# Pain management in RSI



## BEMS906 (Jun 11, 2013)

Iwe also have a polarizing paralytic..(vec). But I think the profalaytic use of analgesics and benzos is unneccisarry considering the half life of the etomidate is night then that of say 50mcg of feynt. (Which is our big boy for pain) why waste time and money on something that the pt doesn't need. If your rsing someone chances are they are spending some time in tge unit. Not going in for some day surgery and getting extibated in 3 hours. I don't see the logic in it. I know that if I don't feel the pt needs rapid sequence intubation just yet but is heading that wsy. I may try 5 of versed and 50  of feynt. And hope for that nod.. but for us rapid sequence intubation.by definition is different the medically assirid intubation.


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## Melclin (Jun 11, 2013)

Question for everyone: what is the reasoning behind the idea of limiting the indications for analgesia based on specific injury patterns in some EMS systems? Surely pain is pain is pain?



BEMS906 said:


> If a trauma pt is unresponsive, hypovolemia, be it absolute or relative is right up there on my concern list. Any type of narcotic would be a risk in dumping the pts pressure even more. I don't know that the question makes a lot of sense.



It is undoubtedly a concern in some cases but I think the 'danger' of iatrogenic hypotension or exacerbating existing hypotension is often exaggerated. I believe blanket rules like no morphine if BP<90 are ridiculous and I'm glad Im not subject to something like that.




BEMS906 said:


> What are you guys using for RSI ?  Fentanyl and versed.? We use paralytics and sedatives .no analgesics



Here, depending on if its a chopper or road ambulance and why you are being intubated, some combination of fentanyl, midazolam, ketamine and profol. All combinations involve some kind of analgesia and as a rule of thumb, pain producing illnesses will get some form of analgesia prior to RSI in many cases, if only to facilitate oxygenation/preparation. Fent/midaz/sux would be the most common by a decent margin I would think. Morphine/midazolam infusions are usually used to keep them down.

I dont intubate as part of my scope but my my reading of the literature and culture suggest analgesia is an extremely important part of intubation and not always just for the analgesic action itself.


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## Melclin (Jun 11, 2013)

BEMS906 said:


> Iwe also have a polarizing paralytic..(vec). But I think the profalaytic use of analgesics and benzos is unneccisarry considering the half life of the etomidate is night then that of say 50mcg of feynt. (Which is our big boy for pain) why waste time and money on something that the pt doesn't need. If your rsing someone chances are they are spending some time in tge unit. Not going in for some day surgery and getting extibated in 3 hours. I don't see the logic in it. I know that if I don't feel the pt needs rapid sequence intubation just yet but is heading that wsy. I may try 5 of versed and 50  of feynt. And hope for that nod.. but for us rapid sequence intubation.by definition is different the medically assirid intubation.



I'm having some trouble reading that post for several reasons but are you saying that your preference is to try to intubate with sedation only prior to attempting a tube with a paralytic and sedation? Does this extend to the head injured patients? Are you also intubating septic patients with etomidate? I thought that was a no no.

Im not that familiar with etomidate on account of the fact it isn't used much in Aus (to my knowledge), but I don't recall it having any analgesic action at all. Just because they can't tell you that they are experiencing pain doesn't mean they aren't or that it isn't having an effect on their physiology or more subtle overall experience of the process. The idea that a little pain never hurt anyone is such a lie.


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## Medic Tim (Jun 11, 2013)

BEMS906 said:


> What are you guys using for RSI ?  Fentanyl and versed.? We use paralytics and sedatives .no analgesics



I have fent, morphine, versed, Valium , ketamine, success and roc to choose from.


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## Christopher (Jun 11, 2013)

BEMS906 said:


> Iwe also have a polarizing paralytic..(vec). But I think the profalaytic use of analgesics and benzos is unneccisarry considering the half life of the etomidate is night then that of say 50mcg of feynt. (Which is our big boy for pain) why waste time and money on something that the pt doesn't need.



Please do not RSI folks with the attitude that paralytics or etomidate covers your post-intubation sedation and analgesia concerns...


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## BEMS906 (Jun 11, 2013)

The etomidate is a powerful short acting anesthetic and must be pushed prior to the succynocoline which is a non polorizing paralytic. These are the two most common drugs used in a hospital setting for rsi. And I'm not sure I understand your reference to sepsis. Allthough sepsis does have a high mortality rate and we are learning more and more about the importance of its pre hospital recognition. Ive yet to see a study where taking thier airway was deemed vital in thier outcome. I work in an urban setting doing 911 work.


