# Rapid Sequence Induction HOWTO?



## Aprz (Dec 22, 2012)

Brown (he's in a retirement home) and I were talking about rapid sequence induction.. I remember he used to talk about it all the time, and I forgot a lot about it since I've read my airway chapter in my paramedic textbook. He disagreed with my book. I wanted to hear how do you guys do it, what do you think is wrong with how my book described.

1. Prepare your equipment.

2. Consider atropine (dose: 0.5 mg for adult, 0.1-0.2 mg/kg for pediatrics) for bradycardia, especially in kids. Succinylcholine is like an acetylcholine receptor agonist and can cause bradycardia I guess. Lidocaine (1.0-1.5 mg/kg any age) for increase intracranial pressure (ICP) or arrhythmias because intubating can increase ICP or cause arrythmias (personally, I thought it usually stimulated the vagus (X) nerve and caused bradycardia, which is one reason why you shouldn't suction for too long). Consider a sedative like midazolam (dose: adult 2-5 mg, didn't recommend for pediatrics) so the patient doesn't remember being intubated and paralyzed.

3. Preoxygenate the patient as best as you can. If you can't prior to induction, you may have to do it as you do the procedure itself.

4. Administer 10% of the initial dose of a nondepolarizing agent like vecuronium bromide (initial dose: 0.1 mg/kg) or pancuronium bromide (initial dose: 0.06-0.01 mg/kg) to cause weakness, not paralysis.

5. Administer succinylcholine (dose: 1.5-2.0 mg/kg), a depolarizing agent, to cause paralysis.

The book said that you wanted to cause weakness, not complete paralysis, so the patient can still breath on their own. Then succinylcholine because it has a short half life, and it will cause paralysis, but if you bail on intubating, you don't have to have to bag for that long.

6. Intubate.

7. After confirming that you've successfully intubated the patient, administer the remaining initial dose of the nondepolarizing agent.

8. Maintain. Readminister vecuronium bromide (0.01-0.015 mg/kg) every 20-45 minutes) or pancuronium bromide (0.01 mg/kg) every 20-60 minutes. Midazolam (2-5 mg) every 2-3 minutes. <_<

Does that sound right? What would you do differently?

I don't know of any county nearby that allows rapid sequence induction. I just wanna know it. Posting this for my sake also just to remember the dose, ordering, and reason. In paramedic school, rapid sequence induction, or they said intubation, covered it by saying "RSI, you'll never do that", and moved on. I personally don't believe they know how to do it either.


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## Fish (Dec 22, 2012)

See PM


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## Veneficus (Dec 22, 2012)

Aprz said:


> Brown (he's in a retirement home) and I were talking about rapid sequence induction.. I remember he used to talk about it all the time, and I forgot a lot about it since I've read my airway chapter in my paramedic textbook. He disagreed with my book. I wanted to hear how do you guys do it, what do you think is wrong with how my book described.
> 
> 1. Prepare your equipment.
> 
> ...



Have to come up with 3 characters in addition to the answers in quotes.


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## Christopher (Dec 22, 2012)

Aprz said:


> The book said that you wanted to cause weakness, not complete paralysis, so the patient can still breath on their own. Then succinylcholine because it has a short half life, and it will cause paralysis, but if you bail on intubating, you don't have to have to bag for that long.



If you're performing RSI you probably had an indication for it...one which wasn't they were doing a great job breathing on their own.

So paralyze to paralyze or don't RSI.


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## Fish (Dec 22, 2012)

Set up equipment

Place Patient on Monitor and NC at 6lpm even if bagging

Obtain IV/IO access

Push 2mg/kg Ketamine
Push 2mg/kg Succs
Increase NC to 15lpm
Apply cricoid pressure as needed
Intubate (confirm placement, Capnography, Lung Sounds, Etc...)
Discontinue NC
Push Versed 0.1mg/kg to max of 10mg
Push 1mcg/kg of Fent

Continue to monitor patients airway and need for further medication

This is not copy and pasted verbatum from the protocols, just a meat and potatoes.


Where did you go to Medic school? Maybe they said "You'll never do that" Because they do not do it where you work or in surrounding areas? BUt many agencies around the country do.


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## FLdoc2011 (Dec 22, 2012)

Agree with Vene, I really don't see a need for an initial "low dose" paralytic prior to the actual full paralytic dose.  I've actually never seen that done.  

The general gist of what you had is correct:
-get everything set up and ready
-pre-oxygenate
-Induction agent
-paralytic agent
-intubate

Goal of RSI is to intubate without BVM ventilation.  You're assuming there's a full stomach and you don't sit there for several minutes bagging the patient while trying to titrate sedatives.   Weight based dosages are given in a short span of time to render patient unconscious and paralyzed.   

Depending on the patient and scenario (increased ICP, COPD, hypotension), will play a role in which meds you use and if you use any additional agents such as lidocaine, fentanyl, etc...  

In the hospital setting here I usually use etomidate, versed or even propofol for induction (depending on scenario and other factors). Then it's usually succs or vec for paralysis.


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## Shishkabob (Dec 22, 2012)

If you're going to administer a paralytic, don't half *** it, give it.  If you've come to the point where RSI is the proper decision, get it done.  Giving less to "weaken them" (which I've never heard of anyway) is wasting time, and is potentially dangerous due to the fact that everyone reacts differently to different doses of drugs.  I'd given a patient 100mg of Roc before and all it did was slow their breathing from 50+ to 16.  

