Rapid Sequence Airway

[SeeNoMore]

Does anyone have any thoughts on the use of RSI drugs but the placement of a BLS airway like an LMA? I am curious about the thought process behind it, is it just that airway control is needed but ETI is becomming a less frequent intervention? Is it for use in patients who would be difficult to intubate but are still concious?

Finally, do you think this could have some value in the prehospital realm given the controversey with paramedic intubation, or are we better off leaving airway management to BLS interventions sans medications.

I know there are threads on intubation and RSI, but did not see this mentioned.

 

[usafmedic45]

is it just that airway control is needed but ETI is becomming a less frequent intervention?

The rules of airway management as I teach them:
#1: Oxygenation and ventilation are the goal, not intubation
#2: Your ego: check it at the door
#3: Call for help; in fact, call for more help than you think you will need
#4: If it is stupid and it works, it isn’t stupid
#5: Newer is not always better
#6: Plan ahead (avoid the “coffin corner”)
#7: Hold your own breath
#8: If it’s not working, let someone else try or try something else
#9: When in doubt, skip to the end of the protocol (surgical airway)
#10: If they are still breathing and you are not sure you can take over, don’t stop them from doing so

RSI has its place. The problem is that we get so focused on "getting the tube" that once we "get it", a significant number of us do an absolutely piss poor and- at times- criminally negligent job of maintaining the tube. Should we be doing RSI with non-visualized airways? The answer is....maybe.

For extremely difficult intubations associated with surgery, it's not uncommon at all for the RSI procedure to end up with an LMA or Combitube. A lot of "normal" airways that are established and maintained during surgical procedures are non-visualized after a "chemically facilitated intubation".

or are we better off leaving airway management to BLS interventions sans medications.

Honestly, I think Rule #10 sums up how to deal with your scenario:

Is it for use in patients who would be difficult to intubate but are still concious?

Those sorts of patients are the ones you generally don't want to screw with in the field if you can avoid it. Sometimes the best airway measure to have in your bag of tricks is the wisdom to know when not to use any "tricks" at all. As I've said before: "Don't just do something, stand there."



BTW, if anyone wants the full CME course, please let me know. If a department or medical control entity is willing to host me, I absolutely love teaching airway management.

 

[SeeNoMore]

Thanks for the reply. I think your rule are good one. Ego is a huge issue. I'm in medic school and everyone can not wait to "get a tube' not caring one bit whether someone needs one. Us soon to be medics are in for a shock when they take intubation away, tell us we are not needed in trauma or cardiac arrests etc. Medic School should have come with a disclaimer : Warning, you may be found to be useless. B)

 

[Shishkabob]

Every day I don't tube a patient is a good one.

Heck, I dread making the decision to RSI... it's not a fun decision, and it scares the crap out of me. If I can keep someone 'stable' enough to call the hospital and have a crash airway team set up, I'm happy.


It's a tool we should have, and like crics, it'd be foolish to take it away, but that doesn't mean I'll use it every chance I get.

 

[usafmedic45]

Us soon to be medics are in for a shock when they take intubation away, tell us we are not needed in trauma or cardiac arrests etc.

If companies would stop being cheap and medics would stop being stubborn, most of the problems with intubation could be dealt with.

Medic School should have come with a disclaimer : Warning, you may be found to be useless.

Not useless, just less of a blunt instrument.

 

[SeeNoMore]

I admire your sentiments Linuss, though I am still too much of a whacker/morally underdeveloped emt not to find the prospect exciting.

But I am not sure there is value currently in retaining intubation for ground crews, RSI or otherwise. Which is why I was interested in RSA with LMA's seems like it elminates some of the issues with ETT but allows a different (though perphaps not better) option for concious patients who require more agressive airway management.

I think even if you can prove that some paramedics can improve outcomes in some patients with intubation, it will pale in comparison with the large number of studies that show general problems, poor outcomes. Also, I think by in large the medical community is going to continue to question, and soon opt for abandonment of intubation in most cases. My control doc told us to our faces the other day that he would rather us never intubate. Kind of kiills any enthusiasm for learning about it, I feel like an idiot praciticng on the manakins and learning to parrot the skill for registry.

 

[Shishkabob]

Don't get me wrong, I find a lot of what we do as cool and exciting... I just don't let it factor in to my decision on patient treatment.



However, I disagree. Intubation SHOULD stay within ground crew Paramedics skills. The ONE and ONLY issue with intubation in EMS is constant tube placement verification. You still have agencies that have ETT, but not continuous waveform capnography. You have Paramedics that don't verify the tube after the initial time, if at all. My last code, another medic tubed the patient. Guess what I did personally after every movement? I checked the tube.


