MFI/RSI
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NomadicMedic
I know a guy who knows a guy.
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Savannah apparently has a "sedation facilitated intubation" protocol. It's etomidate -> tube. I haven't seen it, but that's what I hear.
Sounds like a 100% bad idea.
Sounds like a 100% bad idea.
E tank
Caution: Paralyzing Agent
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New here. Hi. "RSI" is a casually tossed about term that has taken on many meanings so as to become meaningless.
It is an anesthesia term meaning that acceptable intubating conditions are brought about after a period of pre oxygenation by way of rapid sequential blouses of a hypnotic followed by an adequate dose of muscle relaxant. These conditions are induced in 60 seconds or less and should not be accompanied by positive pressure mask ventilation before laryngoscopy.
Any ongoing administration of any cocktail of sedation prior to hypnosis is not RSI. The point is to maintain native airway reflexes until a very brief period of paralysis and unconsciousness is induced, after which a definitive airway is immediately placed.
It is an anesthesia term meaning that acceptable intubating conditions are brought about after a period of pre oxygenation by way of rapid sequential blouses of a hypnotic followed by an adequate dose of muscle relaxant. These conditions are induced in 60 seconds or less and should not be accompanied by positive pressure mask ventilation before laryngoscopy.
Any ongoing administration of any cocktail of sedation prior to hypnosis is not RSI. The point is to maintain native airway reflexes until a very brief period of paralysis and unconsciousness is induced, after which a definitive airway is immediately placed.
We use protocols based off the Difficult Airway course and book by Dr. Ron Walls. Here is good primer, but keep in mind it is written for the ICU and our environment has different concerns as well: http://www.medscape.org/viewarticle/443567
For our purposes, RSI always involves sedation and paralysis. If I give report to an ER doc or intensivist, they will expect I followed those guidelines as often as possible. Our preferred agents are etomidate or ketamine with sux or norcuron. Long term paralysis should be avoided if possible. We don't stock it, but can get propofol for most interfacility runs.
For our purposes, RSI always involves sedation and paralysis. If I give report to an ER doc or intensivist, they will expect I followed those guidelines as often as possible. Our preferred agents are etomidate or ketamine with sux or norcuron. Long term paralysis should be avoided if possible. We don't stock it, but can get propofol for most interfacility runs.
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Moderator's Note: Several posts have been removed. Please keep it on topic and civil. Thanks!
SeeNoMore
Old and Crappy
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I do anywhere from 1-2 a month on average between ALS service and flight service. That does not include OR tubes.
Bullets
Forum Knucklehead
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Our two county ALS project uses RSI pretty regularly. But its a highly populated high call volume region. One of the few good things about NJ EMS, there are plenty of calls and plenty of opportunity for medics to tube and RSI
SixEightWhiskey
Forum Crew Member
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I work for a non-transporting service, 3 trucks during the day (either 1 or 2 at night depending on staffing), providing ALS tiered/dual-response with BLS for several municipalities (a population of roughly 250,000). Full-time paramedics are expected to have between 20-25 intubations per year (mix of cardiac arrests and RSIs). The annual average for the service as a whole is 300+ intubations overall, and the arrest/RSI numbers are about 50/50.
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Sounds pretty busy for your number of trucks. You staff one ALS truck for a population of 250k at night? That's impressive.
cruiseforever
Forum Asst. Chief
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I was thinking the same thing. I also wonder about when you have a set number of intubations to be done. Is there pressure to RSI someone who may not need to be tubed? I am pretty conservative when it comes to RSI. When I work with a newer medic I am amazed at the number they claim they to have done over the year.
I didn't catch the "one RSI per code" post, but most of my codes get an advanced airway, and it's the tube placement that's the hard part (as opposed to pushing the drugs).
A lack of technical proficiency, either real or perceived, is what (IMO) prevents any decent advances in airway management for us
A lack of technical proficiency, either real or perceived, is what (IMO) prevents any decent advances in airway management for us
Do you have any sources to cite that it's a bad idea? Any studies that show it isn't as effective or safe as RSI?
TXmed
Forum Captain
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http://www.ncbi.nlm.nih.gov/pubmed/10102312
medication facilitated intubation will always have complications. what are you protecting by not adding a paralytic? if we are doing this their airway is not working for them so we need to be all in on taking it. versed and etomidate doesnt always take away the gag reflex, stop vocal cord spasm, or keep the patients airway from tensing up when you put the larygescope in their mouth. plus succs and roc constrict the esophageal sphincter helping in that matter.
TXmed
Forum Captain
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It's such a bad idea that there isn't much research on it.
Can it work? Sure. Is it a good idea? Not at all. The deletion of a NMB adds nothing, but the addition of it reduces the chances of several potentially catastrophic complications.
Edit: there certainly are times that it is desirable to keep the patient breathing throughout the airway management sequence. There are several recipes out there for "awake" fiberoptic intubation, for instance. But this is very different than just giving a massive slug of etomidate and hoping for the best.
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A versed only regimen sounds even worse than an etomidate only...