I'm also not a fan of succs anyhow.  


When I RSI'd, it was 3mcg/kg of Fent, 0.3mg/kg of etomidate, and 1mg/kg of Roc.  It got the job done when I needed it to.



Go on Amazon and get the "Manual of Emergency Airway Management"


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## Christopher (Dec 22, 2012)

Linuss said:


> Giving less to "weaken them" (which I've never heard of anyway) is wasting time, and is potentially dangerous due to the fact that everyone reacts differently to different doses of drugs.



In their defense giving a "defasiculating dose" of the non-depolarizing paralytic prior to a the full dose of a depolarizing paralytic is standard in textbooks.

Perhaps they worded it awkwardly, it isn't to weaken them but rather to keep fasiculations from occurring.


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## NomadicMedic (Dec 22, 2012)

Agreed. The defasciculating dose of the depolarizing paralytic is taught in every RSI class… Nobody ever does it. 

For me it's it etomidate, succinylcholine … The tube… then Vecuronium and versed. 

Although, I was taught by an anesthesiologist that 2 mg of midaz prior to the administration of etomidate will reduce the possibility of trismus associated with it.


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## lightsandsirens5 (Dec 22, 2012)

Linuss said:


> If you're going to administer a paralytic, don't half *** it, give it.  If you've come to the point where RSI is the proper decision, get it done.  Giving less to "weaken them" (which I've never heard of anyway) is wasting time, and is potentially dangerous due to the fact that everyone reacts differently to different doses of drugs.  I'd given a patient 100mg of Roc before and all it did was slow their breathing from 50+ to 16.
> 
> I'm also not a fan of succs anyhow.
> 
> ...




We've got ketamine here now to Linuss.

: happydance:


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## Shishkabob (Dec 22, 2012)

lightsandsirens5 said:


> We've got ketamine here now to Linuss.
> 
> : happydance:



Yeah we have it here now too, due to the etomidate shortage...


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## MagicTyler (Dec 22, 2012)

The OP doesnt mention sedation until after paralysis... Please Please Please sedate your patients prior to making them paralized!


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## Fish (Dec 22, 2012)

MagicTyler said:


> The OP doesnt mention sedation until after paralysis... Please Please Please sedate your patients prior to making them paralized!



Yes! To not is cruel!


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## Aprz (Dec 22, 2012)

My bad, the book did mention it being the defasciculation dose, but I feel like it mentioned all over the place to not giving the remainder of the medication until after the tube has been secured, and I felt like that was for to back out.



> The defasciculation dose is typically 10% of the normal dose; it does not induce paralysis, but does cause weakness.



Thanks Linuss, I'll go buy that book with Christmas money, haha. Actually gonna work a ton over the holidays cause nobody wanted to work those shifts. Holiday pay too.

I did mention sedation at the bottom of step 2, lol. Not that it matters, but in the book, they called it the premedicate stage and clumped it together. The book said to maintain sedation after intubating. I've never seen midazolam used/given, but that's probably because I work in IFT in Santa Clara County, Alameda County, and Contra Costa County, CA. From what I've read, it seems like midazolam has a pretty short half life/doesn't last long. It's great to sedate quickly, but sounds like you'd have to keep pushing it every couple of minutes to keep them sedated. Am I correct?

Just so y'know, I think I got the take home point: go big or go home. 

Edit: My class is taught in Santa Clara County, CA. I'm 4 months into it.


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## systemet (Dec 22, 2012)

I think there's been Cochrane's on both atropine in peds send lidocaine in head injury / CVA and there's little evidence for either practice beyond tradition.

Defasciculation sounds logical, although I've never seen it done outside of through OR. If anyone has good references on what it does to the risk of succinylcholine-induced hyperkalemia or MH, I'd love to see them.

Preoxgenation is key to preventing desaturation  if you end up in a difficult airway situation. This can be accomplished with a NRB or BVM, and seems one of the few reasonable times to use FiO2 1.0 on someone normally saturated.

My experience has been that many EMS systems use very low doses of midazolam (mine limits me to 5mg as a single dose, which seems barely adequate even when combined with fentanyl). It seems like physicians are more willing to use a true 0.1mg/kg and enter the 10 mg range.

Anecdotally, it seems like the onset for midazolam is quite slow. I've never been comfortable pushing the versed then the sux, the same way you can with an anesthetic agent like ketamine. A fair percentage of my patients have been hyperventilating and needing PPV when using midazolam.

As usalsfyre and others are fond of pointing out - I'd be reluctant to rely on the sux wearing off prior to critical hypoxia developing. Paralysis can bring its own problems, particularly if the patient is hyperventilating  or is status asthmatics.


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## Aprz (Dec 22, 2012)

I liked that Fish mentioned using a nasal cannula instead of a non rebreather or bag valve mask. Reminds me of an article I read on ems1.

http://www.ems1.com/airway-manageme...eic-oxygenation-Everything-you-know-is-wrong/


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## systemet (Dec 22, 2012)

Just to add to the above - most patients that need paralysis for incubation don't need long-term paralysis postintubation. I think we often jump the gun on this in EMS.


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## Aprz (Dec 22, 2012)

Systemet, how come? Instead of a paralytic, just maintain sedation instead?


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## NomadicMedic (Dec 22, 2012)

Ill agree with not needing a long term paralytic in most cases. However, we are told to have trauma patients paralyzed as well as sedated when flying them. 