ETT shouldn't be our go to advanced airway in every situation, but anyone who advocates its complete removal from EMS is living in the dark ages along with docs that despise narcotic analgesics in abdominal pain.



I would much rather maintain an airway with an NPA, LMA or King... but there are times where the ETT is ideal and anything less should be considered negligence.

 

[NomadicMedic]

Let me be honest... I'm scared to death every time I tube a patient. As a matter of fact, I've been placing mostly Kings and LMAs. Here a supraglottic airway isn't considered the "airway of shame", instead the doc usually appreciates that I didn't make a difficult airway worse with repeated failed intubation attempts. (It doesn't help that the last few people that I had to manage had difficult airways.) Of course, I still RSI and intubate those who need it, but I'm not afraid to go right to my secondary airway.

 

[SeeNoMore]

Even though it's sort of steering the thread off topic, I am curious, what situations is intubation clearly indicated in?

I am far less educated on many of these issues than you folks, but from what I can gather, it would include patietnts with airway burns, severe anaphalaxis, some chf patients, profuse bleeding or vomitus and the need for suction and control, and RSI for TBI.

Maybe more controlled studies are needed for intubation, not just "is intubation good for trauma patients" but looking at how it works out for some of the above populations, TBI excluded as I know that has been studied, with one recent study showing positive neurological results.

But overal I think you all have the right idea, I am kidding to an exten when I talk about being excited, I am, but I mean to try very hard to utliize intubation only when appropriate, in the hopse of becomming a semi useful individual to the patients I interact with.

And while there are still many whackers, our teachers at least have by in large adopted hip new thinking like " hey why don't you make sure the airway and the quality of ventillation is your first priority, not your victory dance over this poorly intubated patietient as his chances for survivial plummet"

That being said, there is a gap between this sentiment and how we are taught to critically think about the use of an ETT as we are still tested to the idea of an ETT being the Gold Standard. I guess that is where personal education comes in.

 

[usalsfyre]

Let me be honest... I'm scared to death every time I tube a patient. As a matter of fact, I've been placing mostly Kings and LMAs. Here a supraglottic airway isn't considered the "airway of shame", instead the doc usually appreciates that I didn't make a difficult airway worse with repeated failed intubation attempts. (It doesn't help that the last few people that I had to manage had difficult airways.) Of course, I still RSI and intubate those who need it, but I'm not afraid to go right to my secondary airway.

So speaking as someone who's done a couple of RSIs (although it's minuscule number compared to what some in here have done) there's not really a good reason to be scared of RSI, as long as you have a VERY high level of respect for what your doing (lethal injection minus one medication). Have your backups ready, understand airway assessment, laryngoscopy and anatomy (the main failing I've seen) and like USAF's rules, don't back yourself into a corner. Keep those things in mind and you'll be fine.

Edited to add: Learning to intubate is the easy part. Learning WHEN to intubate is considerably harder.

 

[usafmedic45]

morally underdeveloped emt not to find the prospect exciting.

Don't confuse emotional immaturity and ignorance with a lack of moral foundations. The fact that you posted that shows that you have concern for your patients and want to do right by them. If that's not the bedrock of medical ethics, I don't know what is.

Immaturity and ignorance in someone just starting out is not a character flaw. It's basically a fact of life. Admitting it affects you, finding ways to deal with it and moving on is the only way to overcome it.

I think even if you can prove that some paramedics can improve outcomes in some patients with intubation, it will pale in comparison with the large number of studies that show general problems, poor outcomes

You understand the issues of correlation versus causation and the problem of a confounding variable right?

My control doc told us to our faces the other day that he would rather us never intubate.

Truth be told, I look for ways to avoid doing it too. However, you have to remember where he is coming from: he oversees a wide variety of medics with a broad range of skill levels. You don't write protocols for the brightest medics otherwise several people on this forum would be doing prehospital thoracotomies. You write them for the guy who slacked off, squeaked by in class, doesn't pay attention during continuing ed and is just there for the adrenaline rush and a paycheck. You know....that guy you pray to G-d isn't on duty if you ever get hurt or your mother has a heart attack or your kid starts choking. That one. There are few ways to kill a person quicker and more assuredly than to botch an intubation or displace a tube and not catch it. Do you really want to trust "that guy" to not do that? You really want to risk going to court and losing your money because "that guy" can't get over himself enough to see the things that can go subtly wrong with an airway during transport or use the technology at hand because he thinks himself to be "that good".

See his reasoning now?

 

[NomadicMedic]

Agreed. I'm not scared of putting the plastic in the hole, I'm scared of what my failure could mean for the patient. I think it's a good trait to have a healthy respect for the procedure. RSI will never be a procedure I am caviler about.

 

[usafmedic45]

what situations is intubation clearly indicated in?

