Ideas for RSI eduction

[Carlos Danger]

Ketamine is a great drug because of its impressive versatility. However, as with any "jack of all trades", while it may be good at pretty much everything, it's probably not the best choice in most scenarios. It's a great tool to have in the box but it's rarely the first thing I reach for, unless I'm intubating someone in the early stages of hemodynamic instability or volume depletion. Or doing a deep sedation with someone whose airway I'm concerned about.

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).

Versed and fentanyl is actually a great combo - probably the best, in fact - at least in the very early phases where hemodynamics may be an issue and you aren't yet thinking about extubation. You don't need a general anesthetic depth of anesthesia to keep an intubated patient comfortable. A few mg's an hour of versed plus a hundred or so mcg's of fentanyl will often do a nice job. More during transport of course, because of the greater sensory stimulus.

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.

Actually, it is the other way around. Ketamine is sometimes added to propofol so that less propofol can be used to achieve a given level of sedation. And ketamine actually does agonize GABA receptors on its own (as well as opioid, serotonin, and adrenergic ones).

One of the reasons ketamine is still controversial as a routine induction agent is because of it's pro-seizure properties. It's probably not a good choice in someone at high risk for seizures (SAH), and I'm not sure a few mg's of versed would have much impact on that risk. The last I knew (it's been a while since I looked at the guidelines), the Brain Trauma Foundation still recommended propofol for sedation of TBI patients because of its ability to maintain CBF in relatively low-flow states, but acknowledges that there is really no research showing that it leads to superior outcomes as compared to the other drugs that are commonly used for that purpose.

 

[Carlos Danger]

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".

Great points. The more you learn, the more you realize you don't know anything.

 

[Merck]

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.

Hiya,

I only question the effectiveness of propofol because my admittedly brief research shows the claims are made primarily using animal (murine) models. Not great evidence. My other concern there is that, well, you know how it goes, all of a sudden - "have to use propofol, it's neuroprotective!" happens with a pressure in a TBI of 91/50.

I agree that versed/ketamine is better than versed/opioid, but even there at least fentanyl is a good choice. Ketamine is good for continued sedation, I've just anecdotally had a harder time getting a stable RASS in the short-term.

As well, no question that benzos are 1st line for seizure. Considering a seizure 'treated' because a pt is roc'd would get you strung up around here.

Oh, and Happy New Year all.

 

[Doczilla]

Ketamine is a great drug because of its impressive versatility. However, as with any "jack of all trades", while it may be good at pretty much everything, it's probably not the best choice in most scenarios. It's a great tool to have in the box but it's rarely the first thing I reach for, unless I'm intubating someone in the early stages of hemodynamic instability or volume depletion. Or doing a deep sedation with someone whose airway I'm concerned about.



Versed and fentanyl is actually a great combo - probably the best, in fact - at least in the very early phases where hemodynamics may be an issue and you aren't yet thinking about extubation. You don't need a general anesthetic depth of anesthesia to keep an intubated patient comfortable. A few mg's an hour of versed plus a hundred or so mcg's of fentanyl will often do a nice job. More during transport of course, because of the greater sensory stimulus.



Actually, it is the other way around. Ketamine is sometimes added to propofol so that less propofol can be used to achieve a given level of sedation. And ketamine actually does agonize GABA receptors on its own (as well as opioid, serotonin, and adrenergic ones).

One of the reasons ketamine is still controversial as a routine induction agent is because of it's pro-seizure properties. It's probably not a good choice in someone at high risk for seizures (SAH), and I'm not sure a few mg's of versed would have much impact on that risk. The last I knew (it's been a while since I looked at the guidelines), the Brain Trauma Foundation still recommended propofol for sedation of TBI patients because of its ability to maintain CBF in relatively low-flow states, but acknowledges that there is really no research showing that it leads to superior outcomes as compared to the other drugs that are commonly used for that purpose.

Interesting. I knew that ketamine has actions beyond NMDA agonism, but none of what I've read was concrete enough to try to share here to be fair though, i havent looked in a while. Can you share where you found that please ? It seems kind of counterintuitive that ketamine would have GABA action, while still being pro-seizure. I wonder what the proposed mechanism behind a medicine that allegedly supresses neuronal transmission through GABA, while also predisposing you to seizures is.

On the topic of "Ketafol", ketamine is mixed with propofol because propofol has zero analgesic properties whatsoever--- and therefore, no meeting the "two A's" that you need.

The amount of propofol needed for its cerebroprotective effects (again, GABA), is likely still under the threshold that would cause hypotension in TBI patients, (as opposed to barbiturates and sodium channel blockers), which is probably why it's reccomended.

I don't think there is a "one size fits all" drug, and I also don't believe that infusing 10mg of versed (for maintenance) will cut it when it comes to seizures. I just suggested that it may be favorable given the situation.

Sorry for the late response, working tonight.

