Critique this RSI protocol.

[medicaltransient]

My boss wants to use this protocol for RSI. I wanted to use the AEL protocol
The main problem I have is no amnesia from Fentanyl in post intubation.
I'm just going to copy down the short and sweet of it.

There is a long list of contraindications, some are less than 2 yrs of age, epiglottis. all the regular stuff.

Premedication
Lidocaine-used if susspected head injury or asthma.
Dosage 1 to 1.5 mg/kg
Atropine-used in bradycardic adults and in children less than 6 to 8 years of age to reduce the risk of bradycardia
Dosage .5 mg IVP for adults exhibiting bradycardia or children less than 3

Sedate and paralzye patient using appropriate medication dose
Versed will be used as sedative/hypnotic
Adult dose .1 -.15 mg/kg
Pediatric dose .03 mg/kg

Succinylcholine as a paralytic
Adult Dose 1-2 mg/kg with max of 150mg
Infant dose 2mg/kg

Insert endotracheal tube with direct visualization and confirm with lung sounds and carbon monoxide device

Rocuronium for ongoing paralysis of successful intubated patients
Dosage 1 mg/kg max of 150

Fentanyl for analagesia
Adult dosage 1-2 mcg/kg
Pediatric dosage: 1-4 mcg/kg

Monitor patient with assessment and vital signs every 5 min.

 

[medicaltransient]

The Atropine for pediatrics is a little confusing also

 

[STXmedic]

Not a huge fan at all. Actually looks like a pretty ****ty protocol. Versed is your only induction agent, and fentanyl is your only post intubation management agent? And Lidocaine still hasn't shown effective at blunting IICP.

 

[medicaltransient]

Thanks I don't like it either.

 

[Carlos Danger]

0.1 mg/kg of versed is completely inadequate as an induction dose. That's only 8 mg's for a 175 pound patient. Many people would still be able to hold a normal conversation with you after only 8mg of versed.

Double the versed dose and give the fent with it for induction and you have an OK protocol. Etomidate or ketamine would be much better though.

Seriously, these protocols are all over the internet - there's no reason to reinvent the wheel.

 

[TXmed]

Atropine and lidocain for premedication is pointless and takes up to much time and energy, versed for induction takes to long, versed for post Intubation has been attributed to longer duration of Intubation along with post Intubation management with long acting paralytics.

Ketamine as an Induction and fentanyl for post Intubation is ideal.

 

[SpecialK]

A very poor RSI procedure. Not one I would recommend or use, ever.

There is no evidence lignocaine or atropine are helpful.

Keep it simple: pre-medication with IV fentanyl 1 mcg/kg, general anaesthesia use ketamine 1.5 mg/kg, suxamethonium IV, post-intubation paralysis is really up to whichver -onium you wish to use (vec, panc, roc, the difference is probably not clinically significant). Fentanyl/midazolam infusion as post-intubation sedation and analgesia.

Elastic gum bougie for all intubations, even simple Grade I views. Electronic waveform ETCO2.

Kit dump mat and checklists.

 

[SpecialK]

I should add if suxamethonium IV is contraindicated, use whatever long-acting paralytic you like alone. There are some HEMS services' which are no longer using suxamethonium and only using e.g. rocuronium.

 

[ERDoc]

I prefer Etomidate over Ketamine but would stay away from Versed for the reasons stated. Sux is a great paralytic if there is no contraindication. Why are we doing post intubation paralysis? As long as they are properly sedated (propofol here) there really isn't a reason for paralysis.

 

[garyh9900]

My boss wants to use this protocol for RSI. I wanted to use the AEL protocol
The main problem I have is no amnesia from Fentanyl in post intubation.
I'm just going to copy down the short and sweet of it.

There is a long list of contraindications, some are less than 2 yrs of age, epiglottis. all the regular stuff.

Premedication
Lidocaine-used if susspected head injury or asthma.
Dosage 1 to 1.5 mg/kg
Atropine-used in bradycardic adults and in children less than 6 to 8 years of age to reduce the risk of bradycardia
Dosage .5 mg IVP for adults exhibiting bradycardia or children less than 3

Sedate and paralzye patient using appropriate medication dose
Versed will be used as sedative/hypnotic
Adult dose .1 -.15 mg/kg
Pediatric dose .03 mg/kg

Succinylcholine as a paralytic
Adult Dose 1-2 mg/kg with max of 150mg
Infant dose 2mg/kg

Insert endotracheal tube with direct visualization and confirm with lung sounds and carbon monoxide device

Rocuronium for ongoing paralysis of successful intubated patients
Dosage 1 mg/kg max of 150

Fentanyl for analagesia
Adult dosage 1-2 mcg/kg
Pediatric dosage: 1-4 mcg/kg

Monitor patient with assessment and vital signs every 5 min.

Not sure a carbon monoxide device is what you need for intubation confirmation.

 

[SpecialK]

I prefer Etomidate over Ketamine but would stay away from Versed for the reasons stated. Sux is a great paralytic if there is no contraindication. Why are we doing post intubation paralysis? As long as they are properly sedated (propofol here) there really isn't a reason for paralysis.

I understand while etomidate is popular in North America, it is almost unheard of in Australasia. Certainly it is ketamine that is used, and some of the HEMS are using propofol for procedural sedation (not general anaesthesia for RSI).

