Iwe also have a polarizing paralytic..(vec). But I think the profalaytic use of analgesics and benzos is unneccisarry considering the half life of the etomidate is night then that of say 50mcg of feynt. (Which is our big boy for pain) why waste time and money on something that the pt doesn't need. If your rsing someone chances are they are spending some time in tge unit. Not going in for some day surgery and getting extibated in 3 hours. I don't see the logic in it. I know that if I don't feel the pt needs rapid sequence intubation just yet but is heading that wsy. I may try 5 of versed and 50 of feynt. And hope for that nod.. but for us rapid sequence intubation.by definition is different the medically assirid intubation.
Pain management in RSI
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Melclin
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Question for everyone: what is the reasoning behind the idea of limiting the indications for analgesia based on specific injury patterns in some EMS systems? Surely pain is pain is pain?
It is undoubtedly a concern in some cases but I think the 'danger' of iatrogenic hypotension or exacerbating existing hypotension is often exaggerated. I believe blanket rules like no morphine if BP<90 are ridiculous and I'm glad Im not subject to something like that.
Here, depending on if its a chopper or road ambulance and why you are being intubated, some combination of fentanyl, midazolam, ketamine and profol. All combinations involve some kind of analgesia and as a rule of thumb, pain producing illnesses will get some form of analgesia prior to RSI in many cases, if only to facilitate oxygenation/preparation. Fent/midaz/sux would be the most common by a decent margin I would think. Morphine/midazolam infusions are usually used to keep them down.
I dont intubate as part of my scope but my my reading of the literature and culture suggest analgesia is an extremely important part of intubation and not always just for the analgesic action itself.
It is undoubtedly a concern in some cases but I think the 'danger' of iatrogenic hypotension or exacerbating existing hypotension is often exaggerated. I believe blanket rules like no morphine if BP<90 are ridiculous and I'm glad Im not subject to something like that.
Here, depending on if its a chopper or road ambulance and why you are being intubated, some combination of fentanyl, midazolam, ketamine and profol. All combinations involve some kind of analgesia and as a rule of thumb, pain producing illnesses will get some form of analgesia prior to RSI in many cases, if only to facilitate oxygenation/preparation. Fent/midaz/sux would be the most common by a decent margin I would think. Morphine/midazolam infusions are usually used to keep them down.
I dont intubate as part of my scope but my my reading of the literature and culture suggest analgesia is an extremely important part of intubation and not always just for the analgesic action itself.
Melclin
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I'm having some trouble reading that post for several reasons but are you saying that your preference is to try to intubate with sedation only prior to attempting a tube with a paralytic and sedation? Does this extend to the head injured patients? Are you also intubating septic patients with etomidate? I thought that was a no no.
Im not that familiar with etomidate on account of the fact it isn't used much in Aus (to my knowledge), but I don't recall it having any analgesic action at all. Just because they can't tell you that they are experiencing pain doesn't mean they aren't or that it isn't having an effect on their physiology or more subtle overall experience of the process. The idea that a little pain never hurt anyone is such a lie.
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I have fent, morphine, versed, Valium , ketamine, success and roc to choose from.
Christopher
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Please do not RSI folks with the attitude that paralytics or etomidate covers your post-intubation sedation and analgesia concerns...
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.
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That's up on my EMS nightmares list. Being paralyzed and not sedated is simply unimaginable to me, especially with an ET tube shoved in me. I'm thinking that my future tattoos will include "Do Not Backboard" and "Don't Forget the Versed."
Not worried about post intubation during the pre intubating a pt. I am worried about saving thier lives. You guys had me questioning myself but I don't see anything about analgesics in any rsi protocols involving parlytics.
Etomidate is pushed first.
NomadicMedic
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Many of us have an RSI protocol that seems to be substantially more robust and complete than yours. We start with succinylcholine and etomidate and then continue sedation with versed, continue paralysis with vecuronium and add fentanyl to blunt the pain from having a tube shoved in the trachea.