-Need to isolate the airway (keep crap out of the lungs)
-Need to maintain an airway and intubation is the easiest option
-Need to knock the patient out to prevent further harm and doing so is going to impair ventilation through either messing with ventilatory drive or the ability to maintain an airway

airway burns, severe anaphalaxis,

Unless you get to them early, chances are you won't be able to intubate them. Those go something like:

1. *look down the throat and everything is so swollen you can't see anything but angry red tissue*
2. Choose one:
a. curse
b. piss
c. throw laryngoscope
d. start crying
(Note: I have literally seen someone do each of these in this scenario)
3. Resort to surgical airway.

some chf patients,

Only in extreme cases or where CPAP/BiPAP is not available.

 

[SeeNoMore]

Certainly I understand, and I hold no ill will against the Doctor. To be fair while I our conversation was short I believe he does in fact support prhospital intuabtion for some paramedics in some systems. In any event, I agree that the education of Paramedics, taken generally, is insanity.

I get good grades, and conside myself fairly competent for where I am in my program, but some ohers do not and are not and are still going out on clinical rotations. We will likely get zero intubatons in the OR. Is this my fault for picking a poor program, yes. But it still points to a general weakness in paramedic education.

And no, I don't understand the science of studies overly well, but I do know that finding studies that favor ground based paramedic intubation with providers with a low ammount of intubations per year is a needle in a haystack situtation. Maybe that is just reality!

EDIT: Also, I guess keeping some familiaity with intubation is a good idea for critical care paramedics, if for no other reason.

 

[Shishkabob]

d. start crying
3. Resort to surgical airway.

Those two will probably go hand in hand for me if I have to do a surgical airway.


I've already warned my partner that I'll probably be saying "Oh God oh God oh God" the entire time the scalpel is in my hand...




I would rather decide to RSI 100 people than make the decision to cut someones throat open....

We will likely get zero intubatons in the OR. Is this my fault for picking a poor program, yes.

Not at all. Paramedic schools that find good ORs that allow a lot of intubation are rare... that doesnt mean the school is bad.

Heck, guess how many I got in Paramedic school? Zero. None. My OR rotations consisted of the doc wanting to maintain the airway with an OPA, and while in theory I agree with that, it didn't do much to help me as a student. Luckily I befirened the RT and was able to get SOME advanced airway skills in.

 

[usafmedic45]

I would rather decide to RSI 100 people than make the decision to cut someones throat open....

Why? A surgical airway is so much easier. Doing an IV is harder. As Pete Rosen (one of the pioneers of emergency medicine and a man who starts off a lot of speaking engagements with a joke of some form pertaining to oral sex) likes to say "The most difficult part of a crike is picking up the knife." It's literally the easiest of the definitive airway procedures. The only way to really botch it in a way that is going to screw a patient up further is to make a horizontal incision instead of the indicated vertical one.

Paramedic schools that find good ORs that allow a lot of intubation are rare... that doesnt mean the school is bad.

Hell, it's becoming increasingly uncommon outside of really complex cases and in kids to see ETI as the main airway option of choice in many facilities. One hospital I worked at the surgical schedule was 85% LMA, 10% intubation, 5% everything else.

 

[Shishkabob]

Mainly because cric is synonymous with "Oh shoot, this is bad". :wacko:



Psh, IVs don't worry me even though I miss my fair share. If the patient truly needs a line, I'm pulling out the EZ-IO.


Heck, had a trauma patient last week, stable but still needing an IV. I tried and missed 5 times. We get to the ER, and they try with ultrasound... and miss another 4 times. I felt better.

 

[usafmedic45]

Mainly because cric is synonymous with "Oh shoot, this is bad".

The thing is that, at least for me, once the decision to cut the neck is made the stress level drops off significantly because the first and often most difficult hurdle is going to quickly be overcome.

 

[SeeNoMore]

I suppose if you are going with the cric option you are already at plan d and unless you really messed up your reasoning for it's use, it's clear sailing from there. I actually found a great video the other day of a doctor giving a lecture on various aiway issues and he had someone actually cric him. It was the damndest thing I have ever seen. I think the presentation was concerning intubations, crics etc when patients are awake. I just could not believe it.

 

[usafmedic45]

I suppose if you are going with the cric option you are already at plan d

That's one of the big problems with crikes is that people wait too long to do them. There are obvious cases where you just can't afford **** around trying to secure the airway any other way but yet people decide to do exactly that because of unwarranted fear of the procedure. It's not a procedure to be taken lightly, but it's not one to be feared.

I think the presentation was concerning intubations, crics etc when patients are awake. I just could not believe it.

Doing percutaneous trachs and crikes on people who are conscious is not as foreign as one might think. A perc trach is a bedside procedure and is seldom done with sedation unless it is otherwise indicated. Awake intubations are also surprisingly common.