Post intubation sedation

[MonkeyArrow]

What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.

It is something that is gaining traction more in the ICU world, and something that at least to me makes sense to do on an ambulance. In the past couple of years, more critical care papers have come out stating the importance of ICU environment, and the effects of natural light, noise control, and day/night cycles on agitation/sedation requirements. As ICUs start to implement more of these maneuvers, I would think they make sense for the CCT crowd also. I haven't heard of any EMS outfits having a protocol for this yet, though.

 

[Carlos Danger]

I've only transported patients sedated with propofol a handful of times, but it seems as though it probably wasn't the best choice of sedation for the rough riding environment of the ambulance. I used to ground transport patinets from a small hospital to Seattle pretty often and the one doc really liked propofol. Those patients regularly seemed to be much more agitated than a patient sedated with Versed or Ativan while en route. Perhaps I was dosing too lightly?

What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.

Dosing is part of it, I think we tend to be a little light on propofol in transport, but I would agree that by itself it just isn't great for the high-stimulus transport environment. Just adding some opioid makes a world of difference, though.

 

[StCEMT]

If someone is really hemodynamically unstable, then a small dose of ketamine is probably your safest bet. And then redose a little at a time as needed.

Versed is a good drug too, though. There aren't too many people who are so unstable that you need to worry about giving them any depressant at all. You'll know them when you see them.

Good to know. There any talk in your section of the world about those septic patients and how they are sedated (yay or nay etomidate) or is that one of those still being researched things?

 

[Carlos Danger]

Good to know. There any talk in your section of the world about those septic patients and how they are sedated (yay or nay etomidate) or is that one of those still being researched things?

I haven't heard anything new about etomidate. We know that it causes some adrenal suppression. Some studies indicate that it isn't clinically significant, others show increases in mortality with it. Overall I think most would agree that it is probably safest to just avoid it in septic or critically ill patients.

Since ketamine has regained popularity people are using it more. If I'm intubating someone hemodynamically tenuous I use a small dose of ketamine and a much smaller than normal dose of propofol, and I always have ephedrine and phenylephrine at hand.

In the field where most intubations are trauma patients and most are generally healthy, I don't see any problem at all with etomidate. It's a good drug for the emergent RSI.

 

[VentMonkey]

I've only transported patients sedated with propofol a handful of times, but it seems as though it probably wasn't the best choice of sedation for the rough riding environment of the ambulance. I used to ground transport patinets from a small hospital to Seattle pretty often and the one doc really liked propofol. Those patients regularly seemed to be much more agitated than a patient sedated with Versed or Ativan while en route. Perhaps I was dosing too lightly?

What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.

Yeah, it's a gentler sedative. I doubt it had anything to do with dosing. It really does seem great for weaning trials and things of that nature, but for transport? I still don't know that I am completely sold on it in the prehospital environment.

And yes, if you have them, earplugs, eye covers etc. all seem reasonably considerate regardless of mode of transport, more so with patients at risk for spikes in ICP.

 

[VentMonkey]

In the field where most intubations are trauma patients and most are generally healthy, I don't see any problem at all with etomidate. It's a good drug for the emergent RSI.

@Remi can you elaborate for the group why? I know I am interested in your thoughts and reasoning behind them.

Etomidate is currently our only RSI sedative/ hypnotic, so I have a natural vested interest.

 

[Carlos Danger]

@Remi can you elaborate for the group why? I know I am interested in your thoughts and reasoning behind them.

Etomidate is currently our only RSI sedative/ hypnotic, so I have a natural vested interest.

I think it's just a good, reliable, safe drug. You get a dense, predictable anesthesia. It can drop the BP but it's pretty stable. Doesn't cause a lot of tachycardia. Favorable cerebrodynamics. Easy to use.

 

[TXmed]

I do agree with @Remi, with the popularity of ketamine some people have begun to frown on etomidate but i do not believe it is earned. I personally use ketamine for the majority of my RSI's because it is very versatile with its dosages. For instance I will give asthmatics 2mg/kg, shock patients 0.5-1mg/kg, and can also do a DSI type procedure for oxygenation. But still like etomidate from time to time.

