# Question about ETI, RSI



## 8jimi8 (Sep 4, 2010)

First I'd like to ask that if you have not ever intubated a live person, please don't respond to this thread.

I have assisted with about 30 different intubations, under 2 different doctors.  The doctor never told us why he chose what drug he just said, I want this and this, or push this or that.  I am looking for a deeper understanding.  I'd like to have a look at different pharmacological frames of thought.

1)  Airway grading??  I have heard people mention various scales, but I cannot remember the names, would someone mind chiming in?

2) Do you practice a 2 minute "nitrogen washout"  e.g. 2 minutes bvm in preparation for intubation?

RSI;

1) would you mind posting your protocols?

2) Would you point me to good discussions of various combinations.  I understand that there is RSI and DAI.  I'm looking for a complete picture of the pro and cons, indications and contraindications... I realize that there are probably books on this subject, please point me to them!



3) Can you explain the thinking as to when a depolarizing or non-depolarizing neuromuscular blocking agent is used.  From what I've been able to pick up, depolarizing agents may cause fasciculations as they paralyze the motor end plate, while non-depolarizing medications work on a presynaptic level.  Is this use of these only guided by a fear of IICP, or laryngoscope induced IICP?


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## MasterIntubator (Sep 5, 2010)

8jimi8 said:


> I have assisted with about 30 different intubations, under 2 different doctors.  The doctor never told us why he chose what drug he just said, I want this and this, or push this or that.  I am looking for a deeper understanding.  I'd like to have a look at different pharmacological frames of thought.
> 
> Unfortunately, that is what doc's do.  With all the drugs at their finger tips, they have learned what works best in various folks. We.... unfortunately do not have that luxury.  And it seems each one likes different things.  One likes Ketamine/Valium/Midazolam/fentanyl... another likes Propofol... another likes Sux... they all seem to get the job done well
> 
> ...



I have heard different things on this stuff. Depolarizing ( Sux ) usually can not be reversed to control fasciculations. Non-depol effects can be reversed with Neostigmine or such. Many of the anesthesiologists advise that ICP can be greatly increased by laryngoscopy, and not from the drugs themselves.  And if its a fear, they sedate more heavily and pre-med with Lido.


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## Veneficus (Sep 5, 2010)

8jimi8 said:


> I have assisted with about 30 different intubations, under 2 different doctors.  The doctor never told us why he chose what drug he just said, I want this and this, or push this or that.  I am looking for a deeper understanding.  I'd like to have a look at different pharmacological frames of thought.



unfortunately, there is a whole branch of medicine relating to this. 



8jimi8 said:


> 1)  Airway grading??  I have heard people mention various scales, but I cannot remember the names, would someone mind chiming in?.



Mallampati is the most commonly used. As mentioned, there are variations of it, but not really _required_.



8jimi8 said:


> 2) Do you practice a 2 minute "nitrogen washout"  e.g. 2 minutes bvm in preparation for intubation?



Only in the OR. Never prehospital or in the ED.




8jimi8 said:


> 1) would you mind posting your protocols?



No longer have a protocol, work under clinical decision making.



8jimi8 said:


> 2) Would you point me to good discussions of various combinations.



Because there are various reasons you would want to use different combinations, this is not easily answered. Different agents have different depths of anesthesia, different lengths of action, different mechanisms and different side effects.

I believe you already have illustrated review of pharm.

Book highly recommended as reference book of Pharmacology :

The Pharmacological basis of the Therapeutics by Goodman & Gilman,

11th edition , New York, Mc Graw-Hill, 2006 ISBN 0-07-142280-3

Anesthesiology by David Longnecker, David Brown, Mark Newman, and Warren Zapol (Hardcover - Dec 14, 2007) 

Clinical Anesthesiology, 4th Edition [Paperback]



8jimi8 said:


> 3) Can you explain the thinking as to when a depolarizing or non-depolarizing neuromuscular blocking agent is used.  From what I've been able to pick up, depolarizing agents may cause fasciculations as they paralyze the motor end plate, while non-depolarizing medications work on a presynaptic level.  Is this use of these only guided by a fear of IICP, or laryngoscope induced IICP?



