Rapid Sequence Induction HOWTO?

[NomadicMedic]

Fish, I understand that many medics may transfer patients on a sedation package that was initiated in the hospital, Whether it's an ICU transfer or a smaller ED to a larger tertiary care facility.

However, I am specifically interested in ALS 911 services that institute a sedation drip in the field. Smash made the point that we should not be sedating patients, specifically in an RSI scenario, without the ability to run an infusion. I don't know of any services that do this on a regular basis.

 

[Fish]

Fish, I understand that many medics may transfer patients on a sedation package that was initiated in the hospital, Whether it's an ICU transfer or a smaller ED to a larger tertiary care facility.

However, I am specifically interested in ALS 911 services that institute a sedation drip in the field. Smash made the point that we should not be sedating patients, specifically in an RSI scenario, without the ability to run an infusion. I don't know of any services that do this on a regular basis.

I think that is silly to say we should not RSI based off of the fact that we cannot run/start infusions in the field.

I know of one West Texas Dept. that does, with prop.

The name? Mmmmmmmm, I do not remember, but it was mentioned somewheres on this site at one time.

 

[Aprz]

One or two of the really rural services around here allow it with written or OLMD orders. I'm not sure they require the medic to be a CCP but from what I've seen it doesn't seem like it. Either that or all of their medics are CCPs.

This thread is pretty interesting. I admittedly don't know a whole lot about RSI. It was covered briefly during school, about a half a day lecture, but we don't have it here so it all kinda dwindled away. Definitely have some studying to do.

That was my thought with rereading about RSI and creating this thread. Like I said, in my paranedic class, my instruct said "RSI? You'll never do that. Don't worry about it," and clicked the power point really quick *click click click*.

 

[usalsfyre]

That was my thought with rereading about RSI and creating this thread. Like I said, in my paranedic class, my instruct said "RSI? You'll never do that. Don't worry about it," and clicked the power point really quick *click click click*.

Classic EMS instructor BS. "We don't do it, I don't have any good war stories to tell, so why bother teaching it."

Never mind I know many medics (including myself) that have ended up working in completely different area than where they went to school.

 

[NomadicMedic]

Or take for example the fact that I went to paramedic school in Washington State where we did RSI on standing orders. I moved to Delaware, and found that RSI is looked at totally different here. Yes, my service does it… But we do it differently then I was taught.

Just because they don't do it where you are, doesn't mean you shouldn't know about it.

 

[Fish]

Was not taught where I went to school, and was not used where I first worked. Where I work now it is a standing order. This skill needs to be taught Nation wide, even if your area does not perform it.

 

[MSDeltaFlt]

Or take for example the fact that I went to paramedic school in Washington State where we did RSI on standing orders. I moved to Delaware, and found that RSI is looked at totally different here. Yes, my service does it… But we do it differently then I was taught.

Just because they don't do it where you are, doesn't mean you shouldn't know about it.

Amen, Mississippi is still in the dark ages, though we do have a DAI protocol approved for the state which is basically heavy dosing on benzos. Although I do believe that if you carefully/properly/judiciously dose them with narcs and benzos, then your need for paralysis will not be as often as you might think. Are paralytics needed? Yes. On all RSI pts? No.

And to answer your question I don't know of a single 911 service in this state that has prehospital sedation infusion protocols and standing orders. The only time I can even imagine that you'd need it in prehospital is when you can't fly your pt and the specialty they need is over an hour away and they need intubation. And for those infrequent pts you can get OLMC orders.

 

[Aprz]

MrBrown sent me a slideshow when I first asked him more on RSI. In the opinion of the maker of the slideshow, sedation-only intubation was bad.

http://www.adhb.govt.nz/Forums07/prehos_intub/Slide16.html

While we are talking about RSI, an important thing is being able to intubate well and being ready to use alternative methods to control the airway. I've been browsing through KellyBracket's blog, and I thought he posted an interesting method to intubate using the miller blade.

http://millhillavecommand.blogspot.com/2011/09/use-of-straight-miller-blade.html

 

[boerbull]

Very interesting slideshow. RSI has always been very controversial. I don't think that in the real world you can get rid of it. Here in the Netherlands we have a extreme ideal situation were we can almost always get a anesthesiologist within 20 min. But that is because this country is so small. In a country like South Africa with a big rural area, lots of TBI,s and limited resources you will have to use paramedics to RSI.
It is always interesting to expand your scope of practice, but reading all the negatives on paramedic RSI, I must say I am glad I don't have to make those decisions.

