Pain management in RSI

[NomadicMedic]

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?

So, lets stop and think about this for a second. The real reason we use paralytics is to prevent regurgitation. Etomidate doesn't prevent regurg. Neither, contrary to every paramedic text, does the Selleck Maneuver.

Can you tube someone with just Etomidate? Sure. Is it the right thing to do? Nope. And I'm sure a bad outcome following an etomidate only DFI could be litigated successfully if an expert witness started asking about standard of care and how the DFI protocol doesn't meet it...

But I digress.

When the RSI algorithm was developed, they didn't just throw meds in there for the heck of it. If your service doesn't trust the medics enough to hand then the keys to true RSI as expects them to give it the old college try with etomidate only, it time to start rattling the bars. Get on the protocol committee. Open a dialogue with the medical director. Start making some noise and asking why. "Because we've always done it this way" isn't an answer that should satisfy a thinking paramedic.

 

[RocketMedic]

That soothes me...I personally try and avoid the cowboy medic attitude where I can.

 

[medicsb]

Can you tube someone with just Etomidate? Sure. Is it the right thing to do? Nope. And I'm sure a bad outcome following an etomidate only DFI could be litigated successfully if an expert witness started asking about standard of care and how the DFI protocol doesn't meet it...

You probably have a much greater chance of litigation if something goes wrong with RSI. How much evidence exists showing prehospital etomidate-only to be associated with bad outcomes? How much exists showing prehospital RSI to be associated with bad outcomes? I think we can guess how most experts would testify.

 

[Handsome Robb]

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. .

This scares me.

Sux is adepolarizing neuromuscular blocker. There are depolarizing and non-depolarizing neuromuscular blockades. Depolarizing neuromuscular blockers cause all the muscles to depolarize leading to fasiculations (sp?) and then flaccidity since the muscles cannot re-polarize whereas a non-depolarizing neuromuscular blocker blacks the ability for the muscles to depolarize and thus contract which results in flaccidity as well. With non-depolarizing agents you don't have to wait for the fasiculations to cease because they never start.

That's my oversimplified, self-self taught, rudimentary understanding of neuromuscular blockers.

While it happens all the time with only etomidate and sux (in that order) but is immediately followed by some sort of analgesic as well as a sedation drip and long acting paralytics.

What scares me is the lack of knowledge of the meds you're using.

Just because someone is sedated and paralyzed doesn't mean their brain won't have a sympathetic response to painful stimuli that can be detrimental to the pt....for example a paralyzed and sedated head injury spiking their ICP due to lack of analgesia post intubation.

We don't do RSI on the ground but our flight medics do:

Versed OR etomidate OR ketamine PLUS fentanyl 2-3 mcg/kg PLUS succinylcholine OR rocuronium OR vecuronium for intubation.

For maintaining paralysis and sedation they do versed/fent OR ketamine PLUS norcuron or rocuronium.

If you want I can provide dosing if you'd like. Didn't because it made it look very cluttered on my phone.

I

 

[Dwindlin]

The real reason we use paralytics is to prevent regurgitation.

Yeah no. Paralytics assist with actually getting the tube in (assuming you actually wait long enough), a paralyzed patient is at higher risk for aspiration (hence NPO recommendations for elective OR cases). Totally agree with on cric pressure though, I think it's bunk for preventing aspiration.

 

[Carlos Danger]

Yeah no. Paralytics assist with actually getting the tube in (assuming you actually wait long enough), a paralyzed patient is at higher risk for aspiration (hence NPO recommendations for elective OR cases). Totally agree with on cric pressure though, I think it's bunk for preventing aspiration.

The fasciculations that follow succinynlcholine actually increase intragastric pressure.

Although, it is true that the RSI procedure was developed primarily as a way to prevent aspiration. The idea of using paralytics was (and still is) that they make it easier / faster to intubate, therefore reducing the likelihood of aspiration.

 

[NomadicMedic]

You probably have a much greater chance of litigation if something goes wrong with RSI. How much evidence exists showing prehospital etomidate-only to be associated with bad outcomes? How much exists showing prehospital RSI to be associated with bad outcomes? I think we can guess how most experts would testify.