When I asked why, I was given some anecdotal story of a trauma patient waking up in the helicopter and becoming violent. When I mentioned that it sounded like inadequate sedation, the person changed the subject. 

I just keep them sedated with midaz. It works for me.


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## Aprz (Dec 22, 2012)

How often would you readminister midazolam? Every 2-3 minutes? The book didn't mention a sedation dose in this procedure, but the dose I was taught in school was 2-5 mg q 2-3 minutes to a max of 0.1 mg/kg. Seems like I'd be giving a lot of midazolam in a short amount of time.


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## NomadicMedic (Dec 22, 2012)

It's not THAT short acting. The duration of action varies per person and dose, but 10mg seems to be an adequate sedation dose for my short, under 20 minute transports.


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## Veneficus (Dec 22, 2012)

Aprz said:


> How often would you readminister midazolam? Every 2-3 minutes? The book didn't mention a sedation dose in this procedure, but the dose I was taught in school was 2-5 mg q 2-3 minutes to a max of 0.1 mg/kg. Seems like I'd be giving a lot of midazolam in a short amount of time.



Midaz usually works about 40 minutes for me. *Edit* In doses of 0.075mg/kg-0.15mg/kg

(forgot to list the range)


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## systemet (Dec 22, 2012)

Aprz said:


> Systemet, how come? Instead of a paralytic, just maintain sedation instead?



The idea of paralysing the patient during the intubation procedure is to prevent any gag reflex that remains -- depending on the sedative / anesthetic used, the gag may be gone, minimal, or fully present, and to relax the muscles of the jaw.  This is particularly useful when the patient has trismus, but generally (but not always) improves visualisation, even when the patient isn't clenched.

Once the tube is through the glottis, and there's no longer a big piece of metal sitting in the vallecula, there's less stimulation of the gag reflex.  Often sedatives and analgesics (or an agent with both properties like ketamine), are enough to allow the patient to tolerate the tube.

Where post-intubation paralysis becomes more appealing is if your patient's spontaneous respirations or reflex activity are interfering with ventilation, which is usually a product of using a low quality ventilator, like we tend to do in EMS.  Or in the rare instance that you're intubating someone with intractable seizures, which is controversial, as now you're masking the signs of the seizure that you need to continue actively treating.

Often much of the patient "fighting the ventilator", is a failure of ongoing sedation/analgesia.  In my region we give aliquots ketamine or fentanyl and midazolam q 10 minutes depending on the pressure and the need.  A better approach might be to run both as an infusion on a longer transport, to avoid the peaks and troughs of bolus administration.

It's much easier to assess the level of sedation if you haven't used a long-acting neuromuscular blocker.  Obvious signs of being a little light would include things like tachycardia, spontaneous movement, spontaneous respirations, and respirations that interfere with ventilation.  

You will still see things like tachycardia and tearing if the patient is paralysed and undersedated, but once you start seeing significant tachycardia and tearing, it's a sign that you haven't done your job properly.


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## systemet (Dec 22, 2012)

Veneficus said:


> Midaz usually works about 40 minutes for me. *Edit* In doses of 0.075mg/kg-0.15mg/kg
> 
> (forgot to list the range)



I think this is the problem I'm seeing. We're giving 0.1mg/kg (max 5mg), which is really 0.1mg/kg for anyone under 50kg, and about 0.05mg/kg for someone who's 100kg.  Admittedly, we're giving this with fentanyl and there's some synergism there, but the onset seems pretty slow.


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## Fish (Dec 22, 2012)

systemet said:


> I think this is the problem I'm seeing. We're giving 0.1mg/kg (max 5mg), which is really 0.1mg/kg for anyone under 50kg, and about 0.05mg/kg for someone who's 100kg.  Admittedly, we're giving this with fentanyl and there's some synergism there, but the onset seems pretty slow.



We max at 10mg, along with Fent. 5mg is pretty low.


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## Aprz (Dec 22, 2012)

I believe I read somewhere that you can judge if a patient is sedate well based on their pleth waves too. I'll Google that now.

Edit: And also other things like tachycardia and movement would make sense. Not going to base it on just one thing.


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## systemet (Dec 22, 2012)

Aprz said:


> I believe I read somewhere that you can judge if a patient is sedate well based on their pleth waves too. I'll Google that now.



You can see "curare notching" on capnograph waveforms, but this is just ineffective patient generated inspiration.



> Edit: And also other things like tachycardia and movement would make sense. Not going to base it on just one thing.



Never thought you would. All the best.


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## Fish (Dec 22, 2012)

Aprz said:


> I believe I read somewhere that you can judge if a patient is sedate well based on their pleth waves too. I'll Google that now.
> 
> Edit: And also other things like tachycardia and movement would make sense. Not going to base it on just one thing.



Bucking the tube, tearing up in the eyes, etc... lots of waysto tell.


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## Veneficus (Dec 22, 2012)

systemet said:


> I think this is the problem I'm seeing. We're giving 0.1mg/kg (max 5mg), which is really 0.1mg/kg for anyone under 50kg, and about 0.05mg/kg for someone who's 100kg.  Admittedly, we're giving this with fentanyl and there's some synergism there, but the onset seems pretty slow.



I can see where such a low dose is the problem. 0.075mg at 70kg is 5.25mg, at 80 is 6mg

If you up that to even 0.1 you are almost doubling the dose.