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## BEMS906 (Jun 11, 2013)

Does anyone here work with paralytics pre hospitally?


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## chaz90 (Jun 11, 2013)

Christopher said:


> Please do not RSI folks with the attitude that paralytics or etomidate covers your post-intubation sedation and analgesia concerns...



That's up on my EMS nightmares list. Being paralyzed and not sedated is simply unimaginable to me, especially with an ET tube shoved in me. I'm thinking that my future tattoos will include "Do Not Backboard" and "Don't Forget the Versed."


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## BEMS906 (Jun 11, 2013)

Christopher said:


> Please do not RSI folks with the attitude that paralytics or etomidate covers your post-intubation sedation and analgesia concerns...



Not worried about post intubation during the pre  intubating a pt. I am worried about saving thier lives.  You guys had me questioning myself but I don't see anything about analgesics in any rsi protocols involving parlytics.


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## BEMS906 (Jun 11, 2013)

chaz90 said:


> That's up on my EMS nightmares list. Being paralyzed and not sedated is simply unimaginable to me, especially with an ET tube shoved in me. I'm thinking that my future tattoos will include "Do Not Backboard" and "Don't Forget the Versed."



Etomidate is pushed first.


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## NomadicMedic (Jun 11, 2013)

BEMS906 said:


> Iwe also have a polarizing paralytic..(vec). But I think the profalaytic use of analgesics and benzos is unneccisarry considering the half life of the etomidate is night then that of say 50mcg of feynt. (Which is our big boy for pain) why waste time and money on something that the pt doesn't need. If your rsing someone chances are they are spending some time in tge unit. Not going in for some day surgery and getting extibated in 3 hours. I don't see the logic in it. I know that if I don't feel the pt needs rapid sequence intubation just yet but is heading that wsy. I may try 5 of versed and 50  of feynt. And hope for that nod.. but for us rapid sequence intubation.by definition is different the medically assirid intubation.





BEMS906 said:


> Does anyone here work with paralytics pre hospitally?



Many of us have an RSI protocol that seems to be substantially more robust and complete than yours. We start with succinylcholine and etomidate and then continue sedation with versed, continue paralysis with vecuronium and add fentanyl to blunt the pain from having a tube shoved in the trachea. 

Seems like many of us have a bit more education as to the true management of the intubated patient, as well. 

I reread your post about not believing that pain management and additional sedation were necessary and was curious if you were actually serious or just posting drek to get a reaction.

If it was to get a reaction, you succeeded. If you're serious, you're dangerous.


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## chaz90 (Jun 11, 2013)

BEMS906 said:


> Etomidate is pushed first.



Etomidate wears off in like 6 minutes, possibly less depending on the person. By the time the Succinylcholine is gone, so is the Etomidate. For me, everyone gets post RSI Versed. The Vecoronium is optional and dependent on if they still need it to avoid trismus or hard core posturing etc., but there's no way I'm holding back sedatives on conscious, intubated patients. This experience is not one they want to remember.


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## BEMS906 (Jun 11, 2013)

DEmedic said:


> Many of us have an RSI protocol that seems to be substantially more robust and complete than yours. We start with succinylcholine and etomidate and then continue sedation with versed, continue paralysis with vecuronium and add fentanyl to blunt the pain from having a tube shoved in the trachea.
> 
> Seems like many of us have a bit more education as to the true management of the intubated patient, as well.
> 
> I reread your post about not believing that pain management and additional sedation was necessary and was curious if you were actually serious or just posting to get a reaction.



Maybe our systems are different. We have 5 level 1 trauma centers less then 10 minutes from away. Our longest transport time is 15 min and 90-95% of the time we are less then 5.


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## chaz90 (Jun 11, 2013)

BEMS906 said:


> Maybe our systems are different. We have 5 level 1 trauma centers less then 10 minutes from away. Our longest transport time is 15 min and 90-95% of the time we are less then 5.



Your initial Etomidate bolus still probably wore off before you got to the ED, and how long does it take before the ED staff starts getting their drugs and supplies together? Transfer of care isn't instantaneous, and sedation is the kind of thing that can be overlooked in a busy ED, especially when the patient is paralyzed and can't complain about it. Be a patient advocate, not an unthinking automaton. Your goal should be to do the best thing for your patients overall well being, comfort, and life rather than the bare minimum of dropping off a live patient with a pulse.