Seems like many of us have a bit more education as to the true management of the intubated patient, as well.
I reread your post about not believing that pain management and additional sedation were necessary and was curious if you were actually serious or just posting drek to get a reaction.
If it was to get a reaction, you succeeded. If you're serious, you're dangerous.
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Etomidate wears off in like 6 minutes, possibly less depending on the person. By the time the Succinylcholine is gone, so is the Etomidate. For me, everyone gets post RSI Versed. The Vecoronium is optional and dependent on if they still need it to avoid trismus or hard core posturing etc., but there's no way I'm holding back sedatives on conscious, intubated patients. This experience is not one they want to remember.
Maybe our systems are different. We have 5 level 1 trauma centers less then 10 minutes from away. Our longest transport time is 15 min and 90-95% of the time we are less then 5.
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Your initial Etomidate bolus still probably wore off before you got to the ED, and how long does it take before the ED staff starts getting their drugs and supplies together? Transfer of care isn't instantaneous, and sedation is the kind of thing that can be overlooked in a busy ED, especially when the patient is paralyzed and can't complain about it. Be a patient advocate, not an unthinking automaton. Your goal should be to do the best thing for your patients overall well being, comfort, and life rather than the bare minimum of dropping off a live patient with a pulse.
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I really hope you aren't serious.
If you are, you need some serious remedial education on the drugs you are pushing.
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.
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As you said, etomidate is short acting. It's purpose is procedural sedation, not management.
Imagine somebody RSIs you the method you're proposing. You're sedated with vec, induced with etomidate. Tube is passed. 10 minutes later the etomidate is wearing off. You're awake and aware of what's going on- feeling the pain of the tube between your cords as you bounce down the road. You can't buck the tube, or even communicate the pain it's causing because you're still paralyzed with vec. Vec does absolutely nothing for pain. The fear chaz described is from people getting inadequately sedated and getting inadequate analgesia. Inadequate sedation management is a common problem, but a problem all the same
There are many people here (who have already posted) that have paralytics and RSI protocols. Many of them are very well versed in the procedure. I've had it previously, too (though not where I currently work). I'm glad you began questioning your practices, and I urge you to continue to question, research, and learn more about it before you write off the advice here.
NomadicMedic
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Our systems are obviously very different. While transport time is obviously a factor, I think base education and belief in "doing the right thing" is important. I don't withhold pain meds or sedation due to a belief that "they'll get it eventually". I am also close to several hospitals and frequently have given a bolus of fentanyl as we arrive because I know it will be upwards of 20 minutes before they're seen by a doctor, orders get entered and the patient receives her next dose of medication. The same thing with RSI. I don't withhold pain medication or sedation simply because, "they will get it eventually"
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Christopher
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Indeed.
Yes.
RSI is way more than pushing paralytics.
RSI starts with the pre-pre-intubation stage. Positioning, oxygenation, contingency plans, hemodynamic optimization, etc. It continues with the pre-intubation phase with induction agents (and premedication depending on your protocols/take on the literature) and ensuring adequate O2 reservoir. Push your paralytic. Work your airway plan. Confirm success of the plan. Re-position the patient, adjust oxygenation/ventilation parameters, ensure hemodynamics are maintained, apply a sedation/analgesia package. Continue transport.
RSI is barely about putting a tube through the cords. This is perhaps the least important part of the whole ordeal (h/t to DSI/RSA).
Aidey
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To be picky, the accepted terms are depolarizing and non depolarizing.
Also, etomidate is contraindicated in sepsis because it can cause adrenal suppression.
NomadicMedic
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Christopher really nailed it. The act of passing the tube is a relatively small entry on the RSI timeline. Post intubation management is, IMHO, the most vital part of the process. Keeping the patient well oxygenated and ventilated, managing pain, sedation and hemodynamics are not something to be considered as an afterthought.