I usually use the 0.15 when I am not mixing it as a cocktail. Fent lasts approximately just as long, but I still much prefer morphine for the longer action as well as some beneficial side effects.


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## Veneficus (Dec 22, 2012)

In the above post the "doubling" refers to the amount given based on the 5mg max protocol talked about. 

Thought I should clarify that.


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## Smash (Dec 23, 2012)

systemet said:


> Defasciculation sounds logical, although I've never seen it done outside of through OR. If anyone has good references on what it does to the risk of succinylcholine-induced hyperkalemia or MH, I'd love to see them.



No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux.  It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.

I have to admit a personal bias in that I find bolus dosing of sedation to be a bad idea.  It is far to easy to lose track of time and have unwanted peaks and troughs of analgesia and sedation, which does no-one any good.

I've said it a million times before: RSI needs to be done properly or not at all.


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## NomadicMedic (Dec 23, 2012)

Smash said:


> No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux.  It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.
> 
> I have to admit a personal bias in that I find bolus dosing of sedation to be a bad idea.  It is far to easy to lose track of time and have unwanted peaks and troughs of analgesia and sedation, which does no-one any good.
> 
> I've said it a million times before: RSI needs to be done properly or not at all.



So you're saying we shouldn't perform sedation unless we have the ability to run the benzo as a continuous infusion?


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## MSDeltaFlt (Dec 23, 2012)

Smash said:


> No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux.  It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.
> 
> I have to admit a personal bias in that I find bolus dosing of sedation to be a bad idea.  It is far to easy to lose track of time and have unwanted peaks and troughs of analgesia and sedation, which does no-one any good.
> 
> I've said it a million times before: RSI needs to be done properly or not at all.



If you "lose track of time", then you've lost your situational awareness and probably shouldn't be allowed to perform this procedure.  There is a difference between giving a sedative and sedating your pt as there is a difference between giving a pain med and treating pain.  If you truly sedate your pt then they will be more likely to relax and stop breathing and allow intubation.

In my humble, honest opinion.


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## Smash (Dec 23, 2012)

n7lxi said:


> So you're saying we shouldn't perform sedation unless we have the ability to run the benzo as a continuous infusion?



Whilst I appreciate that every service, every protocol is different, I'm saying that that is my personal bias, yes.  Notwithstanding Mikes comments above, even the most switched on, time conscious paramedic cannot help but give their patient varying levels of sedation and analgesia if they are relying on bolus dosing.  You may get away with it if your transport time is very short, but otherwise you will almost inevitably have peaks and troughs.  It may not even make any difference in the long run to the patient, but I personally feel like it is sub-optimal.  
The only time I give a bolus of sedation+analgesia is immediately post the tube being passed as generally sedation and analgesia is given a little too conservatively during induction for my liking, so I like to top them up a little then start the fentanyl/midazolam infusion (or ketamine or propofol or whatever)


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## NomadicMedic (Dec 23, 2012)

I'm curious how many ALS agencies, aside from CCT trucks, allow a sedation infusion. I've not seen any...


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## jwk (Dec 24, 2012)

n7lxi said:


> I'm curious how many ALS agencies, aside from CCT trucks, allow a sedation infusion. I've not seen any...



Why would you need it?

On a critical patient in the OR, we're going to be giving bolus doses (when we give them).  If you have a critically ill patient in transport, taking the time to set up an infusion for a relatively short transport to the hospital is pointless.  Inter-facility transports are a different thing.


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## Handsome Robb (Dec 24, 2012)

n7lxi said:


> I'm curious how many ALS agencies, aside from CCT trucks, allow a sedation infusion. I've not seen any...



One or two of the really rural services around here allow it with written or OLMD orders. I'm not sure they require the medic to be a CCP but from what I've seen it doesn't seem like it. Either that or all of their medics are CCPs.

This thread is pretty interesting. I admittedly don't know a whole lot about RSI. It was covered briefly during school, about a half a day lecture, but we don't have it here so it all kinda dwindled away. Definitely have some studying to do.


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## jwk (Dec 24, 2012)

Smash said:


> No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux.  It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.
> 
> I've said it a million times before: RSI needs to be done properly or not at all.



Anesthesia folks are +/- on using a defasciculating dose of a non-depolarizer prior to using sux.  I still do, because I still think there's something to it on SOME patients, and I generally have time to give it.  With other patients it doesn't seem to make any difference, and most of the literature nowadays doesn't really support it.  If you're giving a non-depolarizer first, you also have to wait for it to work (3 minutes or so) and you may not have that time luxury anyway.  BTW - some people will get markedly weak with just 5mg of roc.  So - if your plan is for RSI because your patient is headed into that downward death spiral, I'd forget about a defasciculating dose.  Then you can debate the sux or roc/vec option.   

A defasciculating dose of a non-depolarizer won't do anything as far as preventing MH or hyperkalemia (but those are pretty rare considerations anyway in EMS).  That being said, those are the main reasons (plus bradycardia in kids) that a lot of practitioners have totally abandoned the use of succinylcholine for any reason and have gone to roc only for RSI.


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## NomadicMedic (Dec 24, 2012)

jwk said:


> Why would you need it?
> 
> On a critical patient in the OR, we're going to be giving bolus doses (when we give them).  If you have a critically ill patient in transport, taking the time to set up an infusion for a relatively short transport to the hospital is pointless.  Inter-facility transports are a different thing.