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## Carlos Danger (Jun 11, 2013)

BEMS906 said:


> Iwe also have a polarizing paralytic..(vec). But *I think the profalaytic use of analgesics and benzos is unneccisarry considering the half life of the etomidate is night then that of say 50mcg of feynt.* (Which is our big boy for pain) why waste time and money on something that the pt doesn't need. If your rsing someone chances are they are spending some time in tge unit. Not going in for some day surgery and getting extibated in 3 hours. I don't see the logic in it. I know that if I don't feel the pt needs rapid sequence intubation just yet but is heading that wsy. I may try 5 of versed and 50  of feynt. And hope for that nod.. but for us rapid sequence intubation.by definition is different the medically assirid intubation.



I really hope you aren't serious. 

If you are, you need some serious remedial education on the drugs you are pushing.




Melclin said:


> I'Are you also intubating septic patients with etomidate? I thought that was a no no.



Etomidate is fine in sepsis if its all you have. 

Probably not the best choice if you have options, but the cortisol suppression from a single dose is transient and has never been shown to negatively affect outcomes.


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## STXmedic (Jun 11, 2013)

BEMS906 said:


> Etomidate is pushed first.



As you said, etomidate is short acting. It's purpose is procedural sedation, not management. 

Imagine somebody RSIs you the method you're proposing. You're sedated with vec, induced with etomidate. Tube is passed. 10 minutes later the etomidate is wearing off. You're awake and aware of what's going on- feeling the pain of the tube between your cords as you bounce down the road. You can't buck the tube, or even communicate the pain it's causing because you're still paralyzed with vec. Vec does absolutely nothing for pain. The fear chaz described is from people getting inadequately sedated and getting inadequate analgesia. Inadequate sedation management is a common problem, but a problem all the same

There are many people here (who have already posted) that have paralytics and RSI protocols. Many of them are very well versed in the procedure. I've had it previously, too (though not where I currently work). I'm glad you began questioning your practices, and I urge you to continue to question, research, and learn more about it before you write off the advice here.


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## NomadicMedic (Jun 11, 2013)

BEMS906 said:


> Maybe our systems are different. We have 5 level 1 trauma centers less then 10 minutes from away. Our longest transport time is 15 min and 90-95% of the time we are less then 5.



Our systems are obviously very different. While transport time is obviously a factor, I think base education and belief in "doing the right thing" is important. I don't withhold pain meds or sedation due to a belief that "they'll get it eventually". I am also close to several hospitals and frequently have given a bolus of fentanyl as we arrive because I know it will be upwards of 20 minutes before they're seen by a doctor, orders get entered and the patient receives her next dose of medication. The same thing with RSI. I don't withhold pain medication or sedation simply because, "they will get it eventually"


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## Christopher (Jun 11, 2013)

chaz90 said:


> That's up on my EMS nightmares list. Being paralyzed and not sedated is simply unimaginable to me, especially with an ET tube shoved in me. I'm thinking that my future tattoos will include "Do Not Backboard" and "Don't Forget the Versed."



Indeed.



BEMS906 said:


> Does anyone here work with paralytics pre hospitally?



Yes.



BEMS906 said:


> Not worried about post intubation during the pre intubating a pt. I am worried about saving thier lives. You guys had me questioning myself but I don't see anything about analgesics in any rsi protocols involving parlytics.



RSI is way more than pushing paralytics.

RSI starts with the pre-pre-intubation stage. Positioning, oxygenation, contingency plans, hemodynamic optimization, etc. It continues with the pre-intubation phase with induction agents (and premedication depending on your protocols/take on the literature) and ensuring adequate O2 reservoir. Push your paralytic. *Work your airway plan*. Confirm success of the plan. Re-position the patient, adjust oxygenation/ventilation parameters, ensure hemodynamics are maintained, apply a sedation/analgesia package. Continue transport.

RSI is barely about putting a tube through the cords. This is perhaps the least important part of the whole ordeal (h/t to DSI/RSA).


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## Aidey (Jun 11, 2013)

BEMS906 said:


> The etomidate is a powerful short acting anesthetic and must be pushed prior to the succynocoline which is a non polorizing paralytic. These are the two most common drugs used in a hospital setting for rsi. And I'm not sure I understand your reference to sepsis. Allthough sepsis does have a high mortality rate and we are learning more and more about the importance of its pre hospital recognition. Ive yet to see a study where taking thier airway was deemed vital in thier outcome. I work in an urban setting doing 911 work.



To be picky, the accepted terms are depolarizing and non depolarizing. 

Also, etomidate is contraindicated in sepsis because it can cause adrenal suppression.


