Ideas for RSI eduction

@STXmedic, I appreciate that. I think the quality of discussion on here is really good also, and I learn new things here all the time.

@FiremanMike, I'm not sure what it was about my comments in this thread that so offended you - I was just participating in the discussion on RSI protocols. I didn't even disagree with anyone. I don't know why my opinion would be less valid than anyone else's. And I don't know what to tell you about the "tone" of my posts.
 
CANMAN said:
TXmed, while I agree that focusing on oxygenation is extremely important, and ideally you want to start with the best numbers possible, sometimes clinically that just isn't possible. There are times where intubations occur with less then ideal sats or blood pressure because that is the best you can achieve given what is going on. To say we aren't going to proceed with intubation for a person who might be a trauma patient with a blood pressure of 80 systolic, or stop mid attempt is kinda silly in my opinion. Those number's are certainly going to guide my drug choices, or things we do in the preparation phase such as hyper elevating a morbidly obese person with crappy sats, but they aren't always going to prevent me from pulling the trigger on RSI if that's the best we have seen after some techniques which fail to improve the situation.
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I understand and agree with you to an extent you also have to understand why you are choosing to RSI. Is it V/Q mismatch ? Airway protection? There are many scenarios. You can't continue down that road just to get the tube. If you have that trauma patient with a systolic below 90 refractory to fluid bolus why continue jackin around with the airway ?, place a king tube to assist in airway protection and move on. In the pre-hospital setting Intubation is more of a protective measure than a treatment.
 
TXmed said:
I understand and agree with you to an extent you also have to understand why you are choosing to RSI. Is it V/Q mismatch ? Airway protection? There are many scenarios. You can't continue down that road just to get the tube. If you have that trauma patient with a systolic below 90 refractory to fluid bolus why continue jackin around with the airway ?, place a king tube to assist in airway protection and move on. In the pre-hospital setting Intubation is more of a protective measure than a treatment.
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Are you suggesting giving RSI drugs and placing a King Airway in those scenarios, or are you saying just placing a King Airway if the patient has more then one thing going on to manage? Under my protocols at work we place our King's with a laryngoscope to aid with tongue displacement and proper positioning. That being said there isn't a significant time difference in my system between time to ETT placement or King. Airway still comes before circulation in my book, and I can also work on more thing at once time using my partner and delegation. In the setting of a trauma or medical patient who needs an airway and remains hypotensive I will pick other drugs for the intubation/or king placement, and then proceed on to treat the hypotension with additional fluid, blood, vasopressors, whatever the situation might dictate, however just because the patient needs multiple interventions doesn't mean I am going to drop a King, if an ETT is predicted to be easy placement and will not result in additional delay. To be fair I am also working with a RN partner for all missions, so protocols and approach are different then if I were in a field 911 unit as a solo provider. If that were the case I could certainly get on board with your suggestion.

This topic has gotten a little off track, and we haven't heard alot back from the OP.
 
TXmed said:
I understand and agree with you to an extent you also have to understand why you are choosing to RSI. Is it V/Q mismatch ? Airway protection? There are many scenarios. You can't continue down that road just to get the tube. If you have that trauma patient with a systolic below 90 refractory to fluid bolus why continue jackin around with the airway ?, place a king tube to assist in airway protection and move on. In the pre-hospital setting Intubation is more of a protective measure than a treatment.
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I don't necessarily agree with this line of thinking. An obtunded trauma patient who is showing signs of decompensation should have aggressive airway management, with preference going to a secured ETT over a king airway. Now, if you're saying that you should be ready to move to the king in the event of a failed airway, I would agree, but I'd also say you should be ready to do that no matter what the circumstances.

@Remi - I've said what needed said, brother. If you don't see your tone, then I don't know what else to tell you. I'll concede that I should have done so in a private message instead of out in public. You and I are after the same thing here, which is to help the community learn and grow.
 
Sorry let me clarify. If you go in for the attempt and have yet to get to a point where you advance the tube then just stick the king. Obviously if you see the cords just stick the ET tube in. But the point I'm trying to make is people will brag about being successful on the first attempt but they didn't keep the patient oxygenated and delayed other treatment/transport for a procedure that is a protective measure.

Great thing using a larygescope to place the king.
 
Thanks for the input and thanks for your positive attitude Remi. We do have stats but I am a street medic and I don't deal with those things. Our coverage area is a 2 county area almost 3000 square miles and we do not have an ER. Also we do not have a helicopter in our coverage area. We use helicopters about half the time we need it due to availability and logistics. Our country does not have a lot of money so vents are definitely out. I've been really busy lately so I will answer more questions later. Thanks again.
 
TXmed said:
Sorry let me clarify. If you go in for the attempt and have yet to get to a point where you advance the tube then just stick the king. Obviously if you see the cords just stick the ET tube in. But the point I'm trying to make is people will brag about being successful on the first attempt but they didn't keep the patient oxygenated and delayed other treatment/transport for a procedure that is a protective measure.