How may programs perform RSI and allow it as etomiodate only? I believe any expert witness, testifying on behalf of the family that suffered the bad outcome, could clearly show that an elective etomidate only RSI, not a "crash airway", is not the norm and the patient didn't receive all of the medications that are used, per standard, to achieve successful airway management.

 

[Carlos Danger]

How may programs perform RSI and allow it as etomiodate only? I believe any expert witness, testifying on behalf of the family that suffered the bad outcome, could clearly show that an elective etomidate only RSI, not a "crash airway", is not the norm and the patient didn't receive all of the medications that are used, per standard, to achieve successful airway management.

This is it. When you read closed-claims data, it almost always comes down to "did this practitioner follow the standard of care"? Did they follow generally accepted recommendations? Did they follow institutional policy? Did they act in a way that another similarly-trained practitioner would act? If they did deviate, did they have a good reason for it, in the opinion of expert witnesses?

For a paramedic, that pretty much just means "did he follow his protocol they way it was intended, and did he show good judgment within the confines of that protocol"? It's not the paramedics fault if he didn't have the proper drugs in his drug bag.

For his medical director who wrote a lousy protocol......I imagine it could get much more complicated.

 

[medicdan]

**Paging boingo or TOTWTYTR to clarify???***

 

[medicsb]

How may programs perform RSI and allow it as etomiodate only? I believe any expert witness, testifying on behalf of the family that suffered the bad outcome, could clearly show that an elective etomidate only RSI, not a "crash airway", is not the norm and the patient didn't receive all of the medications that are used, per standard, to achieve successful airway management.

Well, RSI isn't RSI if there isn't a paralytic. But, there are many places that use only etomidate or versed to try and facilitate intubation. Probably a lot more than places that use paralytics. Regardless, paralytics are not a "must" for intubation even if you have access to paralytics (that would be "cookbook" medicine). And as usual, standard of care is largely dictated at the local level, but even at the national level, RSI is in no way a standard of care for EMS. It is a dubious procedure (in the prehospital setting) that has been shown to be associated with worse outcomes, and it may or may not be performed proficiently by the services using it. As usual, other than some medics wishing and wanting it really really bad, there is nothing to suggest that giving paramedics paralytics improves patient outcomes outside of systems with very low numbers of paramedics.

If something goes bad during an intubation, the plaintiff will claim you didn't know what you were doing regardless of what you used. I suppose you could find some "expert" who will accept a large chunk of change to say "that [bad outcome] would not have happened if Paramedic Wacker just gave succs", but it'd be easier to find someone to say "Paramedic Whacker should have just used a BVM" or "transported to the nearest hospital", etc.

 

[Dwindlin]

Well, RSI isn't RSI if there isn't a paralytic. But, there are many places that use only etomidate or versed to try and facilitate intubation. Probably a lot more than places that use paralytics. Regardless, paralytics are not a "must" for intubation even if you have access to paralytics (that would be "cookbook" medicine). And as usual, standard of care is largely dictated at the local level, but even at the national level, RSI is in no way a standard of care for EMS. It is a dubious procedure (in the prehospital setting) that has been shown to be associated with worse outcomes, and it may or may not be performed proficiently by the services using it. As usual, other than some medics wishing and wanting it really really bad, there is nothing to suggest that giving paramedics paralytics improves patient outcomes outside of systems with very low numbers of paramedics.

If something goes bad during an intubation, the plaintiff will claim you didn't know what you were doing regardless of what you used. I suppose you could find some "expert" who will accept a large chunk of change to say "that [bad outcome] would not have happened if Paramedic Wacker just gave succs", but it'd be easier to find someone to say "Paramedic Whacker should have just used a BVM" or "transported to the nearest hospital", etc.

Not to mention that most services with paralytics don't even do true RSI (paralytic pushed with induction agent). I agree with everything you've said. As I've progressed I question more and more the utility of pre-hospital intubation with so many other options.