Because Smash made the statement that we should not be sedating patients in the field unless we can manage the sedation via a continuous infusion. I was curious how many 911 systems allow this.


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## Fish (Dec 24, 2012)

We don't set up infusions in the field, but when we take a Hemorrhagic stroke downtown that is intubated from a smaller Hospital that does not have Neuro, we run an Infusion that the ER has started.


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## NomadicMedic (Dec 24, 2012)

Fish, I understand that many medics may transfer patients on a sedation package that was initiated in the hospital, Whether it's an ICU transfer or a smaller ED to a larger tertiary care facility.

However, I am specifically interested in ALS 911 services that institute a sedation drip in the field. Smash made the point that we should not be sedating patients, specifically in an RSI scenario, without the ability to run an infusion. I don't know of any services that do this on a regular basis.


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## Fish (Dec 24, 2012)

n7lxi said:


> Fish, I understand that many medics may transfer patients on a sedation package that was initiated in the hospital, Whether it's an ICU transfer or a smaller ED to a larger tertiary care facility.
> 
> However, I am specifically interested in ALS 911 services that institute a sedation drip in the field. Smash made the point that we should not be sedating patients, specifically in an RSI scenario, without the ability to run an infusion. I don't know of any services that do this on a regular basis.



I think that is silly to say we should not RSI based off of the fact that we cannot run/start infusions in the field.

I know of one West Texas Dept. that does, with prop.

The name? Mmmmmmmm, I do not remember, but it was mentioned somewheres on this site at one time.


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## Aprz (Dec 24, 2012)

NVRob said:


> One or two of the really rural services around here allow it with written or OLMD orders. I'm not sure they require the medic to be a CCP but from what I've seen it doesn't seem like it. Either that or all of their medics are CCPs.
> 
> This thread is pretty interesting. I admittedly don't know a whole lot about RSI. It was covered briefly during school, about a half a day lecture, but we don't have it here so it all kinda dwindled away. Definitely have some studying to do.


That was my thought with rereading about RSI and creating this thread. Like I said, in my paranedic class, my instruct said "RSI? You'll never do that. Don't worry about it," and clicked the power point really quick *click click click*.


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## usalsfyre (Dec 24, 2012)

Aprz said:


> That was my thought with rereading about RSI and creating this thread. Like I said, in my paranedic class, my instruct said "RSI? You'll never do that. Don't worry about it," and clicked the power point really quick *click click click*.



Classic EMS instructor BS. "We don't do it, I don't have any good war stories to tell, so why bother teaching it."

Never mind I know many medics (including myself) that have ended up working in completely different area than where they went to school.


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## NomadicMedic (Dec 24, 2012)

Or take for example the fact that I went to paramedic school in Washington State where we did RSI on standing orders. I moved to Delaware, and found that RSI is looked at totally different here. Yes, my service does it… But we do it differently then I was taught.

Just because they don't do it where you are, doesn't mean you shouldn't know about it.


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## Fish (Dec 24, 2012)

Was not taught where I went to school, and was not used where I first worked. Where I work now it is a standing order. This skill needs to be taught Nation wide, even if your area does not perform it.


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## MSDeltaFlt (Dec 24, 2012)

n7lxi said:


> Or take for example the fact that I went to paramedic school in Washington State where we did RSI on standing orders. I moved to Delaware, and found that RSI is looked at totally different here. Yes, my service does it… But we do it differently then I was taught.
> 
> Just because they don't do it where you are, doesn't mean you shouldn't know about it.



Amen, Mississippi is still in the dark ages, though we do have a DAI protocol approved for the state which is basically heavy dosing on benzos.  Although I do believe that if you carefully/properly/judiciously dose them with narcs and benzos, then your need for paralysis will not be as often as you might think.  Are paralytics needed?  Yes.  On all RSI pts?  No.

And to answer your question I don't know of a single 911 service in this state that has prehospital sedation infusion protocols and standing orders.  The only time I can even imagine that you'd need it in prehospital is when you can't fly your pt and the specialty they need is over an hour away and they need intubation.  And for those infrequent pts you can get OLMC orders.


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## Aprz (Dec 24, 2012)

MrBrown sent me a slideshow when I first asked him more on RSI. In the opinion of the maker of the slideshow, sedation-only intubation was bad.

http://www.adhb.govt.nz/Forums07/prehos_intub/Slide16.html

While we are talking about RSI, an important thing is being able to intubate well and being ready to use alternative methods to control the airway. I've been browsing through  KellyBracket's blog, and I thought he posted an interesting method to intubate using the miller blade.

http://millhillavecommand.blogspot.com/2011/09/use-of-straight-miller-blade.html


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## boerbull (Dec 25, 2012)

Very interesting slideshow. RSI has always been very controversial. I don't think that in the real world you can get rid of it. Here in the Netherlands we have a extreme ideal situation were we can almost always get a anesthesiologist within 20 min. But that is because this country is so small. In a country like South Africa with a big rural area, lots of TBI,s and limited resources you will have to use paramedics to RSI. 
It is always interesting to expand your scope of practice, but reading all the negatives on paramedic RSI, I must say I am glad I don't have to make those decisions.


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## NomadicMedic (Dec 25, 2012)

The whole "RSI is controversial" discussion frustrates me. RSI is truly only controversial in areas where paramedics are not well educated, don't perform the procedures with enough frequency to stay competent and have a poor success rate.