 

[StCEMT]

I do agree with @Remi, with the popularity of ketamine some people have begun to frown on etomidate but i do not believe it is earned. I personally use ketamine for the majority of my RSI's because it is very versatile with its dosages. For instance I will give asthmatics 2mg/kg, shock patients 0.5-1mg/kg, and can also do a DSI type procedure for oxygenation. But still like etomidate from time to time.

How do you like DSI? I've listened to the gist about it, just not something (as far as I am aware) done anywhere around me nor have I seen it done in hospital.

 

[VFlutter]

How do you like DSI? I've listened to the gist about it, just not something (as far as I am aware) done anywhere around me nor have I seen it done in hospital.

DSI can be very useful. For example the hypoxic patient who is anxious or delirious and not tolerating a NRB or NIPPV. Are you going to just RSI this patient with sats in the 80s? Keep them sitting up, place a NC at 15lpm, then push some ketamine and wait until they relax enough to place a NRB or assist ventilations for a minute then proceed with your paralytics and intubation. Usually the sats will improve as opposed to attempting a crash intubation on an inadequately oxygenated patient possibly resulting in a hypoxic arrest.

This is still a quick procedure and you are not spending multiple minutes messing around after sedating. In my opinion it is kind of a grey area when RSI turns into DSI. The reason most places frown upon DSI is the increased risk of aspiration however many times saturations will improve considerably with just a NRB once the patient is sedate avoiding assisted ventilation.

Also, take into account your sedative. Etomidate wears off pretty quick.

 

[StCEMT]

DSI can be very useful. For example the hypoxic patient who is anxious or delirious and not tolerating a NRB or NIPPV. Are you going to just RSI this patient with sats in the 80s? Keep them sitting up, place a NC at 15lpm, then push some ketamine and wait until they relax enough to place a NRB or assist ventilations for a minute then proceed with your paralytics and intubation. Usually the sats will improve as opposed to attempting a crash intubation on an inadequately oxygenated patient possibly resulting in a hypoxic arrest.

This is still a quick procedure and you are not spending multiple minutes messing around after sedating. In my opinion it is kind of a grey area when RSI turns into DSI. The reason most places frown upon DSI is the increased risk of aspiration however many times saturations will improve considerably with just a NRB once the patient is sedate avoiding assisted ventilation.

Also, take into account your sedative. Etomidate wears off pretty quick.

Could doing so potentially put off an intubation (adequately) long enough to get to an ED?

 

[VFlutter]

Could doing so potentially put off an intubation (adequately) long enough to get to an ED?

I suppose it potentially could but that would not be my intention in doing the above. I have made the decision that the patient needs to be RSI'd due to whatever clinical condition or expected course and when I push the Ketamine my intention is paralyze and intubate that patient. However you would slightly delay the administration of the paralytic to hopefully better preoxygenate the patient and give yourself the most safe apneic time possible. If the patients sats improved from 80 to 100 then that is great but they are still getting intubated not left sedated on a NRB until you get to the ED.

 

[StCEMT]

I suppose it potentially could but that would not be my intention in doing the above. I have made the decision that the patient needs to be RSI'd due to whatever clinical condition or expected course and when I push the Ketamine my intention is paralyze and intubate that patient. However you would slightly delay the administration of the paralytic to hopefully better preoxygenate the patient and give yourself the most safe apneic time possible. If the patients sats improved from 80 to 100 then that is great but they are still getting intubated not left sedated on a NRB until you get to the ED.

Ok. Gonna go do a little brushing up on this one.

 

[Carlos Danger]

If the patients sats improved from 80 to 100 then that is great but they are still getting intubated not left sedated on a NRB until you get to the ED.

If sat improves that dramatically and they are breathing well, why then do they need to be intubated?

 

[VFlutter]

If sat improves that dramatically and they are breathing well, why then do they need to be intubated?

Good point and it may be a viable option to forgo intubation in certain situations however I would be hesitant to fly them.