 

[NomadicMedic]

The whole "RSI is controversial" discussion frustrates me. RSI is truly only controversial in areas where paramedics are not well educated, don't perform the procedures with enough frequency to stay competent and have a poor success rate.

It seems like all we hear about are those services removing RSI due to poor education or poor success rates. In the meantime, agencies that provide continuing education, OR intubation opportunities, frequent opportunities to perform RSI in the field and a strong success rate just continue to chug along unnoticed.

Rather than remove the skill, let's increase the educational standards. For goodness sake, when you need to manage the airway, sometimes RSI is the only option. I'm certainly not waving the "paramedics are only paramedics because we can intubate" flag, but reducing the skill set because some agencies don't provide enough education or opportunity to stay competent is a bad idea.

 

[boerbull]

I agree with education improving the skills. I am definitely for RSI. Like a said: In the real world you don't have a anesthesiologist ready for every RSI case. So instead of dishing RSI, concentrate on training and education.

Just wondering, when we RSI a patient we put him on a ventilator. Every ambulance has got at least a basic ventilator. How does it work in the rest of the world. Seeing as hyperventilation is seen as one of the risks for pre-hospital RSI.

 

[systemet]

The whole "RSI is controversial" discussion frustrates me. RSI is truly only controversial in areas where paramedics are not well educated, don't perform the procedures with enough frequency to stay competent and have a poor success rate.

It would be nice to be able to think that way, that this is just an educational or frequency issue, but if you look at the data it's really not telling that story. The recent Melbourne study suggests there's a small benefit to neuro outcome in TBI. No mortality impact. This is in pretty close to ideal circumstances with a select cohort of highly trained providers doing a lot of procedures. We know that King CO medics seem to do a really good job putting tubes in the trachea, but we have no idea whether it actually helps their patients.

Almost the entirety of the remaining data is negative. I'm sitting not too far away from my ambulance with its sux, ket, roc, etc., but I'm basically forced to accept that this is a procedure that might be causing my patients harm and might be dangerous in my hands. This area needs further study, and is being actively studied - but if we carry on seeing negative results we need to be advocating to remove or greatly restrict the practice. Once we can start moving beyond defining ourselves by a set of interventions and starting looking at the data impassionately and motivating for what's best for our patients, we may be at actual risk of becoming a profession.

This is not intended as a slam or a personal attack.

It seems like all we hear about are those services removing RSI due to poor education or poor success rates. In the meantime, agencies that provide continuing education, OR intubation opportunities, frequent opportunities to perform RSI in the field and a strong success rate just continue to chug along unnoticed.

Then, if it's working so well, they need to start publishing, because right now the aggregate of the data is looking really discouraging.

Rather than remove the skill, let's increase the educational standards. For goodness sake, when you need to manage the airway, sometimes RSI is the only option. I'm certainly not waving the "paramedics are only paramedics because we can intubate" flag, but reducing the skill set because some agencies don't provide enough education or opportunity to stay competent is a bad idea.

I agree that we need to increase educational standards, and have for a long time. Unfortunately, if the number of patients needed to treat to see a realistic benefit is very high, then many paramedics just aren't going to see enough cases to develop or maintain competence.

 

[NomadicMedic]

Just to play the devils advocate, the Melbourne study shows no increase in survivability of patients with TBI that are intubated in the field. Is there a study that shows no increase in survivability of submersion injuries that are intubated in the field? How about reactive airway disease exacerbation refractory to CPAP or pharmacology? Has that been studied?