As for a propofol infusion, to me that is just more complicated. Fine in hospital when you can run it via an infusion pump and have lots of hands to move things and carry everything. Not so good for getting somebody off the floor, onto the stretcher, into the ambulance (or helicopter), out again, and to hospital, often with limited numbers of personnel. Plus it's the addition of another drug ambulance personnel do not routinely use. Much easier both logistically and practically to use a simple mixture of fentanyl and midazolam which can either be push-doses or run via an infusion in a small bag of 0.9% NaCl or glucose.

A single dose of a long-acting paralytic will keep the patient movement free and means they only need just enough on-going sedation and analgesia to not be aware they are intubated and cannot move. "Long-acting" is only long-acting compared to suxamethonium, a single dose of rocuronium for example will last about 30 to 45 minutes, which is probably how long it is going to take to get the patient to hospital anyway. It's not like it's going to last for hours.

 

[Carlos Danger]

Versed is not a good drug for emergent induction. It's fine to use if it's all you have, but if you are doing RSI you really should carry something more suitable.

I would present this to your boss:

• Lidocaine 1 - 1.5 mg/kg
• Atropine 0.25 mg - only if bradycardic
• Fentanyl 0.5 - 1 mcg/kg
• Etomidate 0.2 mg/kg
• Sux 1.5 mg/kg
• Tube. Etc02. Secure. Keep them comfortable with fentanyl and versed.
• Ventilate at a volume that causes visible chest rise and a rate that results in an Etc02 of 30-35.

 

[Carlos Danger]

Lidocaine actually does blunt ICP increases secondary to laryngoscopy - that's not in question. The question is whether it improve outcomes in TBI patients, and it's true that it has never been shown to.

However, I think it is still worth using, both because there probably are some patients who benefit from it's ICP lowering effects, and also because it potentiates opioids and induction agents, reduces the incidence of bronchospasm and laryngospasm, and may even prolong the duration of succinylcholine. It also reduces the incidence and severity of myalgias secondary to fasciculations.

 

[RocKetamine]

I'm also not a fan of that protocol.

I typically use Fentanyl 3 mcg/kg if pre-treatment is indicated, Ketamine 2 mg/kg for induction (Etomidate if patient is hypertensive) then 1.5 mg/kg of succinylcholine.

 

[ParamedicStudent]

Sorry to burst in here but quick relation question: can you intubate someone who is breathing? Maybe no gag reflex, but had the breathing drive; shallow or going into respiratory failure (but still breathing)

 

[RocKetamine]

Sorry to burst in here but quick relation question: can you intubate someone who is breathing? Maybe no gag reflex, but had the breathing drive; shallow or going into respiratory failure (but still breathing)

Yes, that is the (main) reason for RSI. It's easier to stabilize and secure a patients airway before they stop breathing on their own.

 

[SpecialK]

Sorry to burst in here but quick relation question: can you intubate someone who is breathing? Maybe no gag reflex, but had the breathing drive; shallow or going into respiratory failure (but still breathing)

Yes, very much so. Many patients undergoing RSI will have clinically inadequate breathing. A good example is somebody who has a flail chest or multiple fractured ribs (even if not a flail segment); they don't want to breathe deep enough to have a normal tidal volume because it's very painful. Asthma is another example, in a patient with very severe asthma, they simply cannot physically exchange enough gas due to trapping and plugging. ,

 

[jwk]

Lidocaine actually does blunt ICP increases secondary to laryngoscopy - that's not in question. The question is whether it improve outcomes in TBI patients, and it's true that it has never been shown to.

However, I think it is still worth using, both because there probably are some patients who benefit from it's ICP lowering effects, and also because it potentiates opioids and induction agents, reduces the incidence of bronchospasm and laryngospasm, and may even prolong the duration of succinylcholine. It also reduces the incidence and severity of myalgias secondary to fasciculations.

Lidocaine cures the common cold, venereal warts, and the heartbreak of psoriasis. Seriously - it is a great drug, and is used in virtually every anesthesia induction and intubation. And contrary to the AHA, it is a superb anti-arrhythmic drug that, at least in my institution, is much easier to lay hands on than amiodarone or others. It has a pretty wide safety margin unless you're pushing the old 1-2gm syringes used to mix lidocaine drips in the dark ages of EMS.

Etomidate is an OK drug, but in most places I'm familiar with, it's use has been almost abandoned. Having it on national backorder for six months didn't help, and a lot of people never started using it again when it came back in stock. Ketamine has always been a personal favorite, and if by chance you're using propofol (I realize most aren't) then just don't use as much as you normally would.

 

[FiremanMike]

I mentioned ours in your last RSI thread, but I'll bring it up again because I'm fond of its simplicity and effectiveness..

Premedication
2mcg/kg fentanyl
2mg versed

Induction/paralysis
1mg/kg ketamine
1mg/kg rocuronium

Post intubation
2mcg/kg fentanyl
2mg versed (q20 or PRN for signs of awareness)

Or our crash airway, which just goes straight to rocketamine..

 

[MonkeyArrow]

I mentioned ours in your last RSI thread, but I'll bring it up again because I'm fond of its simplicity and effectiveness..

Premedication
2mcg/kg fentanyl
2mg versed

Induction/paralysis
1mg/kg ketamine
1mg/kg rocuronium

Post intubation
2mcg/kg fentanyl
2mg versed (q20 or PRN for signs of awareness)

Or our crash airway, which just goes straight to rocketamine..

Anyone want to chime in on the dosage of the versed? I know 2mg is an extremely small amount for the awake patient, but I also know that opioids (fent) help to potentiate the effects of the midazolam. How much does the drug-drug interaction affect the potency? Also, what is the point of the administration of versed if you're going to give Ketamine shortly after?