# Is this similar to RSI or is it RSI?



## rhan101277 (Sep 9, 2009)

We got some new protocols and one of them is drug assisted intubation.  I wanted to see if this was RSI or not.  It reads like it, but I remember our instructor saying that RSI wasn't allowed in Mississippi yet.  This technique uses versed.  Does versed simply relax muscle or is it a nueromuscular blocking agent?  I know it is used to stop seizing patients.

Anyhow I wanted to get some feedback on this, if this is or isn't considered rapid sequence.

We also have cetacaine to assist.

Here is the algorithm.

http://img269.imageshack.us/img269/9694/drugassistedintubation.jpg


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## akflightmedic (Sep 9, 2009)

There was a thread on this awhile back...

RSI is rapid sequence induction (EMS tends to say intubation)
PAI is pharmacological assisted intubation
DAI is same as PAI, just insert drug


To keep it simple, RSI involves the use of paralytics.

The other uses hypnotics and relaxants.


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## MrBrown (Sep 9, 2009)

That is not RSI because like ak said, RSI involves the use of a paralytic (we use midazolam and one of the "...roniums" (roc or vec i think) and sux)

RSI is not a blanket procedure with the services here; it is something over and above standard ALS scope that you must apply to be selected for training in.

I notice this procedure says 2-4mg of midazolam IV; is that dose not a little low to knock somebody out?


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## rhan101277 (Sep 9, 2009)

Well it says the medicine is a skeletal muscle blocking agent so the folks won't be able to move.  Isn't that the same as the paralytic.  I'm sleepy sorry if this sounds simple.


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## firecoins (Sep 9, 2009)

The use of versed makes it PSI and not RSI just like AK said.  Versed is not a paralytic its a "sediative agent".  

http://emedicine.medscape.com/article/80222-overview



> To this end, the goal of RSI is to intubate the trachea without having to use bag-valve-mask (BVM) ventilation, which is often necessary when attempting to achieve intubating conditions with sedative agents alone (eg, midazolam, diazepam). Instead of titrating to effect, RSI involves administration of weight-based doses of an induction agent (eg, etomidate) immediately followed by a paralytic agent *(eg, succinylcholine, rocuronium)* to render the patient unconscious and paralyzed within 1 minute.


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## VentMedic (Sep 9, 2009)

rhan101277 said:


> Well it says the medicine is a skeletal muscle blocking agent so the folks won't be able to move. Isn't that the same as the paralytic. I'm sleepy sorry if this sounds simple.


 
A lot of meds produce skeletal muscle relaxation. However, this is where some understanding of pharmacology is helpful. 

Midazolam is a short-acting benzodiazepine central nervous system depressant.

Neuromuscular blocking agents or "paralytics" can be nondepolarizing agents, such as metocurine or pancuronium, or depolarizing blocking agents such as succinylcholine chloride. The differences determine which paralytics are used in specific situations and why some uses are more appropriate than others or just not advised at all. 

Midazolam is not very effective for DAI by itself especially in trauma patients. For emergency intubation it may take  0.1 mg/kg of Midazolam to effectively sedate a patient for emergency intubation. I would also be concerned if only this med and a low dose was used on someone who was to receive a paralytic. However, the concern for this dose or sometimes any dose of midazolam is hypotension which then makes etomindate a good alternative in some situations. 

If one is to effectively do DAI, PAI or RSI, one should have enough knowledge of pharmacology to consider the effects of the premedication drug with the age of the patient, medical history if known and the situation. As well, if a paralytic is used, one will have to consider situations it would not be appropriate and the effects on the patient if you can not adequately sedate or may just partially paralyze a patient to where they no longer have an adequate respiratory drive but are still not to a point you can intubate or even controlling their ventilations with a BVM might be difficult. In this situation you could deliver a dead patient to the ED if you can not get more med orders or panic when this occurs.


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## Akulahawk (Sep 9, 2009)

Something else to take note of: you NEVER want to paralyze a patient without using an agent to sedate them too. Benzodiazepines can also induce amnesia to events immediately surrounding it's administration. So, when you sedate and paralyze, your patient won't remember the induction into paralysis and subsequent intubation.

The choice of NMB's gets interesting... to say the least.


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## Smash (Sep 9, 2009)

Definitely not RSI.