It seems like all we hear about are those services removing RSI due to poor education or poor success rates. In the meantime, agencies that provide continuing education, OR intubation opportunities, frequent opportunities to perform RSI in the field and a strong success rate just continue to chug along unnoticed.

Rather than remove the skill, let's increase the educational standards. For goodness sake, when you need to manage the airway, sometimes RSI is the only option. I'm certainly not waving the "paramedics are only paramedics because we can intubate" flag, but reducing the skill set because some agencies don't provide enough education or opportunity to stay competent is a bad idea.


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## boerbull (Dec 25, 2012)

I agree with education improving the skills. I am definitely for RSI. Like a said: In the real world you don't have a anesthesiologist ready for every RSI case. So instead of dishing RSI, concentrate on training and education.

Just wondering, when we RSI a patient we put him on a ventilator. Every ambulance has got at least a basic ventilator. How does it work in the rest of the world. Seeing as hyperventilation is seen as one of the risks for pre-hospital RSI.


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## systemet (Dec 25, 2012)

n7lxi said:


> The whole "RSI is controversial" discussion frustrates me. RSI is truly only controversial in areas where paramedics are not well educated, don't perform the procedures with enough frequency to stay competent and have a poor success rate.



It would be nice to be able to think that way, that this is just an educational or frequency issue, but if you look at the data it's really not telling that story. The recent Melbourne study suggests there's a small benefit to neuro outcome in TBI. No mortality impact. This is in pretty close to ideal circumstances with a select cohort of highly trained providers doing a lot of procedures. We know that King CO medics seem to do a really good job putting tubes in the trachea, but we have no idea whether it actually helps their patients. 

Almost the entirety of the remaining data is negative. I'm sitting not too far away from my ambulance with its sux, ket, roc, etc., but I'm basically forced to accept that this is a procedure that might be causing my patients harm and might be dangerous in my hands. This area needs further study, and is being actively studied - but if we carry on seeing negative results we need to be advocating to remove or greatly restrict the practice. Once we can start moving beyond defining ourselves by a set of interventions and starting looking at the data impassionately and motivating for what's best for our patients,  we may be at actual risk of becoming a profession. 

This is not intended as a slam or a personal attack. 



> It seems like all we hear about are those services removing RSI due to poor education or poor success rates. In the meantime, agencies that provide continuing education, OR intubation opportunities, frequent opportunities to perform RSI in the field and a strong success rate just continue to chug along unnoticed.



Then, if it's working so well,  they need to start publishing, because right now the aggregate of the data is looking really discouraging.



> Rather than remove the skill, let's increase the educational standards. For goodness sake, when you need to manage the airway, sometimes RSI is the only option. I'm certainly not waving the "paramedics are only paramedics because we can intubate" flag, but reducing the skill set because some agencies don't provide enough education or opportunity to stay competent is a bad idea.



I agree that we need to increase educational standards, and have for a long time. Unfortunately,  if the number of patients needed to treat to see a realistic benefit is very high, then many paramedics just aren't going to see enough cases to develop or maintain competence.


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## NomadicMedic (Dec 25, 2012)

Just to play the devils advocate, the Melbourne study shows no increase in survivability of patients with TBI that are intubated in the field. Is there a study that shows no increase in survivability of submersion injuries that are intubated in the field? How about reactive airway disease exacerbation refractory to CPAP or pharmacology? Has that been studied?

As I mentioned, there are instances when the only method to manage an airway is to sedate a patient and place an endotracheal tube. 

The real reason intubation may be removed from the paramedic scope is simply because we're not good enough at performing the skill. Every system that pulls intubation goes back to the LA Gauche study that examines BVM versus endotracheal intubation. We all know that study was flawed and that paramedic intubation skills are woefully lacking both in education and continued competency. 

So maybe we need to examine the ability of paramedics to successfully perform endotracheal intubation before we start to look at its efficacy. A novel idea I know... let's teach people how to do it correctly and determine if it's truly needed before we determine if it actually makes any difference.


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## Handsome Robb (Dec 25, 2012)

n7lxi said:


> Or take for example the fact that I went to paramedic school in Washington State where we did RSI on standing orders. I moved to Delaware, and found that RSI is looked at totally different here. Yes, my service does it… But we do it differently then I was taught.
> 
> Just because they don't do it where you are, doesn't mean you shouldn't know about it.



Agreed.

Like I said, we were taught it but didn't spend a whole lot of time on it. I know the drugs and dosages (for the common ones) but not much beyond that.


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## Handsome Robb (Dec 25, 2012)

boerbull said:


> Very interesting slideshow. RSI has always been very controversial. I don't think that in the real world you can get rid of it. Here in the Netherlands we have a extreme ideal situation were we can almost always get a anesthesiologist within 20 min. But that is because this country is so small. In a country like South Africa with a big rural area, lots of TBI,s and limited resources you will have to use paramedics to RSI.
> It is always interesting to expand your scope of practice, but reading all the negatives on paramedic RSI, I must say I am glad I don't have to make those decisions.



So i have a question. Why wait on scene for 20 minutes for the anesthesiologist to come RSI the patient rather than just transport them to the ER. Seems like it would double the time waiting for them to come to the scene. 

20 minutes seems like a long time to wait for airway control in a patient who's condition is critical enough to require RSI.


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## systemet (Dec 25, 2012)

n7lxi said:


> Just to play the devils advocate, the Melbourne study shows no increase in survivability of patients with TBI that are intubated in the field. Is there a study that shows no increase in survivability of submersion injuries that are intubated in the field? How about reactive airway disease exacerbation refractory to CPAP or pharmacology? Has that been studied?