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## NomadicMedic (Jun 11, 2013)

Christopher really nailed it. The act of passing the tube is a relatively small entry on the RSI timeline. Post intubation management is, IMHO, the most vital part of the process. Keeping the patient well oxygenated and ventilated, managing pain, sedation and hemodynamics are not something to be considered as an afterthought.


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## Melclin (Jun 11, 2013)

*If I could just offer some advice BEMS*, it seems like there is a lot of confusion and argument being caused by an apparent lack of clarity in some of your posts. I assume you are not actually stupid enough to think any of the several odd things you have posted eg  that any paralytic is a "non-polarising agent", "half life of etomidate is night" etc. So if I may, I'd suggest that you take just a fraction more time to proof read your posts and add a bit more context and detail (just a little) to more clearly state your argument and avoid unnecessary misunderstandings. Everybody makes a few mistakes here and there but mate, most of your posts are utterly confusing and its a little hard to tell whether or not they are typos or if you actually think some of the things you are saying. 

Also, you've been asked several questions that you've completely failed to address or answered in a way whereby you state the obvious and fail to really address the point of the question ("etomiate is a short acting anaesthetic"..well yeah, but it doesn't really address the issue of analgesia or adrenal suppression or any of the other issues being discussed). I'm really not having a go at you mate but *in the interests of avoiding a thread that descends into argument based on misunderstandings and typos, there isn't much point in continuing with the discussion until you clear up a few of the details and give a little more context to some of your replies. *

Sepsis: Its not _that_ rare for septic patients to have a respiratory status or conscious state that leads to their being intubated. I wouldn't have thought the idea was that foreign. My point though was along the lines of the adrenal suppression issue addressed by halothane and aidey.





Halothane said:


> Etomidate is fine in sepsis if its all you have.
> 
> Probably not the best choice if you have options, but the cortisol suppression from a single dose is transient and has never been shown to negatively affect outcomes.



Gotcha. Cheers mate 




Christopher said:


> *Work your airway plan*. .



The first time I heard about vortex, I thought, "What a silly idea. Really if this is news to you, then maybe you shouldn't be intubating". But the more I think about it, the more I think its a brilliant conceptual tool to capture and frame an idea that, like most good ideas, seems obvious once thought of.


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## RocketMedic (Jun 11, 2013)

I'm skittish with intubating and medication-assisted intubation. Here, we use etomidate for procedural sedation. Versed is our (optional) induction aid. I personally drop versed and fentanyl for everyone I intubate.


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## Flight-LP (Jun 11, 2013)

BEMS906 said:


> The etomidate is a powerful short acting anesthetic and must be pushed prior to the succynocoline which is a non polorizing paralytic. These are the two most common drugs used in a hospital setting for rsi. And I'm not sure I understand your reference to sepsis. Allthough sepsis does have a high mortality rate and we are learning more and more about the importance of its pre hospital recognition. Ive yet to see a study where taking thier airway was deemed vital in thier outcome. I work in an urban setting doing 911 work.



Anectine is a depolorizing NMBA. 

Analgesia is an absolute with appropriate sedation in the RSI'd patient. Outside of it being a basic standard of care, could you imagine having a large piece of plastic shoved down into your trachea with mechanical changes in pressure throughout your chest? Barbaric comes to mind. Medicate your patients appropriately, that includes sedation, analgesia, and paralysis as needed. If you can't, then your system and MD has failed you and your patients.


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## Wes (Jun 11, 2013)

I could very easily see the lack of understanding of RSI and the underlying pharmacology (not to mention basic ethics -- first, do no harm) exhibited in some posts as the best arguments for a medical director NOT to trust medics with paralytics.


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## Tigger (Jun 11, 2013)

How did your private service get an OEMS RSI waiver without any consideration of post-procedure sedation?


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## Carlos Danger (Jun 11, 2013)

Wes said:


> I could very easily see the lack of understanding of RSI and the underlying pharmacology (not to mention basic ethics -- first, do no harm) exhibited in some posts as the best arguments for a medical director NOT to trust medics with paralytics.



This.

I have argued for a while now that RSI should not be a basic standard of care for paramedics. 

I have seen way too many who don't really understand the drugs, or the procedure, or who just don't have the skill and judgement to do it safely.


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## Wes (Jun 11, 2013)

For the record, at the services I've been involved with, it requires extra education, not only on the protocol itself, but airway management as well.   Our small rural service has it.   We also did a separate RSI course for our medics and additionally have purchased video scopes for intubation.  

Either you do RSI correctly or you don't do it.  Period.