It appears that this is DAI for patients with respiratory compromise such as asthma or possibly pulmonary edema:  "Signs and Symptoms:  Unresponsive Hypoxia, Impending Respiratory Failure, Decresed Mental Status"

It is interesting that one of the steps is "Trismus Present"  Gag reflex I could understand, but not trisums.  I would be extremely doubtful that midazolam alone in such small doses would be any use in relieving trismus.

It is also absolutely NOT something that should be attempted in a head injured patient.


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## ResTech (Sep 9, 2009)

> It is also absolutely NOT something that should be attempted in a head injured patient.



I've read over the thread real quickly so perhaps I am missing a context or something.... but why would you not want to give Versed to the head injured patient? I have always understood that sedatives are beneficial with the head injured patient as they prevent agitation and combativeness which can increase ICP... so to give a benzo can help decrease ICP and also prophylactically help with preventing seizures.

So to give it to assist with an airway in these patients I would think would be totally indicated. Of course, you have some side effect issues to consider that could relate to increased hypoxia if you cant get the airway but if your considering drug assisted intubation the patient is already hypoxic and at risk of seizing which is gonna shoot the ICP up.

Am I wrong in my thinking or missing something?


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## Smash (Sep 9, 2009)

You would only want to give a benzo to a head injured patient if you do not carry etomidate as part of your RSI protocol.  Some places do indeed use versed as part of RSI, however the difference is that it is essentially being used to be kind to the patient, and not to attempt to obtund them enough to overcome trismus (hence the use of NMBAs)

The things that kill head injured patients are Hypoxia, hypotension, hypercarbia and hypocarbia (hypo/hyperglycaemia are bad too)

If you have a head injured patient with trismus and you are only using versed then you will have to give a large doses, which will absolutely trash the blood pressure and cause more harm.

Versed does not have any significant effect on ICP on it's own, so that is not a reason to give versed to a head injured patient.  Also the patient will not necessarily be hypoxic if you are going to carry out and RSI, but indeed probably will be if you are going the DAI route (which I suspect is what the protocol the OP posted is about)  RSI is also about reducing secondary brain injuries as well as airway control.

Seizures in TBI are typically self-limiting and short in duration and will not necessarily require intervention in and of themselves.  We also do not give anti-convulsant prophylactically, particularly not in the form of a benzo.

If I used a benzo alone in an attempt to control the airway in a head injured patient I would be hung, drawn and quartered and never be allowed in the back of an ambulance again, and quite rightly so.

EDIT:  Sorry, I should say that while versed does not significantly reduce ICP, in some cases it can actually raise it, so again, not a good plan when used on it's own.


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## ResTech (Sep 9, 2009)

So what your saying is that if you have a head injured patient with suspected increased ICP who has become combative, you would not give a benzo to calm the patient to allow for proper care and to mitigate an increased ICP from the agitation and combativeness? This would be wrong to do?

I read a journal article on head injuries that advocated the benefits of benzo's prophylactically for the prevention of seizures in certain patients... it was touted as more of a bonus when given to agitated head injured patients.


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## Smash (Sep 9, 2009)

I would give a benzo (but would rather etomidate) only in the process of RSI.

Otherwise I am going to decrease BP and respiratory drive without any way of managing the subsequent hypoxia, hypercarbia and hypotension, thus exacerbating an already bad situation.

If the pt is particularly combative I would consider using my premed (fentanyl) a little earlier than normal to allow a little time for it to work and settle the patient without trashing the BP, although I would really rather just go straight through with the RSI.

I would be interested to see the journal article you speak of as I have not seen it, and it seems like a very... interesting propostion to me.


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## ResTech (Sep 9, 2009)

I see what your saying in regards to the airway issue... what about in the TBI patient that has a secured airway and they are becoming agitated? 

We only have Versed and Morphine... nothing else for sedation or pain. I will try to locate the journal article and I will post the link.


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## Smash (Sep 9, 2009)

If they are intubated, ventilated post RSI they should then be paralysed and have some form of sedation used.  Versed +/- morphine is fine in this situation as you are using small doses (preferrably an infusion to avoid peaks and troughs) that will be less harsh on the BP and you are already managing the airway and ventilation.

