Pain management in RSI

[Melclin]

If I could just offer some advice BEMS, it seems like there is a lot of confusion and argument being caused by an apparent lack of clarity in some of your posts. I assume you are not actually stupid enough to think any of the several odd things you have posted eg that any paralytic is a "non-polarising agent", "half life of etomidate is night" etc. So if I may, I'd suggest that you take just a fraction more time to proof read your posts and add a bit more context and detail (just a little) to more clearly state your argument and avoid unnecessary misunderstandings. Everybody makes a few mistakes here and there but mate, most of your posts are utterly confusing and its a little hard to tell whether or not they are typos or if you actually think some of the things you are saying.

Also, you've been asked several questions that you've completely failed to address or answered in a way whereby you state the obvious and fail to really address the point of the question ("etomiate is a short acting anaesthetic"..well yeah, but it doesn't really address the issue of analgesia or adrenal suppression or any of the other issues being discussed). I'm really not having a go at you mate but in the interests of avoiding a thread that descends into argument based on misunderstandings and typos, there isn't much point in continuing with the discussion until you clear up a few of the details and give a little more context to some of your replies.

Sepsis: Its not that rare for septic patients to have a respiratory status or conscious state that leads to their being intubated. I wouldn't have thought the idea was that foreign. My point though was along the lines of the adrenal suppression issue addressed by halothane and aidey.

Etomidate is fine in sepsis if its all you have.

Probably not the best choice if you have options, but the cortisol suppression from a single dose is transient and has never been shown to negatively affect outcomes.

Gotcha. Cheers mate

Work your airway plan. .

The first time I heard about vortex, I thought, "What a silly idea. Really if this is news to you, then maybe you shouldn't be intubating". But the more I think about it, the more I think its a brilliant conceptual tool to capture and frame an idea that, like most good ideas, seems obvious once thought of.

 

[RocketMedic]

I'm skittish with intubating and medication-assisted intubation. Here, we use etomidate for procedural sedation. Versed is our (optional) induction aid. I personally drop versed and fentanyl for everyone I intubate.

 

[Flight-LP]

The etomidate is a powerful short acting anesthetic and must be pushed prior to the succynocoline which is a non polorizing paralytic. These are the two most common drugs used in a hospital setting for rsi. And I'm not sure I understand your reference to sepsis. Allthough sepsis does have a high mortality rate and we are learning more and more about the importance of its pre hospital recognition. Ive yet to see a study where taking thier airway was deemed vital in thier outcome. I work in an urban setting doing 911 work.

Anectine is a depolorizing NMBA.

Analgesia is an absolute with appropriate sedation in the RSI'd patient. Outside of it being a basic standard of care, could you imagine having a large piece of plastic shoved down into your trachea with mechanical changes in pressure throughout your chest? Barbaric comes to mind. Medicate your patients appropriately, that includes sedation, analgesia, and paralysis as needed. If you can't, then your system and MD has failed you and your patients.

 

[Wes]

I could very easily see the lack of understanding of RSI and the underlying pharmacology (not to mention basic ethics -- first, do no harm) exhibited in some posts as the best arguments for a medical director NOT to trust medics with paralytics.

 

[Tigger]

How did your private service get an OEMS RSI waiver without any consideration of post-procedure sedation?

 

[Carlos Danger]

I could very easily see the lack of understanding of RSI and the underlying pharmacology (not to mention basic ethics -- first, do no harm) exhibited in some posts as the best arguments for a medical director NOT to trust medics with paralytics.

This.

I have argued for a while now that RSI should not be a basic standard of care for paramedics.

I have seen way too many who don't really understand the drugs, or the procedure, or who just don't have the skill and judgement to do it safely.

 

[Wes]

For the record, at the services I've been involved with, it requires extra education, not only on the protocol itself, but airway management as well. Our small rural service has it. We also did a separate RSI course for our medics and additionally have purchased video scopes for intubation.

Either you do RSI correctly or you don't do it. Period.