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## Christopher (Jun 11, 2013)

Wes said:


> For the record, at the services I've been involved with, it requires extra education, not only on the protocol itself, but airway management as well.   Our small rural service has it.   We also did a separate RSI course for our medics and additionally have purchased video scopes for intubation.
> 
> Either you do RSI correctly or you don't do it.  Period.



Amen.

That includes the horrifically scary "DFI" practiced by many non-RSI services. If you're not allowed to RSI, why in the world would it appropriate to give massive doses of benzos to attempt an intubation?!


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## Wes (Jun 11, 2013)

Indeed.  I'm not sure how Etomidate alone would "facilitate" my obtaining an airway.


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## Carlos Danger (Jun 11, 2013)

Just to be intellectually honest about the necessity of analgesia.....

Done properly and atraumatically, intubation is not really painful. I do like to use fentanyl and very often do, but there are quite a few situations in the OR where you really want to minimize opioids and those people are intubated all day long with nothing but propofol, and they do perfectly fine that way.

Now, that said, we don't have the same considerations in the field that we do in the OR, and some pre-intubation fentanyl is certainly not a bad idea by any means. Especially in a head injured patient (which is the indication for probably 95% of prehospital RSI's), a healthy dose of fentanyl can help blunt the SNS response (ICP increase) to intubation. Personally, my first choice for a prehospital intubation of a head injured patient would probably be fentanyl & etomidate. Keep in mind that hypotension is one of the worst things you can do for a head injured patient......even a brief episode increases the risk of mortality by something like 50%?

Same thing post-intubation: adequate sedation alone should cover the discomfort of being intubated and ventilated. However, opioids can reduce the need for sedatives (or enhance their effectiveness, whichever way you look at it), and smaller doses of midazolam plus opioids may be less likely to negatively affect hemodynamics than large doses of midazolam alone. And of course, as several here have pointed out, analgesics certainly may be indicated to cover pain from traumatic injuries.


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## Carlos Danger (Jun 11, 2013)

Christopher said:


> Amen.
> 
> That includes the horrifically scary "DFI" practiced by many non-RSI services. If you're not allowed to RSI, why in the world would it appropriate to give massive doses of benzos to attempt an intubation?!



It's one of the worst things I've ever seen. 

For some reason though, quite a few people hold the misconception that it is safer than using NMB's.


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## VFlutter (Jun 11, 2013)

BEMS906 said:


> The etomidate is a powerful short acting anesthetic and must be pushed prior to the succynocoline which is a non polorizing paralytic. These are the two most common drugs used in a hospital setting for rsi.



How much time have you spent assisting or performing RSI in the hospital setting? Are you referring to the ED only? I can assure you our CCPs and MDAs have a much broader repertoire

Did you just watch the tube get passed and walk out? You seem to have missed that whole post-RSI care thing and the part about hanging maintenance infusions. Walk into an ICU and check the drips on a vented patient. On second thought I don't think you should be anywhere near an ICU


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## Wes (Jun 11, 2013)

This is the same person, who, in another thread, is an EMT for BEMS and a paramedic for a private service -- and looking to move to another locale to work basing his decision, in part, on the amount of penetrating trauma.

As we'd say in the legal arena, "Res ipsa loquitor."  The thing speaks for itself.


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## NomadicMedic (Jun 11, 2013)

Stultus est sicut stultus facit.


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## Wes (Jun 11, 2013)

Impressive!  Did you take Latin?


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## NomadicMedic (Jun 11, 2013)

In high school. And mass. 

But I have a masters in "Google Translate".


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## Wes (Jun 11, 2013)

Junior high, high school, and college.   And nope, I'm not even Catholic.


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## medicsb (Jun 11, 2013)

Wes said:


> This is the same person, who, in another thread, is an EMT for BEMS and a paramedic for a private service -- and looking to move to another locale to work basing his decision, in part, on the amount of penetrating trauma.
> 
> As we'd say in the legal arena, "Res ipsa loquitor."  The thing speaks for itself.



Yeah, it certainly does.


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## RocketMedic (Jun 11, 2013)

I do not intubate many people, and I generally consider a working King LTas a reasonable airway. I am fairly scared of an etomidate only "facilitated intubation". Does this make me a good paramedic or overly worried?


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## Wes (Jun 11, 2013)

I'd like to think that a jury would consider you "reasonable and prudent."


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## NomadicMedic (Jun 11, 2013)

Rocketmedic40 said:


> I do not intubate many people, and I generally consider a working King LTas a reasonable airway. I am fairly scared of an etomidate only "facilitated intubation". Does this make me a good paramedic or overly worried?



