation prior to induction and it’s ok to take a minute if it will save you several post-induction in the back of the providers minds.



Air methods already did a study on this and we have implemented the focus on resuscitation with the use of PDP if needed. Using vasopressin or phenyl depending on type of pt. I forgot the actual numbers regarding peri-arrest with RSI but they found patients with <80mmhg and ETCO2 <25 was not good obviously. Also very strong on the focus of proper pre-oxygenation using different techniques.


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## DesertMedic66 (Jun 18, 2019)

TRSpeed said:


> Air methods already did a study on this and we have implemented the focus on resuscitation with the use of PDP if needed. Using vasopressin or phenyl depending on type of pt. I forgot the actual numbers regarding peri-arrest with RSI but they found patients with <80mmhg and ETCO2 <25 was not good obviously. Also very strong on the focus of proper pre-oxygenation using different techniques.


This is all correct. It was recently published. Right now we are trying to determine if Vaso for trauma and Neo for medical patients is the best option for PDP. 

This is our RSI checklist that is utilized on all RSI patients. PDP are not specifically mentioned but are fit in during the prep/planning stage.


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## TRSpeed (Jun 18, 2019)

DesertMedic66 said:


> This is all correct. It was recently published. Right now we are trying to determine if Vaso for trauma and Neo for medical patients is the best option for PDP.
> 
> This is our RSI checklist that is utilized on all RSI patients. PDP are not specifically mentioned but are fit in during the prep/planning stage.
> 
> ...



Don’t be showing everyone our secrets -_- jk


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## DesertMedic66 (Jun 18, 2019)

TRSpeed said:


> Don’t be showing everyone our secrets -_- jk


I haven’t shown the Air Methods man thong yet.


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## TRSpeed (Jun 18, 2019)

DesertMedic66 said:


> I haven’t shown the Air Methods man thong yet.



Haha I’ve herd.....


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## GMCmedic (Jun 18, 2019)

TRSpeed said:


> Don’t be showing everyone our secrets -_- jk


Eric Bauer will give the secret away soon enough. 

I actually mentioned to my base manager the other day that I think the HEAVEN criteria is much better than LEMONS but we will never switch since its an Air Methods thing.


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## DesertMedic66 (Jun 18, 2019)

GMCmedic said:


> Eric Bauer will give the secret away soon enough.
> 
> I actually mentioned to my base manager the other day that I think the HEAVEN criteria is much better than LEMONS but we will never switch since its an Air Methods thing.


HEAVEN was recently published into the new PHTLS course so it’s going to be widely taught now. HEAVEN is not used as a tool to determine if it’s going to be a difficult intubation but rather focuses on what device (VL vs DL) is possibly going to be the better one to use.


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## VFlutter (Jun 18, 2019)

Another trend that came out of that retrospective study was that the vast majority of peri-intubation arrests were high shock index patients induced with Ketamine


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## VentMonkey (Jul 1, 2019)

A nice little updated piece on current recommendations for RSI meds and different subsets of patients. There isn't a whole lot of change I see, but figured worth a share.






						UpToDate
					






					www.uptodate.com


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## Tigger (Jul 1, 2019)

DesertMedic66 said:


> HEAVEN was recently published into the new PHTLS course so it’s going to be widely taught now. HEAVEN is not used as a tool to determine if it’s going to be a difficult intubation but rather focuses on what device (VL vs DL) is possibly going to be the better one to use.


This 2mg/kg bolus of Ketamine ought to bump their pressure right up...


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## DesertMedic66 (Jul 1, 2019)

Tigger said:


> This 2mg/kg bolus of Ketamine ought to bump their pressure right up...


Actually our medical directors sent out a memo not too long ago that we have not been seeing a rise in pressures with any of our ketamine dosages. Their pressures have either stayed the same or have decreased.


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## GMCmedic (Jul 1, 2019)

DesertMedic66 said:


> Actually our medical directors sent out a memo not too long ago that we have not been seeing a rise in pressures with any of our ketamine dosages. Their pressures have either stayed the same or have decreased.