Small boluses of versed and morphine are effective, but infusions are better.  It's easy to forget a bolus when you are busy, and by the time they are becoming tachycardic, hypertensive and tearing, you have already raised their ICP again.  Infusions generally avoid this (although obviously you still need to watch vital signs)


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## MSDeltaFlt (Sep 12, 2009)

rhan101277 said:


> We got some new protocols and one of them is drug assisted intubation. I wanted to see if this was RSI or not. It reads like it, but I remember our instructor saying that RSI wasn't allowed in Mississippi yet. This technique uses versed. Does versed simply relax muscle or is it a nueromuscular blocking agent? I know it is used to stop seizing patients.
> 
> Anyhow I wanted to get some feedback on this, if this is or isn't considered rapid sequence.
> 
> ...


 


akflightmedic said:


> There was a thread on this awhile back...
> 
> RSI is rapid sequence induction (EMS tends to say intubation)
> PAI is pharmacological assisted intubation
> ...


 


MrBrown said:


> That is not RSI because like ak said, RSI involves the use of a paralytic (we use midazolam and one of the "...roniums" (roc or vec i think) and sux)
> 
> RSI is not a blanket procedure with the services here; it is something over and above standard ALS scope that you must apply to be selected for training in.
> 
> I notice this procedure says 2-4mg of midazolam IV; is that dose not a little low to knock somebody out?


 
Actually it's a bit different than any of that. Depending on your medical director's interpretation, the term of RSI and DAI (if using paralytics) are interchangeable. 

Some services may have a RSI protocol. For some/most docs the operative word in RSI is "Sequence". If you decide to electively intubate a pt, you will follow the whole sequence including the paralytic each and every time. Period.  You will follow the "sequence".

Some services use a DAI protocol. DAI's are a little more broad. Some include paralytics. Some do not. For those that do include paralytics, (depending on your med control) the operative word is "Assisted". Translation: if after the Etomidate and/or Fentanyl your pt stops breathing, jaw goes limp, and they lose a gag reflex, then you do not have to push the paralytic. Just put the tube in and go.  You will use drugs to "assist" you in intubating.

You, my friend, are being taught a DAI protocol authorizing the use of Etomidate. It's not a RSI.


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## rhan101277 (Sep 12, 2009)

MSDeltaFlt said:


> Actually it's a bit different than any of that. Depending on your medical director's interpretation, the term of RSI and DAI (if using paralytics) are interchangeable.
> 
> Some services may have a RSI protocol. For some/most docs the operative word in RSI is "Sequence". If you decide to electively intubate a pt, you will follow the whole sequence including the paralytic each and every time. Period.  You will follow the "sequence".
> 
> ...



These protocols call for Midazolam, which just relaxes muscle but causes sedation.  If you are sedated then you might as well be paralyzed right?  Anyhow I guess when this would come into play would be with asthmatics, if standard epi didn't fix them.  

We also have cetacaine for numbing up the back of the throat to reduce or eliminate gag reflex.

I am learning a whole lot although emt-basic's know alot, it simply doesn't compare to the full-circle awareness you get from paramedic class.

Easy airways come first, if their airway is protected then you just use simple oral airway adjuncts right.


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## Akulahawk (Sep 13, 2009)

rhan101277 said:


> These protocols call for Midazolam, which just relaxes muscle but causes sedation.  If you are sedated then you might as well be paralyzed right?  Anyhow I guess when this would come into play would be with asthmatics, if standard epi didn't fix them.
> 
> We also have cetacaine for numbing up the back of the throat to reduce or eliminate gag reflex.
> 
> ...


Midazolam can do some muscle relaxation, but at the doses used, it's more of a sedating med... and might induce amnesia to the events surrounding it's administration. If the idea to push the midazolam is for getting the patient relaxed enough to take the tube, you might as well go for the full-on RSI with paralytics. If you're sedating the patient to make it more comfortable for the patient while you're doing it... that's a bit different. The dosages of midazolam would be different. For the second instance, numbing or reducing the gag reflex would be a good thing... as you'd be intubating an awake, but sedated patient.


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## VentMedic (Sep 13, 2009)

rhan101277 said:


> We also have cetacaine for numbing up the back of the throat to reduce or eliminate gag reflex.


 
Cetacaine?

Okay Paramedic student (and I mean that with affection),  what would you suspect if your patient developed cyanosis shortly after using cetacaine?


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## MSDeltaFlt (Sep 13, 2009)

rhan101277 said:


> These protocols call for Midazolam, which just relaxes muscle but causes sedation. *If you are sedated then you might as well be paralyzed right*? Anyhow I guess when this would come into play would be with asthmatics, if standard epi didn't fix them.
> 
> We also have cetacaine for numbing up the back of the throat to reduce or eliminate gag reflex.
> 
> ...