So, lets stop and think about this for a second. The real reason we use paralytics is to prevent regurgitation. Etomidate doesn't prevent regurg. Neither, contrary to every paramedic text, does the Selleck Maneuver. 

Can you tube someone with just Etomidate? Sure. Is it the right thing to do? Nope. And I'm sure a bad outcome following an etomidate only DFI could be litigated successfully if an expert witness started asking about standard of care and how the DFI protocol doesn't meet it...

But I digress. 

When the RSI algorithm was developed, they didn't just throw meds in there for the heck of it. If your service doesn't trust the medics enough to hand then the keys to true RSI as expects them to give it the old college try with etomidate only, it time to start rattling the bars. Get on the protocol committee. Open a dialogue with the medical director. Start making some noise and asking why. "Because we've always done it this way" isn't an answer that should satisfy a thinking paramedic.


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## RocketMedic (Jun 11, 2013)

That soothes me...I personally try and avoid the cowboy medic attitude where I can.


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## medicsb (Jun 11, 2013)

DEmedic said:


> Can you tube someone with just Etomidate? Sure. Is it the right thing to do? Nope. And I'm sure a bad outcome following an etomidate only DFI could be litigated successfully if an expert witness started asking about standard of care and how the DFI protocol doesn't meet it...



You probably have a much greater chance of litigation if something goes wrong with RSI.  How much evidence exists showing prehospital etomidate-only to be associated with bad outcomes?  How much exists showing prehospital RSI to be associated with bad outcomes?  I think we can guess how most experts would testify.


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## Handsome Robb (Jun 12, 2013)

BEMS906 said:


> The etomidate is a powerful short acting anesthetic and must be pushed prior to the *succynocoline which is a non polorizing paralytic.* These are the two most common drugs used in a hospital setting for rsi. .



This scares me.

Sux is a*de*polarizing neuromuscular blocker. There are depolarizing and non-depolarizing neuromuscular blockades. Depolarizing neuromuscular blockers cause all the muscles to depolarize leading to fasiculations (sp?) and then flaccidity since the muscles cannot re-polarize whereas a non-depolarizing neuromuscular blocker blacks the ability for the muscles to depolarize and thus contract which results in flaccidity as well. With non-depolarizing agents you don't have to wait for the fasiculations to cease because they never start. 

That's my oversimplified, self-self taught, rudimentary understanding of neuromuscular blockers.

While it happens all the time with only etomidate and sux (in that order) but is immediately followed by some sort of analgesic as well as a sedation drip  and long acting paralytics.

What scares me is the lack of knowledge of the meds you're using. 

Just because someone is sedated and paralyzed doesn't mean their brain won't have a sympathetic response to painful stimuli that can be detrimental to the pt....for example a paralyzed and sedated head injury spiking their ICP due to lack of analgesia post intubation.

We don't do RSI on the ground but our flight medics do: 

Versed OR etomidate OR ketamine PLUS* fentanyl 2-3 mcg/kg* PLUS succinylcholine OR rocuronium OR vecuronium for intubation.

For maintaining paralysis and sedation they do versed/fent OR ketamine PLUS norcuron or rocuronium.

If you want I can provide dosing if you'd like. Didn't because it made it look very cluttered on my phone. 

I


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## Dwindlin (Jun 12, 2013)

DEmedic said:


> The real reason we use paralytics is to prevent regurgitation.



Yeah no. Paralytics assist with actually getting the tube in (assuming you actually wait long enough), a paralyzed patient is at higher risk for aspiration (hence NPO recommendations for elective OR cases). Totally agree with on cric pressure though, I think it's bunk for preventing aspiration.


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## Carlos Danger (Jun 12, 2013)

Dwindlin said:


> Yeah no. Paralytics assist with actually getting the tube in (assuming you actually wait long enough), a paralyzed patient is at higher risk for aspiration (hence NPO recommendations for elective OR cases). Totally agree with on cric pressure though, I think it's bunk for preventing aspiration.



The fasciculations that follow succinynlcholine actually increase intragastric pressure.

Although, it is true that the RSI procedure was developed primarily as a way to prevent aspiration. The idea of using paralytics was (and still is) that they make it easier / faster to intubate, therefore reducing the likelihood of aspiration.


