Airway Management and Intubating without Drugs

StCEMT

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What exactly are people's concerns with "over RSI-ing" patients who have ambiguously intact airway reflexes? Is it hypotension? Oversedation?


Regardless of what meds, if any, you are pushing in an alive patient, you should be extremely cognizant of the patients blood pressure and resuscitate them (fluids, push dose pressors) up above 90-100 systolic at the absolute minimum before even thinking about intubation, because just the act of passing the tube and ventilating is going to drop their pressure from the vagal response and potentially a preload drop from the ventilation itself. I don't think trying to avoid sedation or paralysis for fear of this is going to fix the issue, plus its pretty inhumane to not at least sedate alive patients who are getting plastic shoved down their throat. You can always give them more epi to bring them back up after the RSI meds go in.
Take this for what it's worth since I can't RSI, but my main issues are what you outlined. I think the laryngoscope as a murder weapon series (or at least the concepts) should be something drilled into our heads (both in training and medic school), because I've seen post intubation arrests multiple times in the ED due to those things not being addressed. At least on the RSI's and crics I've seen, I can't think of very many where a easy paced resus then induction would have been inappropriate.
 

RocketMedic

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Take this for what it's worth since I can't RSI, but my main issues are what you outlined. I think the laryngoscope as a murder weapon series (or at least the concepts) should be something drilled into our heads (both in training and medic school), because I've seen post intubation arrests multiple times in the ED due to those things not being addressed. At least on the RSI's and crics I've seen, I can't think of very many where a easy paced resus then induction would have been inappropriate.
Pretty much this. Although ketamine for sedation blunts the hypotension potential, I have seen multiple hypotensive RSIs that got worse with etomidate or *terrible medicine choice* versed + succs, and I was sort of reckoning that there must be a better way for those patients.
 

KingCountyMedic

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Pretty much this. Although ketamine for sedation blunts the hypotension potential, I have seen multiple hypotensive RSIs that got worse with etomidate or *terrible medicine choice* versed + succs, and I was sort of reckoning that there must be a better way for those patients.
We don’t RSI unstable patients anymore. If your patient is hypotensive you address that first, the same with O2 sats. Get their pressure & sats up before RSI.

Anyone remember 3 stacked shocks? Lol
 

Remi

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Pretty much this. Although ketamine for sedation blunts the hypotension potential, I have seen multiple hypotensive RSIs that got worse with etomidate or *terrible medicine choice* versed + succs, and I was sort of reckoning that there must be a better way for those patients.
Why is versed and succinylcholine a terrible choice?

I think the vast majority of people who do this routinely would agree that generally, versed is inferior to the other commonly used options. But it definitely has a place in some scenarios.
 

VFlutter

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Providers commonly intubate patients with impending circulatory collapse without adequate resuscitation and then blame the RSI medications when they crash. Like said, versed is not ideal but is more than adequate along with paralytics for RSI.
 

RocketMedic

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Why is versed and succinylcholine a terrible choice?

I think the vast majority of people who do this routinely would agree that generally, versed is inferior to the other commonly used options. But it definitely has a place in some scenarios.
Versed isn't/wasn't a great go-to in a hypotensive CHF patient with secondary sepsis, particularly when there is no effort at resuscitation made. I don't blame the versed alone, but I think that sedation could have been better-achieved with an alternative like etomidate or ketamine.
 

Remi

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People don't always need to be fully anesthetized in order for intubation to happen. If you are committed to using a full induction dose of any sedative, then yeah, you might have a bad time if they are sick and you don't take the time to resuscitate first.

But if it's a scenario where you really need the tube in now and you don't have time to resuscitate (or mechanical ventilation IS the resuscitation), then a small amnestic dose of something is perfectly acceptable, and in that case versed is generally a good option.
 

rescue1

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I think barring some fairly rare situations (airway burns, laryngospasm, some sort of traumatic airway disaster), you always have enough time to take a few minutes to beef up the pressure and maximize your oxygenation/CO2 before you drop the tube, even if you have to bag for a short amount of time first. You're always going to drop the pressure regardless of what you do, so I don't think the choice of sedation is super important, as long as its dosed appropriately. Like in @RocketMedic 's example, I don't think the Versed is to blame, I think it's trying to rapidly intubate a hilariously unstable patient with a very fragile blood pressure.