Great thing using a larygescope to place the king.
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I don't delay transport for intubation, I do it en route, and I keep a high flow cannula on during the peri intubation phase.
 
medicaltransient said:
Thanks for the input and thanks for your positive attitude Remi. We do have stats but I am a street medic and I don't deal with those things. Our coverage area is a 2 county area almost 3000 square miles and we do not have an ER. Also we do not have a helicopter in our coverage area. We use helicopters about half the time we need it due to availability and logistics. Our country does not have a lot of money so vents are definitely out. I've been really busy lately so I will answer more questions later. Thanks again.
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Im sorry, but by your description, I just don't think it sounds like you guys have the resources to have a good RSI program.

The didactic aspect is easy - there are tons of resources online. The specific protocol is not important, either. Probably the best single resource is Manual of Emergency Airway Management by Ron Walls.

What matters is that you are able to provide good, frequent hands-on training and close monitoring of performance and related patient outcomes. In order to do that, I think at a minimum you need close medical director involvement, training done by someone with a lot of experience, and access to both an OR and simulator for frequent practice.
 
If I can sidebar:

Why are people using ketamine for induction but not for maintenence sedation? Ketamine is excellent for that also (well, it's excellent for pretty much everything).
 
I use it alot for maintenance. Works great with propofol, I can give a big dose before movement and if you push it slow it doesn't have a great effect on the respiratory drive which I think will lead to the patient being extubated sooner.
 
I see a lot of versed/Fenanyl protocols, that seems pretty popular. I'm just not sold on it, because the old mantra "anesthesia AND analgesia" isn't being met. Versed simply isn't an anesthetic (at least not at the pitiful doses it's given at).

Ketamine does both in one drug; with the caveat of having to add a small dose of a benzo, which is no big deal. I used to keep people down for hours with a ketamine/versed/vecuronium infusion for hours. Simple, easy, and resource-saving.

Then again, maybe we're just easing into it as a culture still. When I got out and started preaching about ketamine to people in 2013, having used it for a variety of things (PSA for chest tubes and fracture reductions, induction/maintenence, dental work, etc) people looked at me like I was crazy. It's only recently started to catch on it seems.
 
We've been trying desperately to get Ketamine added to our protocols here in Delaware. So far the state and county medical directors haven't bit. We continue to utilize Versed, Fentanyl, and vecuronium as our only options for post RSI sedation and paralysis. I think the fact that we haven't really reported any problems as a system with that combo is making our MDs reluctant to "fix" what they see as not being broken in the first place. I'd love to have Ketamine as an option for procedural sedation, chemical restraint, and RSI, but we just haven't quite managed to pull the trigger.
 
In reference to doczilla's last post:

I've read that adding benzos is great for staving off emergence reaction, but is there another reason to add versed to ketamine during post-intubation sedation?

We have the option for either ketamine or fent/versed for maintenance sedation, but they aren't too keen on us adding versed to ketamine in the absence of agitation.
 
STXmedic said:
In reference to doczilla's last post:

I've read that adding benzos is great for staving off emergence reaction, but is there another reason to add versed to ketamine during post-intubation sedation?

We have the option for either ketamine or fent/versed for maintenance sedation, but they aren't too keen on us adding versed to ketamine in the absence of agitation.
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In theory, no; if you're infusing enough ketamine they shouldn't break the k-hole. However, while I was searching for just the right "cocktail" after running out of narcs one night in what basically was the EMS equivalent of an MCI, every cocktail involving ketamine also had versed involved. I chose the 10vec/10versed/100 ketamine in a 500 bag at 30ml/hr, which worked fine. No spikes in the waveform, or vital sign fluctuations (well, outside of teetering through various stages of shock).

It was probably recommended as a safeguard in case they momentarily started to come down from dreaming in algebra, due to the fact that they were still paralyzed and we would be none the wiser.

Mind you the addition of versed is also helpful for severe TBI's, and while benzos aren't recommended for seizure prophylaxis, it's nice to have some GABA action if you RSI one of em. In fact, the GABA action is the very reason they add propofol to ketamine infusions; so think of versed as propofol's distant, ugly cousin.

Unfortunately, I didn't have access to an I.V pump, so propofol was off the table. Shame, because propofol Is very cerebroprotective.
 
Doczilla said:
In theory, no; if you're infusing enough ketamine they shouldn't break the k-hole. However, while I was searching for just the right "cocktail" after running out of narcs one night in what basically was the EMS equivalent of an MCI, every cocktail involving ketamine also had versed involved. I chose the 10vec/10versed/100 ketamine in a 500 bag at 30ml/hr, which worked fine. No spikes in the waveform, or vital sign fluctuations (well, outside of teetering through various stages of shock).

It was probably recommended as a safeguard in case they momentarily started to come down from dreaming in algebra, due to the fact that they were still paralyzed and we would be none the wiser.

Mind you the addition of versed is also helpful for severe TBI's, and while benzos aren't recommended for seizure prophylaxis, it's nice to have some GABA action if you RSI one of em. In fact, the GABA action is the very reason they add propofol to ketamine infusions; so think of versed as propofol's distant, ugly cousin.

