RSI: Critical Decision Making (Advanced Provider response requested)

[NomadicMedic]

I think he only said that because he knows that I don't just knock people down and tube them for the hell of it. I'll try everything I can before going there. Also, MH is relatively rare. It's certainly bad news, but the chance of seeing it in the field is pretty slim.

 

[usafmedic45]

Why not just skip the need for a paralytic and just use ketamine to induce anesthesia and then tube the patient? The best part is you don't kill the patient that way if you can't get the tube.

 

[MSDeltaFlt]

One paralytic is as good as another the majority of the time. If you're worried about fasciculations Then I'd to with something other than Anectine. However, if you have protocols written for both benzo's and opioites, especially of they're weight based doses, then I'd say give as much of the full dose of each as clinically allowed. If the pt stops breathing and loses a gag then you won't even need a paralytic in the first place.

For my aeromedical company, we have 4 options: succ, rocc, vec, or no paralytic at all just benzos & opiotes.

 

[M3dicDO]

Nope, wrong answer. WRONG, WRONG.....Again WRONG, WRONG answer...lazy...Bottom line is you repeated some of the most common misconceptions that get people into trouble with paralytics. Understanding the endpoint goals here is key to best serving the patient's interest.

Thank you for sharing with us your views and opinions. Your professionalism is admirable.

I'll have to do a better job next time making sure I add all the little details and disclaimers to avoid readers from making improper assumptions.

 

[johnmedic]

Does fasciculation really contribute to hypoxia enough to be worth noting? Because like Mr Brown said, Sux to tube & Vec to follow seems like a good game-plan.. giving the best of both worlds. Short-term initial paralysis, & long-term paralysis once tube is established, one agency I've interned with does it that way & it's said to have worked well for them.

 

[usafmedic45]

Does fasciculation really contribute to hypoxia enough to be worth noting? Because like Mr Brown said, Sux to tube & Vec to follow seems like a good game-plan.. giving the best of both worlds. Short-term initial paralysis, & long-term paralysis once tube is established, one agency I've interned with does it that way & it's said to have worked well for them.

No, most of the problem with fasciculations is with the providers rather than the patient. Some people find it troubling or annoying.

 

[usalsfyre]

Thank you for sharing with us your views and opinions. Your professionalism is admirable.

If you'll look, I later appologized for my bluntness.

I'll have to do a better job next time making sure I add all the little details and disclaimers to avoid readers from making improper assumptions.

Your the one who advocated, in no particular order 1. using succs on a difficult airway "just in case" you can't get the tube 2. using long-term paralysis inappropritely 3. reversing a paratytic or letting the effects of paralytic wear off rather than placing alternative airways. None of these is an approprite action. This is not my view or opinon, this goes against accepted medical care. The way you stated you practice is out and out wrong. Part of the professionalism your so ready to condem me for is viewing your practice objectively, and making changes when needed in response to criticism and new information/evidence. Another part of it is not treating based on the myths/poor practices of others. So yes, I was vigiorous in my criticism of what you describe, but the reason I was so vigirous is because it's crappy care.

Don't be "that guy", the one who continuely repeats the myths about RSI. We've got enough of those already. It's a legitimate technique that improves outcomes in the field if done correctly. There's not enough people doing it correctly to keep it in the tool box the way things are going though.

 

[usalsfyre]

Why not just skip the need for a paralytic and just use ketamine to induce anesthesia and then tube the patient? The best part is you don't kill the patient that way if you can't get the tube.

"But don't people get HIGH on ketamine?!?"

(Agree with you to a point. I still think there's value to a paralytic in the non-NPO patient. However if there's ANY indication that there may be difficulty encountered in airway control awake is the better way to go. Most of the concerns about Ketamine I've found have been FAR more related to opperational and administrative concerns than anything medical).

 

[reaper]

Here is a good article that gives you a good run down on all the different meds used.

http://emedicine.medscape.com/article/109739-overview

 

[usafmedic45]

"But don't people get HIGH on ketamine?!?"

As opposed to morphine, fentanyl, midazolam, diazepam, lorazepam, etc?

(Agree with you to a point. I still think there's value to a paralytic in the non-NPO patient.

Can you show me anything that indicates a benfit to the use a paralytic versus disassociation? If they are going to puke with one, they are just as likely to puke with the other so far as I am aware.

However if there's ANY indication that there may be difficulty encountered in airway control awake is the better way to go.

....or you go with the medication that renders them intubatable without knocking out their drive to breathe.

Most of the concerns about Ketamine I've found have been FAR more related to operational and administrative concerns than anything medical

Yup. That and that pesky rumor about it having negative effects on ICP. I find it funny that people have no problem with the operational issues associated with narcotics and the shelf life on the rigs of some paralytics but should you mention ketamine and they look at you as though you are daft.

 

[usalsfyre]

As opposed to morphine, fentanyl, midazolam, diazepam, lorazepam, etc?

D@mn kids and their raves...

Can you show me anything that indicates a benfit to the use a paralytic versus disassociation? If they are going to puke with one, they are just as likely to puke with the other so far as I am aware.