Depends...
Sorry there is no simple explanation of this that I know that would do the question justice. You have to look at not only the duration of onset and action but IICP, and what will happen to the pt by hyperstimulation or inhibition.

A lot of these questions are actually all answered by the same sources.



8jimi8 said:


> I understand that there is RSI and DAI.  I'm looking for a complete picture of the pro and cons, indications and contraindications...



RSI adds a neuromuscular blocker so it requires lower levels of anesthesia. Benefits are all that come with it, lower recovery time, lower theraputic dose, increased speed of recovery, etc.

Cons are, neuromuscular blockers do not sedate, so now you have to manage maintenece of at least 2 medications simultaneously.  

DAI is basically the reverse theory, the patient is heavily sedated (usually with a benzo alone or mixed with something else, though some old folks will use ketamine or opioids alone)

Neither of them have the side effects of barbiturates, though for long term cases it does work really well and is still used in some places. Particularly for status epilepticus or when seizures resume after an acute reversal of benzos.


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## usalsfyre (Sep 5, 2010)

8jimi8 said:


> I have assisted with about 30 different intubations, under 2 different doctors.  The doctor never told us why he chose what drug he just said, I want this and this, or push this or that.  I am looking for a deeper understanding.  I'd like to have a look at different pharmacological frames of thought.
> 
> 1)  Airway grading??  I have heard people mention various scales, but I cannot remember the names, would someone mind chiming in?
> 
> ...


 My thoughts are included in bold


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## Veneficus (Sep 5, 2010)

If I am not mistaken Succs can be given IM when V access is not available.

Not that I expect to see that in prehospital protocols.


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## medicRob (Sep 5, 2010)

Here you go, Jimi. I have all my protocols on my iPad, so I had to take three screenshots and split them up as the RSI is a pretty long entry.


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## medicRob (Sep 5, 2010)

Here is the hospital protocol for RSI

http://www.mc.vanderbilt.edu/surgery/trauma/Protocols/RapidSequenceIntubationVisio.pdf


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## MSDeltaFlt (Sep 5, 2010)

8jimi8 said:


> First I'd like to ask that if you have not ever intubated a live person, please don't respond to this thread.
> 
> I have assisted with about 30 different intubations, under 2 different doctors. The doctor never told us why he chose what drug he just said, I want this and this, or push this or that. I am looking for a deeper understanding. I'd like to have a look at different pharmacological frames of thought.
> 
> ...


 
*Here's the thing about depolarizing and non-depolarizing agents.  If an "unstable" C-spine fracture is a concern then Anectine might be an issue; especially if you don't sedate the patient adequately.  They basically have to be apneic with no gag BEFORE you push Anectine for there to be no fasciculations.  By that time you shouldn't need to push it in the first place.*

*Renal pts.  Check their K+ BEFORE you push it.  *

*If they (any pt) are 24hrs POST burn, check the K+ as well.  *

*Myesthenia Gravis pts will more than likely not be able to metabolize Anectine and probably remain paralyzed longer; days longer.*

*If you know they have Malignant Hyperthermia, don't give Anectine.*

*As far as lidocaine goes, I can't find any evidence of lidocaine being beneficial or counterproductive during RSI/DAI.  I personally believe it's there to make you look smart.  It is merely in protocols as a public relations tool so people will go, "Ooh, look!  They're using lidocaine to blunt increased ICP!  Wow!  They must really know what they're doing!"*

*Also, when doing RSI/DAI keep your backup airway out and within easy arms' reach along with suction.  You don't want to get caught with your pants down.*

*Hope this helps.*


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## FLEMTP (Sep 5, 2010)

MSDeltaFlt said:


> *Here's the thing about depolarizing and non-depolarizing agents.  If an "unstable" C-spine fracture is a concern then Anectine might be an issue; especially if you don't sedate the patient adequately.  They basically have to be apneic with no gag BEFORE you push Anectine for there to be no fasciculations.  By that time you shouldn't need to push it in the first place.*



Umm.. if you give a DE POLARIZING neuromuscular blocker.. there will be fasiculations whether they are apneic & have a gag reflex or not.