 

[Carlos Danger]

Not to mention that most services with paralytics don't even do true RSI (paralytic pushed with induction agent). I agree with everything you've said. As I've progressed I question more and more the utility of pre-hospital intubation with so many other options.

What have you seen? Most (definitely not all) of the places I've seen had a pretty decent, "true RSI" protocol; the problems came from a lack of skill and judgement on the part of the paramedics implementing them.

I do see poor post-intubation sedation as a very common thread in EMS. If you are giving vec post-intubation, you damn well oughtta be giving more than .5 mg of midazolam with it.....

 

[chaz90]

Not to mention that most services with paralytics don't even do true RSI (paralytic pushed with induction agent). I agree with everything you've said. As I've progressed I question more and more the utility of pre-hospital intubation with so many other options.

What do you mean true RSI? I don't profess to be an expert on induction agents, but Etomidate is widely regarded to be an appropriate sedative to use for RSI. Most services I've heard of do use Etomidate with their initial paralytic, with some also having the option to use Ketamine or other meds. Most variety appears to be in post procedural care.

 

[Carlos Danger]

What do you mean true RSI? I don't profess to be an expert on induction agents, but Etomidate is widely regarded to be an appropriate sedative to use for RSI. Most services I've heard of do use Etomidate with their initial paralytic, with some also having the option to use Ketamine or other meds. Most variety appears to be in post procedural care.

Etomidate is an excellent agent for emergency induction. It's just not at all a good drug to use by itself, without a NMB.

Ketamine would be my first choice for a field intubation where I couldn't use a NMB.

 

[Wes]

I need to find the article, but there's a concept called delayed sequence intubation where you sedate/premedicate the patient with Ketamine, then passively oxygenate with a NRB prior to determining if the patient actually requires intubation.

 

[Wes]

Here's one link to the concept: http://www.medscape.com/viewarticle/745228_4

 

[NomadicMedic]

We've gotten pretty far off-topic. This is a good discussion however. I'll split off the RSI comments into a new thread.

 

[Carlos Danger]

I need to find the article, but there's a concept called delayed sequence intubation where you sedate/premedicate the patient with Ketamine, then passively oxygenate with a NRB prior to determining if the patient actually requires intubation.

Here's one link to the concept: http://www.medscape.com/viewarticle/745228_4

I think this was the original blog post that described it: EMCrit DSI

I'm not a big fan of the idea.

The entire point of the procedure is the avoidance of even a brief period of apnea in an already-hypoxic patient. The problem, though, is there is no guarantee that their respiratory status won't worsen with sedation. Ketamine in the right dose generally maintains respiratory drive, but it's not uncommon to see a brief apneic period or a reduction in minute volume. This would defeat the entire purpose of the procedure, IMO.

A potential problem is this: you put the patient on high-flow oxygen or CPAP, and their oxygenation improves. Their color looks better, their Sp02 is up, their respiratory rate is down. They are nice and calm and you think that's a result of the sedation and improving oxygenation, but in reality their acidosis is worsening because they aren't ventilating adequately. That could happen to even a good clinician, and it could end very badly.

Also, the idea of giving PPV to a critical patient who is confused, sedated, and non-NPO makes me a little uneasy....pick any two of those 4 and we're probably good, but together it's just too much badness for my liking.

I guess to me, the patient described in the scenario is sick enough that they just need to be intubated. If you are afraid ETI might be difficult and take too long, just drop your SGA right off the bat. I suppose a trial of bipap might be appropriate, of course it would depend on the specifics.

 

[Dwindlin]

The Delayed Sequence stuff is what I see the vast majority of the time, which is fine most of the time. I don't know of any services here that push their induction and paralytics at the same time (if I'm going to truly RSI someone I mix my induction agent and paralytic in the same syringe). And I don't bag them at all (after pushing meds), since you're kinda defeating the purpose of RSI, which is tube in as fast as possible while minimizing anything that will increase chance of aspiration.

 

[Handsome Robb]

Redacted due to the resurrection and because I didn't read the whole thread and posted the exact same thing I did in my original post in this thread...tapatalk recommended it and I didn't look at the date...