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## NomadicMedic (Jun 12, 2013)

medicsb said:


> You probably have a much greater chance of litigation if something goes wrong with RSI.  How much evidence exists showing prehospital etomidate-only to be associated with bad outcomes?  How much exists showing prehospital RSI to be associated with bad outcomes?  I think we can guess how most experts would testify.



How may programs perform RSI and allow it as etomiodate only? I believe any expert witness, testifying on behalf of the family that suffered the bad outcome, could clearly show that an elective etomidate only RSI, not a "crash airway", is not the norm and the patient didn't receive all of the medications that are used, per standard, to achieve successful airway management.


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## Carlos Danger (Jun 12, 2013)

DEmedic said:


> How may programs perform RSI and allow it as etomiodate only? I believe any expert witness, testifying on behalf of the family that suffered the bad outcome, *could clearly show that an elective etomidate only RSI, not a "crash airway", is not the norm and the patient didn't receive all of the medications that are used, per standard,* to achieve successful airway management.



This is it. When you read closed-claims data, it almost always comes down to "did this practitioner follow the standard of care"? Did they follow generally accepted recommendations? Did they follow institutional policy? Did they act in a way that another similarly-trained practitioner would act? If they did deviate, did they have a good reason for it, in the opinion of expert witnesses?

For a paramedic, that pretty much just means "did he follow his protocol they way it was intended, and did he show good judgment within the confines of that protocol"? It's not the paramedics fault if he didn't have the proper drugs in his drug bag. 

For his medical director who wrote a lousy protocol......I imagine it could get much more complicated.


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## medicdan (Jun 12, 2013)

**Paging boingo or TOTWTYTR to clarify???***


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## medicsb (Jun 12, 2013)

DEmedic said:


> How may programs perform RSI and allow it as etomiodate only? I believe any expert witness, testifying on behalf of the family that suffered the bad outcome, could clearly show that an elective etomidate only RSI, not a "crash airway", is not the norm and the patient didn't receive all of the medications that are used, per standard, to achieve successful airway management.



Well, RSI isn't RSI if there isn't a paralytic.   But, there are many places that use only etomidate or versed to try and facilitate intubation.  Probably a lot more than places that use paralytics.  Regardless, paralytics are not a "must" for intubation even if you have access to paralytics (that would be "cookbook" medicine).  And as usual, standard of care is largely dictated at the local level, but even at the national level, RSI is in no way a standard of care for EMS.  It is a dubious procedure (in the prehospital setting) that has been shown to be associated with worse outcomes, and it may or may not be performed proficiently by the services using it.  As usual, other than some medics wishing and wanting it really really bad, there is nothing to suggest that giving paramedics paralytics improves patient outcomes outside of systems with very low numbers of paramedics.

If something goes bad during an intubation, the plaintiff will claim you didn't know what you were doing regardless of what you used.  I suppose you could find some "expert" who will accept a large chunk of change to say "that [bad outcome] would not have happened if Paramedic Wacker just gave succs", but it'd be easier to find someone to say "Paramedic Whacker should have just used a BVM" or "transported to the nearest hospital", etc.


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## Dwindlin (Jun 12, 2013)

medicsb said:


> Well, RSI isn't RSI if there isn't a paralytic.   But, there are many places that use only etomidate or versed to try and facilitate intubation.  Probably a lot more than places that use paralytics.  Regardless, paralytics are not a "must" for intubation even if you have access to paralytics (that would be "cookbook" medicine).  And as usual, standard of care is largely dictated at the local level, but even at the national level, RSI is in no way a standard of care for EMS.  It is a dubious procedure (in the prehospital setting) that has been shown to be associated with worse outcomes, and it may or may not be performed proficiently by the services using it.  As usual, other than some medics wishing and wanting it really really bad, there is nothing to suggest that giving paramedics paralytics improves patient outcomes outside of systems with very low numbers of paramedics.
> 
> If something goes bad during an intubation, the plaintiff will claim you didn't know what you were doing regardless of what you used.  I suppose you could find some "expert" who will accept a large chunk of change to say "that [bad outcome] would not have happened if Paramedic Wacker just gave succs", but it'd be easier to find someone to say "Paramedic Whacker should have just used a BVM" or "transported to the nearest hospital", etc.



Not to mention that most services with paralytics don't even do true RSI (paralytic pushed with induction agent).  I agree with everything you've said.  As I've progressed I question more and more the utility of pre-hospital intubation with so many other options.


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## Carlos Danger (Jun 13, 2013)

Dwindlin said:


> Not to mention that *most services with paralytics don't even do true RSI (paralytic pushed with induction agent)*.  I agree with everything you've said.  As I've progressed I question more and more the utility of pre-hospital intubation with so many other options.