Submersion injuries requiring intubation are such a small subgroup of prehospital intubation that I doubt anyone has done any outcomes based research. RAD refractory to CPAP is likely more common, but prehospital CPAP is a relatively new intervention in many places. I'm not aware of any research comparing ETI to BVM - it likely hasn't been done. We do know that intubation in RAD is a marker for higher acuity, and that it places patients at a risk for barotrauma, autoPEEP and pneumothoraces. But, in contrast BVM ventilation is likely to be ineffective without some sort of adjunct in patients with very high airway resistances.

I think TBI is usually selected because we know that even a single instance of hypoxia, hypercapnia or hypotension dramatically increases (doubles?) mortality, so its a condition where the patients are very sensitive to airway mismanagement or inadequacies of oxygenation or ventilation.  Theoretically,  this is where the greatest benefit lies.

I think this illustrates a limitation of EBM - when there's only limited data to extrapolate from, at what point can you start making definitive judgments?  I think we both believe that the paramedics in the San Diego trial were substandard, and that the study design had drawbacks, but for a long time this was really the best data out there and it was been taken to be representative of all paramedics. The Melbourne trial may have addressed some of these issues, but it still feels like a loss. Their system was so well optimised, I think I'd expected a bigger difference. 



> As I mentioned, there are instances when the only method to manage an airway is to sedate a patient and place an endotracheal tube.



Yeah, I know - you can almost start making similar arguments with cricothyrotomy, that its a high acuity, low opportunity event - so do we remove surgical airways because there's evidence of potential harm, no well designed studies showing evidence of benefit, etc.

I think we gave to balance the risks. If we're harming the patients that we most frequently see to help a rare subset - does the math work out in favour in the end?



> The real reason intubation may be removed from the paramedic scope is simply because we're not good enough at performing the skill. Every system that pulls intubation goes back to the LA Gauche study that examines BVM versus endotracheal intubation. We all know that study was flawed and that paramedic intubation skills are woefully lacking both in education and continued competency.



The problem is that all studies are flawed, or to be more polite, "have their limitations". We can't discount Gauche et al. just because we don't like aspects of the design - instead we need a study with a similar or better design showing a different result. Right now there's not really much there.



> So maybe we need to examine the ability of paramedics to successfully perform endotracheal intubation before we start to look at its efficacy. A novel idea I know... let's teach people how to do it correctly and determine if it's truly needed before we determine if it actually makes any difference.



I agree - but unless we improve the initial training and education soon, it's going to be too late. The judgment is going to be that we can't or shouldn't do these things, and that's all that's going to be remembered.


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## boerbull (Dec 26, 2012)

NVRob said:


> So i have a question. Why wait on scene for 20 minutes for the anesthesiologist to come RSI the patient rather than just transport them to the ER. Seems like it would double the time waiting for them to come to the scene.
> 
> 20 minutes seems like a long time to wait for airway control in a patient who's condition is critical enough to require RSI.



We don't wait 20min. Our control room can judge by the call if they are needed and alarm them together with us. I can then cancel them if I don't need them. If I run into trouble on scene, we will rv on a LZ on the way to a trauma center. 

I'm just wondering what all these researchers are aiming at. Are they trying to prove that RSI is increasing mortality, or are they trying to prove that paramedics are not good at it? Are there any research on In-Hospital RSI compared to Pre-hospital RSI by doctors?
It's easy to criticize paramedics if you compare them to people working in ER conditions.


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## Christopher (Dec 26, 2012)

jwk said:


> A defasciculating dose of a non-depolarizer won't do anything as far as preventing MH or hyperkalemia (but those are pretty rare considerations anyway in EMS).



Interestingly enough in our area, MH has the opportunity to be prevalent as we have a large population of Lumbee Indians who are susceptible to MH after succ (hello dantrolene)...granted it isn't so common I'm asking for a family tree


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## systemet (Dec 26, 2012)

jwk said:


> A defasciculating dose of a non-depolarizer won't do anything as far as preventing MH or hyperkalemia (but those are pretty rare considerations anyway in EMS).



I guess this is the problem with trying to extrapolate from physiology.  I'm sitting here as a paramedic thinking, "Well... if we blockade a percentage of the nAChR with a non-depolariser, then we'll get less depolarisation with sux, less outward K+ current, and a reduced amount of RyR / SR Ca2+ release, so we'll see less hyperK and a lower incidence of MH".

Then an expert like yourself comes along, and puts everything in perspective.  Thanks again -- your contributions to the forum are invaluable.


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## medicsb (Dec 26, 2012)

n7lxi said:


> The whole "RSI is controversial" discussion frustrates me. RSI is truly only controversial in areas where paramedics are not well educated, don't perform the procedures with enough frequency to stay competent and have a poor success rate.



You've probably just described 95% (or more) of EMS systems.  Even in places with good education, most medics will not perform the procedure with enough frequency to remain proficient without going to the OR, which most places can't do, mind you.  

The only reason your service *might* be proficient (I haven't seen any publications) is because you have access to an OR.  Your service, despite being "tiered", has more medics per capita than most cities  and is probably on the average for the US (~73 medics, per website for 200k = 36/100K; King Co. is around 13, Boston around 11, NJ as a state is ~18, and I think New Castle Co. is around 18).  

