Heres one for you guys!

[Handsome Robb]

DO you use ET tubes though?

Yes. I'm with jjesusfreak01, what else is there to use?

 

[medicsb]

It IS the standard of care anywhere outside of ground EMS. You won't find CCT teams, HEMS, EDs, or anesthetist RSI'ing without analgesia on board.

Anyone who doesn't have opiates in their RSI protocol should be using the pain management protocol to treat them as well. And lobbying the hell out of their OMD.

I'll get off my soap box now.

You have a lot of soap-boxing to do, because there are a lot of places, both EMS (ground- and aero-) and EM, not using opiates for RSI.

This is probably something that is relatively local. I've witnessed many RSIs in ORs and EDs, and, well, not too often are analgesics used as a pretreatment or for induction. I went and checked an EM text (Rosen's) and an anesthesia text (Miller's) and though opiates are discussed, neither seems to mandate the use of an opiate for RSI. In Miller's it is actually pretty clearly listed as "optional". In Rosen's, it is recommended in certain instances (e.g. increased ICP or AMI). So, I'm not too sure of the "standard of care" designation.

 

[Dwindlin]

You have a lot of soap-boxing to do, because there are a lot of places, both EMS (ground- and aero-) and EM, not using opiates for RSI.

This is probably something that is relatively local. I've witnessed many RSIs in ORs and EDs, and, well, not too often are analgesics used as a pretreatment or for induction. I went and checked an EM text (Rosen's) and an anesthesia text (Miller's) and though opiates are discussed, neither seems to mandate the use of an opiate for RSI. In Miller's it is actually pretty clearly listed as "optional". In Rosen's, it is recommended in certain instances (e.g. increased ICP or AMI). So, I'm not too sure of the "standard of care" designation.

The bolded is important. "Standard of care" gets thrown around a lot. Post induction analgesics are a good thing and likely improve outcomes (more good studies needed) but they are far from standard of care.

 

[usalsfyre]

You have a lot of soap-boxing to do, because there are a lot of places, both EMS (ground- and aero-) and EM, not using opiates for RSI.

This is probably something that is relatively local. I've witnessed many RSIs in ORs and EDs, and, well, not too often are analgesics used as a pretreatment or for induction. I went and checked an EM text (Rosen's) and an anesthesia text (Miller's) and though opiates are discussed, neither seems to mandate the use of an opiate for RSI. In Miller's it is actually pretty clearly listed as "optional". In Rosen's, it is recommended in certain instances (e.g. increased ICP or AMI). So, I'm not too sure of the "standard of care" designation.

Every major medical center RSI I've been around has included opiates pre and post induction. The benefits are well documented. As far as HEMS, I've yet to run across an organization that didn't include opiates in their RSI guidelines. Examples?

Waveform capnography is still considered "optional" for EMS in many text as well, good luck using that defense. I agree standard of care is a legal term. But should a bad outcome result you'll find any number of people willing to hang you out to dry on it. I don't think you'll find too many who will state opiates were a bad idea.

 

[jjesusfreak01]

Waveform capnography is still considered "optional" for EMS in many text as well, good luck using that defense.

New monitors are expensive, as are stand-alone ETCO2 waveform displays. I think everyone will probably start using them when they can justify upgrading the monitors. That said, none of the ERs in my area have bedside access to ETCO2, and I don't think the docs use it for intubations. They have it in the anesthesia dept though, where the docs know how well it works.

 

[medicsb]

Every major medical center RSI I've been around has included opiates pre and post induction. The benefits are well documented. As far as HEMS, I've yet to run across an organization that didn't include opiates in their RSI guidelines. Examples?

Every major medical center RSI I've been around has not always or even commonly used opiates for pre-induction.

Lets not overstate the "benefits" of opiates. The benefits are founded on surrogate outcomes and mostly on patients undergoing planned procedures (i.e. in the OR under non-emergent circumstances).

I know of a flight program associated with a "top 10" medical center that uses opiates as part of its protocol, but for post-ETI management (i.e. not for pre-Tx or induction).

While I can't offer any other specific examples, I thought this may give a better idea than some anecdotes:
Resuscitation. 2009 Jun;80(6):650-7.
Emergency airway management in critically injured patients: a survey of U.S. aero-medical transport programs.

This included 89 aeromedical programs, and only about half used an opiate as part of RSI (about 80% used etomidate and versed, so who knows what is actually used in the typical RSI) and half for post ETI management. I'm doubtful that much has changed since the survey was performed.

Waveform capnography is still considered "optional" for EMS in many text as well, good luck using that defense. I agree standard of care is a legal term. But should a bad outcome result you'll find any number of people willing to hang you out to dry on it. I don't think you'll find too many who will state opiates were a bad idea.

My point is that this topic isn't as cut-and-dry as you and others try to make it. I don't think there is anything to indicate an opiate as part of RSI is a standard of care (except maybe in post-ETI management) and probably not nearly as common as you state. It might be more of a standard of care to not use an opiate and just use a sedative. (Not saying this is right thing to do... but, not saying it is the wrong thing, either.)

The only thing that is cut-and-dry is that you need to sedate and then paralyze for RSI; what drug combination is used is up for debate and will probably never be conclusively decided upon.