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## MrBrown (Sep 6, 2010)

6.3 RAPID SEQUENCE INTUBATION (RSI)
• Indicated for patients with a GCS <10 with airway or ventilatory compromise.

• Absolute contraindications:
a. Known history or family history of malignant hyperthermia or
b. Paraplegics/quadriplegics or
c. Any muscle disorder with long term weakness or
d. Hyperkalemia strongly suspected or
e. Electronic capnography unavailable or
f. No dedicated suitable assistant (2nd AP preferred).

• Relative contraindications:
a. Age < 5 or > 75 yrs or
b. Age > 75 years with stroke or COAD as underlying cause or
c. Predicted difficult airway or
d. Less than 15 minutes to hospital or
e. Underlying cause is likely to rapidly improve e.g. GHB poisoning or post seizure.

• Preparation:
a. Assess the patient for signs of difficult intubation.
b. Prepare all equipment and brief assistant.
c. Draw up and label drugs, ensure running IV line.
d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP.
e. Pre-oxygenate for 3 minutes with 100% oxygen via manual ventilation bag. 
If unable to pre-oxygenate administer 6 large breaths immediately after apnoea occurs.

• Medicines:
a. Give IV fentanyl over 1 minute, 2-3 minutes before induction.
b. Regimen 1. For all patients with neurological cause for coma
(e.g. TBI, stroke, post cardiac arrest) that do not have significant
shock - give IV midazolam and IV suxamethonium.
c. Regimen 2. For all other patients and particularly for those with
shock – give IV ketamine and IV suxamethonium.

• Intubate and confirm ETT position with capnography.
• If unable to intubate implement failed intubation drill.
• Give IV vecuronium once ETT confirmed in trachea.
• Ventilate to ETCO2 30-35 mmHg (exception – life threatening
asthma, ventilate at 6 breaths/min and ignore ETCO2).
• Give additional sedation (midazolam 1-3 mg and morphine 1-3
mg) and vecuronium as required.

RSI Drug Dose
• Fentanyl: 1mcg/kg (max 100mcg)
• Midazolam: 0.1mg/kg (max 5mg)
• Ketamine: 1.5mg/kg (max 150mg)
• Suxamethonium: 1.5mg/kg (max 150mg)
• Vecuronium: 0.1mg/kg (max 10mg)

• *Halve fentanyl and midazolam dose if: age > 60 yrs, or HR > 100/min or systolic BP < 100mmHg.
• Round the patients weight to the nearest 10 kg.
• Midazolam must be given using 1 mg/ml in a 5ml syringe.
• Ketamine must be diluted to 10 mg/ml in a 20ml syringe.
• Vecuronium must be diluted to 1 mg/ml in a 10ml syringe.
• Fentanyl in children must be diluted to 10 mcg/ml in a 10ml syringe.
• Suxamethonium in children must be diluted to 10 mg/ml in a 10ml syringe.


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## 8jimi8 (Sep 6, 2010)

Just to reiterate a question from my OP.  Are we concerned with fasiculations, only because of an increase in ICP/IOP?  Is that the only time that a "defasiculating" dose is warranted?  I understand that one of the side effects /after effects is pain which is thought to be secondary to fasiculations.


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## MasterIntubator (Sep 6, 2010)

I don't think it has that much of an effect on IOP/ICP, nor that it causes it ( some study I read... ICP increase with sux was somewhat theoretical ).... I could be wrong.  Its probably more disturbing to watch pts jerk around, and that probably bugs people the most.  I'm not too concerned about it... unless the pt absolutely should not move.... like a c-spine Fx.  Sedate a little heavier and should not be an issue.  Ketamine can make folks do crazy things as it wears off... but that is why most back it up/give it with a benzo or such.


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## 8jimi8 (Sep 6, 2010)

MasterIntubator said:


> I don't think it has that much of an effect on IOP/ICP, nor that it causes it ( some study I read... ICP increase with sux was somewhat theoretical ).... I could be wrong.  Its probably more disturbing to watch pts jerk around, and that probably bugs people the most.  I'm not too concerned about it... unless the pt absolutely should not move.... like a c-spine Fx.  Sedate a little heavier and should not be an issue.  Ketamine can make folks do crazy things as it wears off... but that is why most back it up/give it with a benzo or such.



and by Benzo you mean midaz right?  I've seen ativan make otherwise normal seeming people, get reealllly wacky.