Basically, OR access may be ideal, it is not feasible in most places, and essentially makes your service an out-lier.



> It seems like all we hear about are those services removing RSI due to poor education or poor success rates. In the meantime, agencies that provide continuing education, OR intubation opportunities, frequent opportunities to perform RSI in the field and a strong success rate just continue to chug along unnoticed.



Only unnoticed because they allow themselves to remain unnoticed.  



> Rather than remove the skill, let's increase the educational standards. For goodness sake, when you need to manage the airway, sometimes RSI is the only option. I'm certainly not waving the "paramedics are only paramedics because we can intubate" flag, but reducing the skill set because some agencies don't provide enough education or opportunity to stay competent is a bad idea.



A good education would likely be wasted money without the medics being able to get experience, unfortunately.   Ultimately, the decision is best made locally, but removing RSI may very well be in the patients best interest in most places.


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## Aprz (Dec 26, 2012)

Linuss, I am 2 chapters into the book, and enjoying it/it's excellent so far. Look forward to chapter 3, which is on RSI itself.

The book mentioned LEMONS, MOAN, SHORT, and RODS. It also mentioned the 7 Ps, which I don't know. I've heard of LEMON before, but haven't heard of the others yet. Does anybody know them? I may found out later in the book, or end up Googling. I forgot that I haven't added LEMONS to our acronym/abbreviation/mnemonic (makes me realize I forgot all the "5 Fs of cholecystitis" an the "6 Ps of compartment syndrome/neurovascular injuries" and stuff like that too) list either.


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## Christopher (Dec 26, 2012)

Aprz said:


> Linuss, I am 2 chapters into the book, and enjoying it/it's excellent so far. Look forward to chapter 3, which is on RSI itself.
> 
> The book mentioned LEMONS, MOAN, SHORT, and RODS. I've heard of LEMON before, but haven't heard of the others yet. Does anybody know them? I may found out later in the book, or end up Googling. I forgot that I haven't added LEMONS to our acronym/abbreviation list either.



MOANS (should have an S, meant for predicting BVM success): Mask seal, obesity/obstruction, age (young/old), no teeth, stiff cervical spine

SHORT is cric success and RODS is supraglottic success, but I've not memorized those.


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## Fish (Dec 26, 2012)

Lime


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## Aprz (Dec 27, 2012)

What's lime?

I looked it up since I was curious.

S-H-O-R-T
Surgery (previous)
Hematoma (or neck swelling)
Obesity (this seems like a common factor)
Radiation distortion (I am guessing has to do with patient that get radiation treatment?)
Tumor

R-O-D-S
Restricted mouth opening
Obstructed upper airway
Distorted/disrupted upper airway
Stiff lungs

Oo.. You responded too quickly. I added the 7Ps also.

Preparation
Preoxygenate
Premedicate
Paralysis
Pressure on cricoid/protection
Placement of ETT
Post Intubation management

There were a ton of excellent resources online about this. I liked the link that showed up at the top for me when I Googled "MOANS airway mnemonic", lol.

http://emergencymedic.blogspot.com/2009/08/common-mnemonics-and-formula-in.html


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## Fish (Dec 27, 2012)

Lime? Nothing, just saw people talking about Lemons so I said Lime, Lemon-Lime


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## Aprz (Dec 27, 2012)

There's an another mnemonic similar to MOANS.

B-O-O-T-S
Beard
Obese
Old
Toothless
Snores


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## recruiter1 (Dec 28, 2012)

those are some great tips.


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## ICU ALS (Dec 29, 2012)

Suxamethonium and thiopentone or ketamine, fentanyl and sux then depending on haemodynamics, maintain with rocuronium and midaz/fent or roc and propofol/fent. That's how we donut in Australia!


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## ICU ALS (Dec 29, 2012)

Also, atropone us seldom needed. Mostly we would use it to limit secretions but you do often need a handy syringe of synthetic pressor like metaraminol. Especially if you instead choose propofol to induct.


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## jwk (Dec 29, 2012)

ICU ALS said:


> Suxamethonium and thiopentone or ketamine, fentanyl and sux then depending on haemodynamics, maintain with rocuronium and midaz/fent or roc and propofol/fent. That's how we donut in Australia!





ICU ALS said:


> Also, atropone us seldom needed. Mostly we would use it to limit secretions but you do often need a handy syringe of synthetic pressor like metaraminol. Especially if you instead choose propofol to induct.



It's always interesting to see the different drugs used here in the US compared to elsewhere in the world.

Thiopentone (thiopental or pentothal in the US) is not commercially available in the US due to manufacturer concerns about it's use in capital punishment.  It has simply been withdrawn from the market (not that it's been a big moneymaker anyway since the advent of propofol).

Metaraminol (Aramine) is a drug I haven't even heard mentioned in more than 30 years.  It's a pretty old drug used to treat hypotension and has largely been replaced by newer and/or better drugs, in particular, ephedrine and phenylephrine.


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## Veneficus (Dec 29, 2012)

jwk said:


> Thiopentone (thiopental or pentothal in the US) is not commercially available in the US due to manufacturer concerns about it's use in capital punishment.  It has simply been withdrawn from the market (not that it's been a big moneymaker anyway since the advent of propofol)..



Don't knock it until you have tried it.


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## ICU ALS (Dec 29, 2012)

Wow. Ephedrine. We never use that! Metaraminol works well and is widely used.


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