Unfortunately, I didn't have access to an I.V pump, so propofol was off the table. Shame, because propofol Is very cerebroprotective.
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Thanks for that. I'll have to look up the role of versed in TBIs (though I would assume it has to do with seizure prophylaxis and cerebral hypoxia)
 
STXmedic said:
Thanks for that. I'll have to look up the role of versed in TBIs (though I would assume it has to do with seizure prophylaxis and cerebral hypoxia)
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Well, it's just that if you RSI a herniating or seizing TBI, you still have to terminate the seizure on the cellular level. Paralyzing them doesn't really help much, (aside from preventing spikes in ICP and rhabdo) cause theyll go brain dead after about 7 minutes of continuous seizure activity.

That's why I mentioned the GABA action being a plus; it's not really "on-label" for prophylactic reasons, but seeing as how that's kind of a blanket cocktail, every little bit helps in situations like that.
 
Do you guys have AIME education in the states? Might just be Canadian:

http://aimeairway.ca/

Anyway, all of our practitioners go through it, one for ALS and one for BLS. Teaches principles, not protocols generally. I'm not associated with them in any way, and have my own critiques of the program, but it is a good approach.

On the original topic, I firmly believe that RSI for paramedics has to be handled cautiously. Our ALS medics (ACPs here) do not RSI, and there are arguments both for and against that. When I was one I certainly had more 'against' arguments in an attempt to support my desire to have the skill available. However, with more training and education I have to say I'm not sure. People treat RSI like some sort of prehospital holy grail. It's not the RSI that's important, as has been mentioned in other posts, but rather everything around it. What are the right drugs? Depends. What is the right paralytic? Depends. If people give you a strict dogmatic answer to those, then they need to reflect on their own practice.

Our critical care program addresses anesthesia, not intubation. Otherwise it's like focusing on starting an IV rather than learning to run a cardiac arrest. Planning, executing, and maintaining someone on sedation/paralysis has to be well-considered and pt-specific. I think we always have to be aware of stating absolutes. I only say this because I was sure I was doing the right things eight years ago on the street as ALS. Now I think, "man, I was an idiot".

Briefly, on the above, midazolam is an acceptable sedation tool following intubation, but maybe not the best. Pre-hospital - don't sweat the emergence reaction. Are you planning on waking them up? Not really. My concern with polypharmacy is always hypotension. In a TBI people often give a lot of drugs because of the delay in onset. Do people really wait for the onset of a drug before giving more? I've seen people give lots of drug in an attempt to bring about rapid unconsciousness only to have a whole lot of no blood pressure ten minutes later.

Last note, yep, propofol is awesome, but I'm not sure I can agree with "very cerebroprotective".
 
Merck said:
Do you guys have AIME education in the states? Might just be Canadian:

http://aimeairway.ca/

Anyway, all of our practitioners go through it, one for ALS and one for BLS. Teaches principles, not protocols generally. I'm not associated with them in any way, and have my own critiques of the program, but it is a good approach.

On the original topic, I firmly believe that RSI for paramedics has to be handled cautiously. Our ALS medics (ACPs here) do not RSI, and there are arguments both for and against that. When I was one I certainly had more 'against' arguments in an attempt to support my desire to have the skill available. However, with more training and education I have to say I'm not sure. People treat RSI like some sort of prehospital holy grail. It's not the RSI that's important, as has been mentioned in other posts, but rather everything around it. What are the right drugs? Depends. What is the right paralytic? Depends. If people give you a strict dogmatic answer to those, then they need to reflect on their own practice.

Our critical care program addresses anesthesia, not intubation. Otherwise it's like focusing on starting an IV rather than learning to run a cardiac arrest. Planning, executing, and maintaining someone on sedation/paralysis has to be well-considered and pt-specific. I think we always have to be aware of stating absolutes. I only say this because I was sure I was doing the right things eight years ago on the street as ALS. Now I think, "man, I was an idiot".

Briefly, on the above, midazolam is an acceptable sedation tool following intubation, but maybe not the best. Pre-hospital - don't sweat the emergence reaction. Are you planning on waking them up? Not really. My concern with polypharmacy is always hypotension. In a TBI people often give a lot of drugs because of the delay in onset. Do people really wait for the onset of a drug before giving more? I've seen people give lots of drug in an attempt to bring about rapid unconsciousness only to have a whole lot of no blood pressure ten minutes later.

Last note, yep, propofol is awesome, but I'm not sure I can agree with "very cerebroprotective".
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Greetings from the US, bud. Cheers! Thanks for the insight!

Can you share your thoughts on propofol? Why don't you feel that it's "very" cerebroprotective?

Also, I don't think versed should ever be in mass quantities, especially in the anesthesia topic. I think there's a reason that it isn't commonly used for induction anymore, because the dose you need is outright rediculous.

I feel that using versed in this case is proactive, not reactive. The only caveat to that is if you actually witness a seizure (talking about head injuries here) and you're forced to RSI. It's still a consideration.

I believe that the combination of versed and ketamine is far less likely to cause hypotension than versed and fentanyl.
 
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