As I mentioned, there are instances when the only method to manage an airway is to sedate a patient and place an endotracheal tube.

The real reason intubation may be removed from the paramedic scope is simply because we're not good enough at performing the skill. Every system that pulls intubation goes back to the LA Gauche study that examines BVM versus endotracheal intubation. We all know that study was flawed and that paramedic intubation skills are woefully lacking both in education and continued competency.

So maybe we need to examine the ability of paramedics to successfully perform endotracheal intubation before we start to look at its efficacy. A novel idea I know... let's teach people how to do it correctly and determine if it's truly needed before we determine if it actually makes any difference.

 

[Handsome Robb]

Or take for example the fact that I went to paramedic school in Washington State where we did RSI on standing orders. I moved to Delaware, and found that RSI is looked at totally different here. Yes, my service does it… But we do it differently then I was taught.

Just because they don't do it where you are, doesn't mean you shouldn't know about it.

Agreed.

Like I said, we were taught it but didn't spend a whole lot of time on it. I know the drugs and dosages (for the common ones) but not much beyond that.

 

[Handsome Robb]

Very interesting slideshow. RSI has always been very controversial. I don't think that in the real world you can get rid of it. Here in the Netherlands we have a extreme ideal situation were we can almost always get a anesthesiologist within 20 min. But that is because this country is so small. In a country like South Africa with a big rural area, lots of TBI,s and limited resources you will have to use paramedics to RSI.
It is always interesting to expand your scope of practice, but reading all the negatives on paramedic RSI, I must say I am glad I don't have to make those decisions.

So i have a question. Why wait on scene for 20 minutes for the anesthesiologist to come RSI the patient rather than just transport them to the ER. Seems like it would double the time waiting for them to come to the scene.

20 minutes seems like a long time to wait for airway control in a patient who's condition is critical enough to require RSI.

 

[systemet]

Just to play the devils advocate, the Melbourne study shows no increase in survivability of patients with TBI that are intubated in the field. Is there a study that shows no increase in survivability of submersion injuries that are intubated in the field? How about reactive airway disease exacerbation refractory to CPAP or pharmacology? Has that been studied?

Submersion injuries requiring intubation are such a small subgroup of prehospital intubation that I doubt anyone has done any outcomes based research. RAD refractory to CPAP is likely more common, but prehospital CPAP is a relatively new intervention in many places. I'm not aware of any research comparing ETI to BVM - it likely hasn't been done. We do know that intubation in RAD is a marker for higher acuity, and that it places patients at a risk for barotrauma, autoPEEP and pneumothoraces. But, in contrast BVM ventilation is likely to be ineffective without some sort of adjunct in patients with very high airway resistances.

I think TBI is usually selected because we know that even a single instance of hypoxia, hypercapnia or hypotension dramatically increases (doubles?) mortality, so its a condition where the patients are very sensitive to airway mismanagement or inadequacies of oxygenation or ventilation. Theoretically, this is where the greatest benefit lies.

I think this illustrates a limitation of EBM - when there's only limited data to extrapolate from, at what point can you start making definitive judgments? I think we both believe that the paramedics in the San Diego trial were substandard, and that the study design had drawbacks, but for a long time this was really the best data out there and it was been taken to be representative of all paramedics. The Melbourne trial may have addressed some of these issues, but it still feels like a loss. Their system was so well optimised, I think I'd expected a bigger difference.

As I mentioned, there are instances when the only method to manage an airway is to sedate a patient and place an endotracheal tube.

Yeah, I know - you can almost start making similar arguments with cricothyrotomy, that its a high acuity, low opportunity event - so do we remove surgical airways because there's evidence of potential harm, no well designed studies showing evidence of benefit, etc.

I think we gave to balance the risks. If we're harming the patients that we most frequently see to help a rare subset - does the math work out in favour in the end?

The real reason intubation may be removed from the paramedic scope is simply because we're not good enough at performing the skill. Every system that pulls intubation goes back to the LA Gauche study that examines BVM versus endotracheal intubation. We all know that study was flawed and that paramedic intubation skills are woefully lacking both in education and continued competency.