I know intubation is puffed up to be the coolest and most lifesaving thing a healthcare provider can do, but it's rare that tubing a patient actually fixes their underlying problem--most patients are tubed for some form of cardiac or respiratory failure that still needs to be addressed, all you're doing is buying more time to fix it. Sometimes it's best to just try and stabilize them as best you can and then let them get tubed down the road once they're a little more stable.
 

FiremanMike

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I think barring some fairly rare situations (airway burns, laryngospasm, some sort of traumatic airway disaster), you always have enough time to take a few minutes to beef up the pressure and maximize your oxygenation/CO2 before you drop the tube, even if you have to bag for a short amount of time first. You're always going to drop the pressure regardless of what you do, so I don't think the choice of sedation is super important, as long as its dosed appropriately. Like in @RocketMedic 's example, I don't think the Versed is to blame, I think it's trying to rapidly intubate a hilariously unstable patient with a very fragile blood pressure.
Versed is vasoactive, as is etomidate, the two of them together can drop pressure..

Funny you mention bolstering the oxygenation. One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).
 

Remi

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In most scenarios, resuscitation before intubation probably makes sense. Especially if you are bound by protocol or tradition to use an induction agent or a dose of induction agent that is inappropriate given the shocked state.

But if you deal with enough sick patients - especially trauma patients - you will definitely come across scenarios where even though the vitals are crap and even though intubation isn't going to fix the underlying problem, the first priority in the resuscitation is still definitive airway control.
 

KingCountyMedic

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Versed is vasoactive, as is etomidate, the two of them together can drop pressure..

Funny you mention bolstering the oxygenation. One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).
This has been a big push in our neck of the woods too. Spokane Fire in Eastern Washington even put out a study in 2018 and published it in Prehospital Emergency Care. We are using O2 sat, ETCO2, and BP as indicators and if they are low we work to fluid resuscitate, and BVM until we have a "stable" patient to initiate RSI. It's a big change for a lot of us that have just been dropping ET's as soon as possible. If the patient is super sick we will go straight to intubation, but if you can manage to make things a bit better prior to RSI it's a good thing to do
 

rescue1

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Versed is vasoactive, as is etomidate, the two of them together can drop pressure..

Funny you mention bolstering the oxygenation. One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).
Yeah, sorry, my point was "you're likely going to drop the pressure regardless of what you do, so don't think that using ketamine is going to save your patient who is hypotensive". Like you said, some drugs will drop it more than others, but you should always anticipate the hypotension.
 

FiremanMike

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In most scenarios, resuscitation before intubation probably makes sense. Especially if you are bound by protocol or tradition to use an induction agent or a dose of induction agent that is inappropriate given the shocked state.

But if you deal with enough sick patients - especially trauma patients - you will definitely come across scenarios where even though the vitals are crap and even though intubation isn't going to fix the underlying problem, the first priority in the resuscitation is still definitive airway control.
Yeah that was my first reaction with the oxygenation criteria as well..
 

GMCmedic

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Versed is vasoactive, as is etomidate, the two of them together can drop pressure..

Funny you mention bolstering the oxygenation. One of the topics at Eagles this year was the idea of NOT initiating your RSI until you have the SpO2 above a certain threshold (I think it was 95 but that may be wrong).
I feel like this one comes up at eagles every year. This has been our local practice with passive oxygenation for a few years now.
 

KingCountyMedic

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RocketMedic

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Possibly.... Seattle is already undergoing all kinds of changes, there is talk up north of transport vents and some bizarre witch doctor devices called CRAP or CCRAP or something? Scary times indeed. As long as my checking account stays well fed I'm good with whatever! :)

You....you don't have CPAP or transport vents?
 
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Tigger

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Possibly.... Seattle is already undergoing all kinds of changes, there is talk up north of transport vents and some bizarre witch doctor devices called CRAP or CCRAP or something? Scary times indeed. As long as my checking account stays well fed I'm good with whatever! :)
Wait, so you guys RSI and intubate a high number of patients...and then BVM them to the hospital? Is there at least a PEEP valve?
 

StCEMT

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Wait, so you guys RSI and intubate a high number of patients...and then BVM them to the hospital? Is there at least a PEEP valve?
We dont have vents, but I'm also not electively RSIing....not that I find that to be a good reason.
 
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