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## MasterIntubator (Sep 6, 2010)

Ativan is usually has stronger muscle relaxing properties than midaz.  Versed is quicker acting and shorter lasting... which in many peoples books... is the preferred one for emergent intubation


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## Veneficus (Sep 6, 2010)

i have never seen fasiculations so dramatic to comprimise c-spine, usually it looks like just a nervous twitch.


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## MasterIntubator (Sep 6, 2010)

normally it does....


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## MediMike (Sep 7, 2010)

3) Can you explain the thinking as to when a depolarizing or non-depolarizing neuromuscular blocking agent is used. From what I've been able to pick up, depolarizing agents may cause fasciculations as they paralyze the motor end plate, while non-depolarizing medications work on a presynaptic level. Is this use of these only guided by a fear of IICP, or laryngoscope induced IICP?

Looks like the majority of your other questions have gotten answered pretty well ^_^

Depolarizing NMB (Succs) are used as the first line paralytic in our system, it has been the #1 choice for years do to its short duration of action and rapid onset.  I've seen 10 minutes mentioned by people on here, but with the proper dosage of 1.0-1.5mg/kg I've never seen it last more than 3-5mins.   

We utilize NDNMB (Vec 0.1mg/kg) with patients that need to be kept down for prolonged transports (>20mins), otherwise we just keep 'em down with Midazolam.


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## MrBrown (Sep 7, 2010)

It seems RSI works a bit differently over your side of the world in that your sedation seems rather light.

Refer above, we use 1mcg/kg fentanyl and 1.5mg/kg ketamine unless the patient has neurogenic cause for coma with a GCS of < 10 in which case we use fentanyl and midazolam.


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## MasterIntubator (Sep 7, 2010)

Our ED uses Sux as first line unless contraindicated crush trauma, burns and by some of the rare side effects, just because it is faster and pretty much proven.  Then you have the occasional doc that wants Roc for the benefits of reversal, longer down time, better pain management post paralysis.  
They gave us the best option for field use to cover all the bases.  Would be nice to carry the both.... but that would probably be too much pressure on some of our medics...:wacko::wacko: Sometimes less options are better.


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## Veneficus (Sep 7, 2010)

MasterIntubator said:


> normally it does....



just so  i understand?

succs normally creates fasiculations so dramatic as to cause secondary injury to an injured spine or primary injury to an uninjured spine whent there is vertebral injury so great as to instigate it?


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## MasterIntubator (Sep 7, 2010)

My bad....  I guess I could have clarified.  I agree... it normally it does look like a twitch.  I have seen some look a bit more than twiches and could potentially cause issues if they were borderline to disecting.  That was just a concern I have read and heard thru the lines over time, never experienced any great motor movement to make me worry.... or make me say, "Ohh snap".  B)


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## Melbourne MICA (Sep 17, 2010)

*Fasiculations and other stuff.*

Iv'e never seen more than a quiver of the legs or arms or both when using sux for inductions. Most of the time you can barely notice anything at all. We use sux because it has a short half life. The reason being of course is the prospect of the failed intubation. 

As for those who say they don't pre-oxygenate before paralysis. Is that all the time? Considering many or even most patients needing a tube using RSI already have some level of airway +/- oxygenation issue that needs addressing and you paralyse the patient I would have thought lung fields saturated with O2 would'nt be such a bad thing - might give you that extra margin of error when you struggle to place the tube after giving them the sux. Otherwise watch the SpO2 go south like a plunging neck line.

Our pre-flight checks include monitoring and recording of all vitals including ensuring near 100% O2 sats before you turn off the lungs.

MM

PS On the RSI DAI terminology thing. I just put a post into the thread on the subject. DAI is not sedation to intubate. Drug assisted intubation is an umbrella term to describe using drugs to place a tube against intact airway and other reflexes eg gag and trismus. Thus RSI and sedate to tube are two types of "drug assisted" intubation.


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