 

[Underoath87]

How much ketamine is needed for DSI? My protocols only allow ketamine for RSI (2mg/kg IBW), but if the patient's sats were to improve "before I can finish pushing all the ketamine"...

 

[Carlos Danger]

I guess I'm just not sold on the whole "DSI" thing. In his original podcast on the technique, Dr. Weingart gave the example of the patient who was delirious from hypoxemia and wouldn't cooperate with oxygenation efforts, making it impossible to place CPAP or a NRB. Give some ketamine and he relaxes, you place CPAP, now his Sp02 is in the upper 90's and you can more safely intubate.

My questions have always been these: If we fix their delirium with sedation and their hypoxemia with CPAP, why are we proceeding with intubation - especially in the field? Is this technique really safer or more effective than proceeding with a normal induction and simply mask-ventilating if necessary?

If all someone needs is some supplemental oxygen or CPAP, then do that for them. And if doing so requires a little anxiolysis, fine. But if someone is critically ill and hypoxemic and needs to be intubated regardless, then messing around with ketamine and CPAP probably isn't the best idea. Prop-->sux-->tube, mask if you need to. Keep it simple.

And there are some patients who you know might need to be intubated, but you also think CPAP might fix them up, too. So you try CPAP. And again, if you need to give them a little ketamine or whatever, fine. If it works, awesome - you avoided an intubation. If it doesn't work, no problem - tube them. We've always done this, and we never called it DSI.

I think conceptualizing DSI vs RSI as separate procedures just makes things complicated. It's all just airway management.

 

[TXmed]

If i am committing to a RSI/DSI procedure i am fully committing. With asthmatic/COPD patients their sats can improve but you still have to address the hypercarbia, respiratory muscle fatigue, and bronchospasm that will possibly come back when their ketamine level drops. I also do this for combative head injury patients and combative drug OD patients with no immediate fix. One thing i do like about DSI is it helps people around me settle down, so many times people believe RSI is a rapid procedure and they forgo the small details "just to get the tube". I will generally do an apniec CPAP with NC+BVM with PEEP valve at 10 and not ever squeeze the bag. This also lets me place NPA's, more adequate suctioning, and assign duties to the people/team around me.

@Remi I agree to an extent about conceptualizing DSI vs RSI, but I do believe it gets peoples narrow mindedness on RSI and chance to grow. A big pet peeve of mine is paramedics/doctors choosing to do "classic RSI" on everyone no matter the MOI/NOI, instead of changing the medication, dosage, technique of things to best suit the patient.

 

[Handsome Robb]

We exclusively do DSI now, no RSIs. Our MD looked at our peri-intubation arrest/hypoxia rates and our morbidity and we were killing people by RSIing them. We generally start with 2mg/kg of ketamine but can go up from there, we don't carry etomidate.

I've done a handful and like the process, it slows down a hectic, high stress situation. We are required to use and turn in a paper check list.

DSI combined with the king vision we've had 100% first pass success for the vast majority of the last year with a few months in the 90s.


Sent from my iPhone using Tapatalk

 

[RocKetamine]

I mean DSI is basically just procedural sedation + pre-oxygenation with CPAP being an option not a requirement to provide pre-oxygenation. Weingart has repeatedly said he also likes it because of the chance of avoiding intubation all together.

I don't think that it's appropriate for every patient, probably not even for most patients but it does seem to be beneficial for some. I'm sure we call all (hopefully) agree that having a patients saturation drop into the 60-70s during RSI because you weren't able to provide adequate pre-oxygenation isn't the best thing to happen.

Different people/services/areas of the country have different definition of what RSI consists of, though the correct definition is endotracheal intubation after the administration of a sedative and neuromuscular blocking agent in rapid succession. It makes sense to me to separate RSI from DSI as the drugs are not given in rapidly, but rather in a delayed fashion after adequate pre-oxygenation/denitrogenation is achieved.

Placing a NPA is just airway management, maybe we shouldn't separate that out from RSI either.