The problem is that all studies are flawed, or to be more polite, "have their limitations". We can't discount Gauche et al. just because we don't like aspects of the design - instead we need a study with a similar or better design showing a different result. Right now there's not really much there.

So maybe we need to examine the ability of paramedics to successfully perform endotracheal intubation before we start to look at its efficacy. A novel idea I know... let's teach people how to do it correctly and determine if it's truly needed before we determine if it actually makes any difference.

I agree - but unless we improve the initial training and education soon, it's going to be too late. The judgment is going to be that we can't or shouldn't do these things, and that's all that's going to be remembered.

 

[boerbull]

So i have a question. Why wait on scene for 20 minutes for the anesthesiologist to come RSI the patient rather than just transport them to the ER. Seems like it would double the time waiting for them to come to the scene.

20 minutes seems like a long time to wait for airway control in a patient who's condition is critical enough to require RSI.

We don't wait 20min. Our control room can judge by the call if they are needed and alarm them together with us. I can then cancel them if I don't need them. If I run into trouble on scene, we will rv on a LZ on the way to a trauma center.

I'm just wondering what all these researchers are aiming at. Are they trying to prove that RSI is increasing mortality, or are they trying to prove that paramedics are not good at it? Are there any research on In-Hospital RSI compared to Pre-hospital RSI by doctors?
It's easy to criticize paramedics if you compare them to people working in ER conditions.

 

[Christopher]

A defasciculating dose of a non-depolarizer won't do anything as far as preventing MH or hyperkalemia (but those are pretty rare considerations anyway in EMS).

Interestingly enough in our area, MH has the opportunity to be prevalent as we have a large population of Lumbee Indians who are susceptible to MH after succ (hello dantrolene)...granted it isn't so common I'm asking for a family tree

 

[systemet]

A defasciculating dose of a non-depolarizer won't do anything as far as preventing MH or hyperkalemia (but those are pretty rare considerations anyway in EMS).

I guess this is the problem with trying to extrapolate from physiology. I'm sitting here as a paramedic thinking, "Well... if we blockade a percentage of the nAChR with a non-depolariser, then we'll get less depolarisation with sux, less outward K+ current, and a reduced amount of RyR / SR Ca2+ release, so we'll see less hyperK and a lower incidence of MH".

Then an expert like yourself comes along, and puts everything in perspective. Thanks again -- your contributions to the forum are invaluable.

 

[medicsb]

The whole "RSI is controversial" discussion frustrates me. RSI is truly only controversial in areas where paramedics are not well educated, don't perform the procedures with enough frequency to stay competent and have a poor success rate.

You've probably just described 95% (or more) of EMS systems. Even in places with good education, most medics will not perform the procedure with enough frequency to remain proficient without going to the OR, which most places can't do, mind you.

The only reason your service *might* be proficient (I haven't seen any publications) is because you have access to an OR. Your service, despite being "tiered", has more medics per capita than most cities and is probably on the average for the US (~73 medics, per website for 200k = 36/100K; King Co. is around 13, Boston around 11, NJ as a state is ~18, and I think New Castle Co. is around 18).

Basically, OR access may be ideal, it is not feasible in most places, and essentially makes your service an out-lier.

It seems like all we hear about are those services removing RSI due to poor education or poor success rates. In the meantime, agencies that provide continuing education, OR intubation opportunities, frequent opportunities to perform RSI in the field and a strong success rate just continue to chug along unnoticed.

Only unnoticed because they allow themselves to remain unnoticed.

Rather than remove the skill, let's increase the educational standards. For goodness sake, when you need to manage the airway, sometimes RSI is the only option. I'm certainly not waving the "paramedics are only paramedics because we can intubate" flag, but reducing the skill set because some agencies don't provide enough education or opportunity to stay competent is a bad idea.

A good education would likely be wasted money without the medics being able to get experience, unfortunately. Ultimately, the decision is best made locally, but removing RSI may very well be in the patients best interest in most places.