 

[Christopher]

For the record, at the services I've been involved with, it requires extra education, not only on the protocol itself, but airway management as well. Our small rural service has it. We also did a separate RSI course for our medics and additionally have purchased video scopes for intubation.

Either you do RSI correctly or you don't do it. Period.

Amen.

That includes the horrifically scary "DFI" practiced by many non-RSI services. If you're not allowed to RSI, why in the world would it appropriate to give massive doses of benzos to attempt an intubation?!

 

[Wes]

Indeed. I'm not sure how Etomidate alone would "facilitate" my obtaining an airway.

 

[Carlos Danger]

Just to be intellectually honest about the necessity of analgesia.....

Done properly and atraumatically, intubation is not really painful. I do like to use fentanyl and very often do, but there are quite a few situations in the OR where you really want to minimize opioids and those people are intubated all day long with nothing but propofol, and they do perfectly fine that way.

Now, that said, we don't have the same considerations in the field that we do in the OR, and some pre-intubation fentanyl is certainly not a bad idea by any means. Especially in a head injured patient (which is the indication for probably 95% of prehospital RSI's), a healthy dose of fentanyl can help blunt the SNS response (ICP increase) to intubation. Personally, my first choice for a prehospital intubation of a head injured patient would probably be fentanyl & etomidate. Keep in mind that hypotension is one of the worst things you can do for a head injured patient......even a brief episode increases the risk of mortality by something like 50%?

Same thing post-intubation: adequate sedation alone should cover the discomfort of being intubated and ventilated. However, opioids can reduce the need for sedatives (or enhance their effectiveness, whichever way you look at it), and smaller doses of midazolam plus opioids may be less likely to negatively affect hemodynamics than large doses of midazolam alone. And of course, as several here have pointed out, analgesics certainly may be indicated to cover pain from traumatic injuries.

 

[Carlos Danger]

Amen.

That includes the horrifically scary "DFI" practiced by many non-RSI services. If you're not allowed to RSI, why in the world would it appropriate to give massive doses of benzos to attempt an intubation?!

It's one of the worst things I've ever seen.

For some reason though, quite a few people hold the misconception that it is safer than using NMB's.

 

[VFlutter]

The etomidate is a powerful short acting anesthetic and must be pushed prior to the succynocoline which is a non polorizing paralytic. These are the two most common drugs used in a hospital setting for rsi.

How much time have you spent assisting or performing RSI in the hospital setting? Are you referring to the ED only? I can assure you our CCPs and MDAs have a much broader repertoire

Did you just watch the tube get passed and walk out? You seem to have missed that whole post-RSI care thing and the part about hanging maintenance infusions. Walk into an ICU and check the drips on a vented patient. On second thought I don't think you should be anywhere near an ICU

 

[Wes]

This is the same person, who, in another thread, is an EMT for BEMS and a paramedic for a private service -- and looking to move to another locale to work basing his decision, in part, on the amount of penetrating trauma.

As we'd say in the legal arena, "Res ipsa loquitor." The thing speaks for itself.

 

[NomadicMedic]

Stultus est sicut stultus facit.

 

[Wes]

Impressive! Did you take Latin?

 

[NomadicMedic]

In high school. And mass.

But I have a masters in "Google Translate".

 

[Wes]

Junior high, high school, and college. And nope, I'm not even Catholic.

 

[medicsb]

This is the same person, who, in another thread, is an EMT for BEMS and a paramedic for a private service -- and looking to move to another locale to work basing his decision, in part, on the amount of penetrating trauma.

As we'd say in the legal arena, "Res ipsa loquitor." The thing speaks for itself.

Yeah, it certainly does.

 

[RocketMedic]

I do not intubate many people, and I generally consider a working King LTas a reasonable airway. I am fairly scared of an etomidate only "facilitated intubation". Does this make me a good paramedic or overly worried?

 

[Wes]

I'd like to think that a jury would consider you "reasonable and prudent."