Off the top of my head, no. I do know it's the anesthesia standard of care in a patient who's presumed to have a full stomach, to prevent ACTIVE puking. Of course it's also presumed that an anesthesia provider will use proper positioning and mask ventilation technique to prevent passive regurg. Proper positioning and mask ventilation are usually in short supply around EMS.

....or you go with the medication that renders them intubatable without knocking out their drive to breathe.

This is what I really meant. Very few providers are REALLY made aware of this or even the awake intubation using a topical. Instead it seems like they are given two options, "brutane" or a full RSI sequence including paralytic. This leads to people with questionable laryngoscopy skills and a dearth of backup options pushing paralytics on 350 pound no neck Mallampati 4s, and the subsequent bad outcomes associated with it.

Yup. That and that pesky rumor about it having negative effects on ICP. I find it funny that people have no problem with the operational issues associated with narcotics and the shelf life on the rigs of some paralytics but should you mention ketamine and they look at you as though you are daft.

I wonder how much of it is because ketamine won't show up on a standard (read: cheap) UDS.

 

[Veneficus]

Of course it's also presumed that an anesthesia provider will use proper positioning and mask ventilation technique to prevent passive regurg. Proper positioning and mask ventilation are usually in short supply around EMS.

I think the problem isn't so much positioning is it is actually bagging the patient 40+ times a minute. The reasons for such are numerous, but I would say that probably 80% of providers see so few actual emergencies, that they are just too excited.

 

[AndyK]

I think the problem isn't so much positioning is it is actually bagging the patient 40+ times a minute. The reasons for such are numerous, but I would say that probably 80% of providers see so few actual emergencies, that they are just too excited.

You would have thought the cramping sensation in the wrist would give 'em a clue they're going wayyy to fast B) The other one I tend to see is people crushing the bag instead of nice, gentle squeezes.

 

[Veneficus]

You would have thought the cramping sensation in the wrist would give 'em a clue they're going wayyy to fast B) The other one I tend to see is people crushing the bag instead of nice, gentle squeezes.

Endophins, not always a good thing.

 

[M3dicDO]

If you're worried about fasciculations Then I'd to with something other than Anectine.

Are you able to pre-medicate with a defasciculating round of either low dose anectine or a non-depolarizing paralytic?

 

[NomadicMedic]

Are you able to pre-medicate with a defasciculating round of either low dose anectine or a non-depolarizing paralytic?

I didn't realize anectine was used in a defasciculating dose of paralytics. I thought it was only a Non depolarizing agent. Am I wrong?

 

[Smash]

I didn't realize anectine was used in a defasciculating dose of paralytics. I thought it was only a Non depolarizing agent. Am I wrong?

Non-depolarizers are used. They aren't any use though. The idea behind using a non-depolarizers first was to reduce myalgia associated with sux, nothing else. Again it falls into the "least of their worries" category when we are talking about RSI in the field.

Ketamine is a superb, versatile drug and it would be nice to break down some of the prejudice towards it. I don't think I would be using it as a sole agent to try to intubate though. For hemodynamically compromised patients I would love to be able to use it as part if RSI. But I can't

 

[MrBrown]

Ketamine is a superb, versatile drug and it would be nice to break down some of the prejudice towards it. I don't think I would be using it as a sole agent to try to intubate though. For hemodynamically compromised patients I would love to be able to use it as part if RSI. But I can't

Brown heard you blokes were a bit anti-ketamine .... silly nonsense about wanting to get paid more. What would Frank say?

Brown just loves ketamine to bits, its the words bestest induction agent ever since sliced [moldy] bread was used as an antibiotic back in the Civil War.

 

[M3dicDO]

I didn't realize anectine was used in a defasciculating dose of paralytics. I thought it was only a Non depolarizing agent. Am I wrong?

I was surprised when I first saw it too, but yes Anectine can be used at low-dosage for defasciculation. One of the flight programs in northern IL uses 0.5 mg/kg Anectine as defasciculating agent before the regular full dose.

Ketamine is a superb, versatile drug ...... I would love to be able to use it as part if RSI. But I can't

Absolutely. All the benefits of anesthesia without the negative cardiovascular side effects. Just curious, does anyone know of transport programs (w/o a physician) that use Ketamine? If so, what kind of dosage and provisions do they have?

 

[the_negro_puppy]

I was surprised when I first saw it too, but yes Anectine can be used at low-dosage for defasciculation. One of the flight programs in northern IL uses 0.5 mg/kg Anectine as defasciculating agent before the regular full dose.



Absolutely. All the benefits of anesthesia without the negative cardiovascular side effects. Just curious, does anyone know of transport programs (w/o a physician) that use Ketamine? If so, what kind of dosage and provisions do they have?

Our Intensive Care Paramedics can use Ketamine as an adjunct to morphine in patients with severe traumatic pain associated with:
- A. Fracture reduction and splinting
- B. Multiple or significant fractures requiring facilitated extricatin

Dosages (IV)

Adult - 10-20mg repeated every 2-3 minutes- total max dose 1mg/kg

Paed- ( = or above 1 years) 100mcg/kg repeated every 2-3 minutes- total max dose 1mg/kg