Weve seen the same


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## Peak (Jul 1, 2019)

I haven't seen pressures go up in critically ill patients with ketamine. I have seen it with procedural sedation in otherwise health patients, but that is certainly a different population.


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## TXmed (Jul 2, 2019)

@DesertMedic66 @GMCmedic same here. We've seen it go up in non-critical patients in whom BP isn't a concern. But we've seen a significant decrease in our critical patients


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## Tigger (Jul 2, 2019)

I was being facetious. Unfortunately many people still think this, despite it being very apparent that it doesn't work that way.


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## SandpitMedic (Jul 5, 2019)

Mercy Air (AMC) went to PDP with the last update of their Patient Care Guidelines (PCGs).

1-2mg/kg Ketamine is still the preferred induction agent in trauma or sepsis (hypotension).

In an adult with a SBP <90, phenylephrine is the preferred PDP in the NON-traumatic patient. 200mcg q 2 mins until SBP>90.
In a trauma patient, the PDP is Vasopressin 2 units q 2 minutes until SBP>90.

ETA: these are IV/IO doses.

Also, I do believe there is a contradictory study out there showing PDP have poor long term outcomes. I’ll have to do some searching for that one.


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## SandpitMedic (Jul 5, 2019)

Here’s a great article with multiple studies and some take home tips for PDP applicability inhospital ED/ICU. However, it can be applied to EMS critical care. 

One study showed nearly 30% of the patients had adverse reactions which included reflex bradycardia. However, others showed none. One BIG however, is that these are retrospective studies and while this article was published in 2019 it is not based on any RCTs. 

Personally, I’m a fan of PDP, although 28-70% of patient still require additional vasopressor infusions. 

Good stuff here.


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## Tigger (Jul 5, 2019)

PDPs I think are intended to be bridge therapies until an infusion is readied. To me, patients requiring them are going to be very sick and therefore likely to have poor outcomes, I wonder how the study controlled for that.


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## VFlutter (Jul 5, 2019)

I hope AMC expands the PDP protocol to also be used as a bridge to infusion as opposed to strictly peri-intubation. The protocol is frequently being misused or liberally applied.

Also still frustrated not having pre-filled PDPs. Mixing PDPs kind of defeats the purpose and is not quick or accessible in an emergency. If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.


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## SandpitMedic (Jul 5, 2019)

VFlutter said:


> I hope AMC expands the PDP protocol to also be used as a bridge to infusion as opposed to strictly peri-intubation. The protocol is frequently being misused or liberally applied.
> 
> Also still frustrated not having pre-filled PDPs. Mixing PDPs kind of defeats the purpose and is not quick or accessible in an emergency. If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.


In the article I posted they did say that mixing your own PDPs was a major cause of medication errors, of which there were many. 

Again, these are retrospective studies not RCTs.


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## SandpitMedic (Jul 5, 2019)

I’m a tard... here is the link I mentioned but apparently didn’t post last night.









						Push-Dose Vasopressors: An Update for 2019
					

How should you use push-dose vasopressors in the ED? This post looks at the evidence behind their use and provides key points for patient care. As an added bonus, the post contains cards that can be printed for easy use on shift.




					www.emdocs.net


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## VFlutter (Jul 5, 2019)

Personally I think that Epi is the ideal PDP however it does have the most potential for drug errors and I understand the reluctance to adopt it outside of the hospital.

I mix our Vasopressin 20units/20ml and Phenylephrine 10mg/100ml then pull out 20ml so either drug its 2 ml every 2 minutes. Hook up the 20ml syringe of PDPs and a 3ml syringe with a stopcock to the IV line. Treat it like Pediatric doses. Seems to be the safest, albeit not quickest, way of doing things without prefilled. Wish it wasn't so expensive and you could mix it up and keep it for 72hrs but oh well.


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## StCEMT (Jul 5, 2019)

VFlutter said:


> If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.