 

[Doczilla]

Hiya,

I only question the effectiveness of propofol because my admittedly brief research shows the claims are made primarily using animal (murine) models. Not great evidence. My other concern there is that, well, you know how it goes, all of a sudden - "have to use propofol, it's neuroprotective!" happens with a pressure in a TBI of 91/50.

I agree that versed/ketamine is better than versed/opioid, but even there at least fentanyl is a good choice. Ketamine is good for continued sedation, I've just anecdotally had a harder time getting a stable RASS in the short-term.

As well, no question that benzos are 1st line for seizure. Considering a seizure 'treated' because a pt is roc'd would get you strung up around here.

Oh, and Happy New Year all.

I suppose it depends on how the propofol is initiated, (example: 40mg bonuses titrate to coma, versus a straight IV in fusion of mcg/kg/min).

 

[TXmed]

Speaking on sedation. I am lucky enough to use a fairly sophisticated ventilator. And I see that if I focus on proper vent settings then I can use alot less sedation, as it is more comfortable for the patient.

 

[Doczilla]

One more thing, (since it's not letting me edit), I'm a huge fan of combining benzos and opiates. You use less of each, they're synergistic, and overall safer as opposed to snowing someone with either one alone.

Ive talked to people who have been "kept down" with versed and fentanyl, and between their personal testimony and my gut as a provider, I just don't feel like it's enough to attenuate the traumatic experience of having a tube jammed down your throat for any intermediate or extended period of time.

 

[Merck]

+1 for the vent. You can mitigate the need for drugs with a little bit of care for your strategy.

 

[RocketMedic]

Medicaltransient, let me be blunt. You and your system are not ready for RSI. You lack the funds, it sounds like you lack the intellectual and informational support and you lack the really relevant material support and the realistic prospect of gaining those.

 

[SeeNoMore]

OP I think it's great you took the initiative at work , and to look for some insight from this community. Perhaps you can speak to your medical director and find out whether some of the concerns raised here can be addressed? It may not be a reality to purchase specific equipment (like vents), but at a minimum you certainly need a robust and organized approach to implementing RSI that is far beyond the scope of hosting a class by a provider who is fairly inexperienced in airway management. That's not meant to offend you in any way or demean your practice, I am only saying it because of the small number of RSIs you have performed. Best,

 

[TXmed]

Just because your not ready today doesn't mean you'll never be ready. That's what education is for. I encourage you to keep working towards it. The majority of RSI systems in Texas don't have all the resources named here but they find different ways to make it work.

Also if you're gonna use AEL protocols you can ask them for help with education. They will be more than happy to come out to your service and assist you with this.

 

[Carlos Danger]

Interesting. I knew that ketamine has actions beyond NMDA agonism, but none of what I've read was concrete enough to try to share here to be fair though, i havent looked in a while. Can you share where you found that please?

Ketamine does not bind to GABAa receptors, but enhances GABA transmission indirectly via the glutamate-GABA interaction. The thing to understand about ketamine is that it is not a "clean" drug - it has very complex effects on virtually all of the major CNS neurotransmitter pathways, as well as peripherally. This is touched on in both Miller's Anesthesia and Stoelting's Pharmacology & Physiology in Anesthetic Practice, and explained in more depth in one of the big pharm texts (Evers Anesthetic Pharmacology, I think?).

On the topic of "Ketafol", ketamine is mixed with propofol because propofol has zero analgesic properties whatsoever--- and therefore, no meeting the "two A's" that you need.

Well yeah, for a painful procedure, propofol alone isn't ideal. What I disagreed with before was your statement that "the GABA action is the very reason they add propofol to ketamine infusions".

In anesthesia, ketafol could be used for all types of things, but is typically used alone for brief, relatively painless procedures like colonoscopies, or in conjunction with a local anesthetic for small painful procedures like a a carpal tunnel release, or with a nerve block for something bigger like a distal radius ORIF. In these case, because you have good local anesthesia, you don't really need a lot of IV analgesia (if any), and in fact propofol is very commonly used all by itself for these things. So when ketamine is added, it isn't usually being used for it's analgesic effects per se, but more for its propofol-sparing effect. Meaning that propofol depresses pharyngeal tone, which is fairly easily managed in most patients, but in some can result in difficulty maintaining a patent airway. Opioids would just worsen the airway problem, so you add some ketamine to your prop (or just bolus the ketamine separately, which is what I prefer to do - I really don't see the point in mixing them), and then you can reach a given level of sedation with less total dose of propofol and correspondingly less pharyngeal relaxation.

Ive talked to people who have been "kept down" with versed and fentanyl, and between their personal testimony and my gut as a provider, I just don't feel like it's enough to attenuate the traumatic experience of having a tube jammed down your throat for any intermediate or extended period of time.

Oh, it it definitely enough. Providing an adequate dose is being used, of course.

If you can do major surgery under just versed/fentanyl anesthesia - and you certainly could - you can definitely maintain comfort during mechanical ventilation with the same drugs.