What have you seen? Most (definitely not all) of the places I've seen had a pretty decent, "true RSI" protocol; the problems came from a lack of skill and judgement on the part of the paramedics implementing them.

I do see poor post-intubation sedation as a very common thread in EMS. If you are giving vec post-intubation, you damn well oughtta be giving more than .5 mg of midazolam with it.....


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## chaz90 (Jun 13, 2013)

Dwindlin said:


> Not to mention that most services with paralytics don't even do true RSI (paralytic pushed with induction agent).  I agree with everything you've said.  As I've progressed I question more and more the utility of pre-hospital intubation with so many other options.



What do you mean true RSI? I don't profess to be an expert on induction agents, but Etomidate is widely regarded to be an appropriate sedative to use for RSI. Most services I've heard of do use Etomidate with their initial paralytic, with some also having the option to use Ketamine or other meds. Most variety appears to be in post procedural care.


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## Carlos Danger (Jun 13, 2013)

chaz90 said:


> What do you mean true RSI? I don't profess to be an expert on induction agents, but Etomidate is widely regarded to be an appropriate sedative to use for RSI. Most services I've heard of do use Etomidate with their initial paralytic, with some also having the option to use Ketamine or other meds. Most variety appears to be in post procedural care.



Etomidate is an excellent agent for emergency induction. It's just not at all a good drug to use by itself, without a NMB. 

Ketamine would be my first choice for a field intubation where I couldn't use a NMB.


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## Wes (Jun 13, 2013)

I need to find the article, but there's a concept called delayed sequence intubation where you sedate/premedicate the patient with Ketamine, then passively oxygenate with a NRB prior to determining if the patient actually requires intubation.


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## Wes (Jun 13, 2013)

Here's one link to the concept:  http://www.medscape.com/viewarticle/745228_4


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## NomadicMedic (Jun 13, 2013)

We've gotten pretty far off-topic. This is a good discussion however. I'll split off the RSI comments into a new thread.


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## Carlos Danger (Jun 13, 2013)

Wes said:


> I need to find the article, but there's a concept called delayed sequence intubation where you sedate/premedicate the patient with Ketamine, then passively oxygenate with a NRB prior to determining if the patient actually requires intubation.





Wes said:


> Here's one link to the concept:  http://www.medscape.com/viewarticle/745228_4




I think this was the original blog post that described it: EMCrit DSI

I'm not a big fan of the idea. 

The entire point of the procedure is the avoidance of even a brief period of apnea in an already-hypoxic patient. The problem, though, is there is no guarantee that their respiratory status won't worsen with sedation. Ketamine in the right dose generally maintains respiratory drive, but it's not uncommon to see a brief apneic period or a reduction in minute volume. This would defeat the entire purpose of the procedure, IMO. 

A potential problem is this: you put the patient on high-flow oxygen or CPAP, and their oxygenation improves. Their color looks better, their Sp02 is up, their respiratory rate is down. They are nice and calm and you think that's a result of the sedation and improving oxygenation, but in reality their acidosis is worsening because they aren't ventilating adequately. That could happen to even a good clinician, and it could end very badly. 

Also, the idea of giving PPV to a critical patient who is confused, sedated, and non-NPO makes me a little uneasy....pick any two of those 4 and we're probably good, but together it's just too much badness for my liking.

I guess to me, the patient described in the scenario is sick enough that they just need to be intubated. If you are afraid ETI might be difficult and take too long, just drop your SGA right off the bat. I suppose a trial of bipap might be appropriate, of course it would depend on the specifics.


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## Dwindlin (Jun 13, 2013)

The Delayed Sequence stuff is what I see the vast majority of the time, which is fine most of the time.  I don't know of any services here that push their induction and paralytics at the same time (if I'm going to truly RSI someone I mix my induction agent and paralytic in the same syringe).  And I don't bag them at all (after pushing meds), since you're kinda defeating the purpose of RSI, which is tube in as fast as possible while minimizing anything that will increase chance of aspiration.


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## Handsome Robb (Jan 5, 2014)

Redacted due to the resurrection and because I didn't read the whole thread and posted the exact same thing I did in my original post in this thread...tapatalk recommended it and I didn't look at the date...


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## STXmedic (Jan 5, 2014)

Robb said:


> Redacted due to the resurrection and because I didn't read the whole thread and posted the exact same thing I did in my original post in this thread...tapatalk recommended it and I didn't look at the date...



Smh... Dispatchers...


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