Probably why it's something I've never pushed here. If I had RSI capabilities then I would, but anyone I'd even consider it on will get an infusion. The set ups we have for pumps is pretty simple and I can have it primed and running in not much more time.


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## Carlos Danger (Jul 5, 2019)

VFlutter said:


> Also still frustrated not having pre-filled PDPs. Mixing PDPs kind of defeats the purpose and is not quick or accessible in an emergency. If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.



Having prefills is nice, but I wouldn’t say not having them defeats the purpose. It shouldn’t take long at all to mix up an infusion, but it should be quite a bit quicker to make a syringe and give a bolus. It literally takes seconds to make a syringe of 100mcg/ml of epi or neo, if you know exactly how much to draw up based on whatever concentration you carry.

Honestly, it shouldn’t even be needed that often during airway management. It’s much better to simply adjust your dose of induction agent and prevent a big drop in the first place than it is to chase the BP with pressors.


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## SandpitMedic (Jul 7, 2019)

Remi said:


> Having prefills is nice, but I wouldn’t say not having them defeats the purpose. It shouldn’t take long at all to mix up an infusion, but it should be quite a bit quicker to make a syringe and give a bolus. It literally takes seconds to make a syringe of 100mcg/ml of epi or neo, if you know exactly how much to draw up based on whatever concentration you carry.
> 
> Honestly, it shouldn’t even be needed that often during airway management. It’s much better to simply adjust your dose of induction agent and prevent a big drop in the first place than it is to chase the BP with pressors.


I think the idea the AMC is going with is if they start out with hypotension prior to intubation and fluids aren’t doing it then move to PDP. Also, blood admin is preferred also if you have that capability. I wouldn’t interpret the guidelines to mean chasing BPs with PDP when they are going to be on a levo or other continuous infusion anyhow. It’s the bridge. But then again, there are some cowboys out there. 

As for Epi vs phenyl, the phenylephrine is preferred due being a direct alpha agonist. You get all the vasoconstrictor effect and increased SVR with no inotropic or chronotropic effects to worry about.


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## VFlutter (Jul 7, 2019)

SandpitMedic said:


> As for Epi vs phenyl, the phenylephrine is preferred due being a direct alpha agonist. You get all the vasoconstrictor effect and increased SVR with no inotropic or chronotropic effects to worry about.



I understand alpha only when the goal is to mitigate the potential hypotension caused by induction but is increased SVR without inotropy really preferred in a peri-arrest shocky patient?


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## Carlos Danger (Jul 7, 2019)

VFlutter said:


> I understand alpha only when the goal is to mitigate the potential hypotension caused by induction but is increased SVR without inotropy really preferred in a peri-arrest shocky patient?



If the sole cause of the hypotension is vasodilation (i.e. propofol in a non-bleeding patient), then yes, neo or vaso tends to work really well.

In a sick patient though, vasodilation induced by induction agents is not usually the sole cause of peri-induction hypotension and inotropy can be helpful, so ephedrine or epi tends to work better. Patients who are already tachycardic see a much smaller increase in heart rate from these drugs than patients who are not tachy to begin with.

In a trauma patient, you may be better off accepting the transient hypotension, even if it is severe. Vasopressors are a poor substitute for circulating blood volume, and can increase bleeding.

If you are really concerned about inducing hypotension with your inductions drugs, the best strategy, as I mentioned earlier, is to simply reduce your dose of those drugs.


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## SandpitMedic (Jul 8, 2019)

We must remember that although we (folks on this forum reading this thread) see this a lot, each patient is different and will respond differently to different drugs. Do the best you can with your latest approved guidelines and you won’t be wrong. Medicine is ever-evolving. Despite the latest and greatest, everyone cannot be saved.

People like CRNAs and PAs and Docs get to pick and choose what they want. Flight and CCT medics/ RNs the same within bounds. But the average paramedic out there needs to follow their guidelines with confidence. (Hint: so do Docs and other providers).

Medics need to know the drugs, the physiology, and the anatomy. And they need to do do their best each and every time.


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