 

[Doczilla]

Ketamine does not bind to GABAa receptors, but enhances GABA transmission indirectly via the glutamate-GABA interaction. The thing to understand about ketamine is that it is not a "clean" drug - it has very complex effects on virtually all of the major CNS neurotransmitter pathways, as well as peripherally. This is touched on in both Miller's Anesthesia and Stoelting's Pharmacology & Physiology in Anesthetic Practice, and explained in more depth in one of the big pharm texts (Evers Anesthetic Pharmacology, I think?).



Well yeah, for a painful procedure, propofol alone isn't ideal. What I disagreed with before was your statement that "the GABA action is the very reason they add propofol to ketamine infusions".

In anesthesia, ketafol could be used for all types of things, but is typically used alone for brief, relatively painless procedures like colonoscopies, or in conjunction with a local anesthetic for painful procedures like a a carpal tunnel release, or with a nerve block for something bigger like a distal radius ORIF. In these case you don't really need a lot of analgesia, so the ketamine isn't usually being used for it's analgesic effects per se, but more for it's propofol-sparing effect. Meaning that propofol depresses pharyngeal tone, which is fairly easily managed in most patients, but in some can result in difficulty maintaining a patent airway. Opioids would just worsen the airway problem, so you add some ketamine to your prop (or just bolus the ketamine separately, which is what I prefer to do - I really don't see the point in mixing them), and then you can reach a given level of sedation with less total dose of propofol and correspondingly less pharyngeal relaxation.




Oh, it it definitely enough. Providing an adequate dose is being used, of course.

If you can do major surgery under just versed/fentanyl anesthesia - and you certainly could - you can definitely maintain comfort during mechanical ventilation with the same drugs.

Well, I use the term "mix" very loosely; I meant given simultaneously. I don't think I've ever seen propofol directly mixed with anything actually.

I also realize that ketamine is a complex beast--- too complex in fact, to go in depth about here (especially since I've started this sidebar). The point I wanted our colleagues to glean here is that adding some type of GABA agonist to ketamine is benificial (but not required in some cases), and isn't crystallized into the "emergence phenomenon prophylaxis".

In the case of RSI, and the subsequent maintenance sedation, I'm a firm believer that considering the other options that the prehospital realm has, ketamine has the most utility.

 

[Carlos Danger]

Well, I use the term "mix" very loosely; I meant given simultaneously. I don't think I've ever seen propofol directly mixed with anything actually.

Yep, many people like to actually mix the ketamine into their syringe of propofol, that's where the term "ketafol" came from. I think it's easier to just give a bolus of ketamine and then start your propofol at half the dose that you would if you were using it alone.

 

[Doczilla]

Yep, many people like to actually mix the ketamine into their syringe of propofol, that's where the term "ketafol" came from. I think it's easier to just give a bolus of ketamine and then start your propofol at half the dose that you would if you were using it alone.

Yeah, I don't think I would ever use a mixed dose personally. I value ketamine for it's dissociative effects (and long-term analgesia following the anesthesia phase), and it would probably be difficult to determine if they're fully disassociated if you're bolusing the propofol at the same time.

The infusion afterwards, sure.

 

[medicaltransient]

Thanks for the input, I definitely learned a lot from the dialogue and I know I have some work cut out for me. You guys made a lot of good points that I will explore. The pharmacology I will be getting from the Hospira website and I will be using the Manual of Emergency Airway Management by Ron Walls for the rest. I have no word on the practical portion yet and I suggested getting a new more involved medical director eventually and it was not received well. We don't have much money but we do have a problem working airways for long periods of time so hopefully the program is a success.

 

[medicaltransient]

Do you guys use RASS score regularly? Anyone have problems with it?

 

[FiremanMike]

Our transport time is 5-10 minutes at the most and before we used Roc, we would follow up our tube confirmation with Vec, in both cases we'd use a good amount of fent and versed. Short answer, no, we do not use RASS score.

IMHO (and I'm sure some will disagree), RASS is more appropriate for longer IFT transports of somewhat stabilized patients and not the emergent patients that we have RSI'd because they were really sick.

 

[Doczilla]

Our transport time is 5-10 minutes at the most and before we used Roc, we would follow up our tube confirmation with Vec, in both cases we'd use a good amount of fent and versed. Short answer, no, we do not use RASS score.

IMHO (and I'm sure some will disagree), RASS is more appropriate for longer IFT transports of somewhat stabilized patients and not the emergent patients that we have RSI'd because they were really sick.

Yeah, especially since you're likely being, as you said, generous with the drugs to keep em down. I think the RASS is more to see if the long term stuff is adequate.

 

[Carlos Danger]

The RASS is intended for the ICU, where you are trying to use as little sedation as possible while still keeping the patient comfortable, because you are hoping to extubate as soon as possible and are trying to minimize delirium. Not a good tool for field use, I don't think.