 
No.  Sedation and paralysis are two completely different things.  When sedated you might be semi-conscious to unconscious, but wth enough stimulation, you can be aroused somewhat.  I don't remember my dental surgeon extracting my wisom teeth, but I remember every single moment of exquisite pain when my neurosurgeon kept tightening all 4 screws on my halo.

When you're paralyzed, you will not move at all, but you will still be completely conscious.  I can't tell you how many times I've flown in to a sending facility to pick up an intubated pt for transfer, ask them what they used to intubate their pt, and they respond with, "Oh we *sedated* him/her with Pavulon (or Anectine or Norcuron or Rocuronium)".  The first thing me or my RN do is start hitting the pt with Versed because the HR and BP are through the roof because they're *still conscious*.  They can still hear, feel, and remember everything that is going on.


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## VentMedic (Sep 13, 2009)

rhan101277 said:


> T If you are sedated then you might as well be paralyzed right? Anyhow I guess when this would come into play would be with asthmatics, if standard epi didn't fix them.


 
No. There must be some serious consideration when you paralyze someone as well as determinining if the paralytic you are giving is the correct one. If you paralyze a patient just enough to hamper their respiratory effort but not enough for you to get control of their airway either with a tube or BVM, you will severely harm that patient. And, just getting the tube in is only half the battle. You must have enough knowledge and protocols to maintain that tube. If their gag is very active, they will struggle against that tube making ventilation very difficult causing more pulmonary and ICP complications than what they may have had without the tube.

As well, when paralyze someone, you are knocking out part of their own natural systemic pump for venous return. This can be very critical if you managing a cardiac or CHF patient. Short acting paralytics may be fine but again there may be other factors that you must be aware of even with those and may need to support their blood pressure through pressors or fluids. This is especially true if you use something like Versed as sedation.

Also, for the asthmatic, that patient may be given an initial dose of a steroid in the field. Some paralytics and steroids interact with each other and permanent paralysis may be one of the side effects.

Even in the hospital or on long transports we will avoid the use of paralytics for either intubation or maintenance of a patient on a ventilator.  However, it takes extensive knowledge of pharmacology to fit the patient and the situation.  Of course, when the patient presents a safety risk to himself and the crew such as in a helicopter flight, whatever needs to be done will be done but again that crew should have been well educated for these decisions. 

The problem with the way EMS education is done now is that everything is looked at as a separate entity or recipe. The procedure of RSI is looked at as just a method of intubation without examining the meds or the if this then as it only pertains to alternative airways. When people make out med cards, they are usually very specific. This drug is used for this. They don't always cross over such as "I can give steroids for asthma" and "I can give a paralytic for RSI and to maintain the patient for airway management". Many will view this as two separate pathways independent of the other. 

Once you've taken the step into doing advanced procedures such as RSI with medications such as paralytics, you can no longer just look at "skills" but now must become knowledgable about medicine and how what each thing you do will have a reaction for the action.


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## Akulahawk (Sep 13, 2009)

VentMedic said:


> ...Big Snip... to reach a point.
> 
> Once you've taken the step into doing advanced procedures such as RSI with medications such as paralytics, you can no longer just look at "skills" but now must become knowledgable about medicine and how what each thing you do will have a reaction for the action.


Once you've gotten to this point and you start learning the why of medicine and how things interact, you can no longer, in good conscience, be a "cookbook" medic. 

Something else to remember... as an example. Many of the elderly patients we transport are walking pharmacological experiments. Their meds can interact in some very odd ways. Those interactions... also can happen with the meds we carry for our job.


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## MissMedicCMO (Sep 13, 2009)

yea..def.not RSI..like everyone has said...RSI is the use of a paralytic and Im not keen on just using versed to intubate someone who needs to be put down to do it.  We carry succs, versed, norc, and etomidate.  And Ive never heard of versed being called a skeletal muscle blocker.  It is a sedative...like everyone else said but good question to ask not knowing and since its a new protocol for you.


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## austinmedic2004 (Sep 13, 2009)

Yes, the key is "assisted". Using just enough appropriate medication to assist with the intubation is the key and then using the appropriate medications to maintain effective sedation with paralysis or just sedation as needed depending on the patient.


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