Rapid Sequence Induction HOWTO?

[NomadicMedic]

It's not THAT short acting. The duration of action varies per person and dose, but 10mg seems to be an adequate sedation dose for my short, under 20 minute transports.

 

[Veneficus]

How often would you readminister midazolam? Every 2-3 minutes? The book didn't mention a sedation dose in this procedure, but the dose I was taught in school was 2-5 mg q 2-3 minutes to a max of 0.1 mg/kg. Seems like I'd be giving a lot of midazolam in a short amount of time.

Midaz usually works about 40 minutes for me. Edit In doses of 0.075mg/kg-0.15mg/kg

(forgot to list the range)

 

[systemet]

Systemet, how come? Instead of a paralytic, just maintain sedation instead?

The idea of paralysing the patient during the intubation procedure is to prevent any gag reflex that remains -- depending on the sedative / anesthetic used, the gag may be gone, minimal, or fully present, and to relax the muscles of the jaw. This is particularly useful when the patient has trismus, but generally (but not always) improves visualisation, even when the patient isn't clenched.

Once the tube is through the glottis, and there's no longer a big piece of metal sitting in the vallecula, there's less stimulation of the gag reflex. Often sedatives and analgesics (or an agent with both properties like ketamine), are enough to allow the patient to tolerate the tube.

Where post-intubation paralysis becomes more appealing is if your patient's spontaneous respirations or reflex activity are interfering with ventilation, which is usually a product of using a low quality ventilator, like we tend to do in EMS. Or in the rare instance that you're intubating someone with intractable seizures, which is controversial, as now you're masking the signs of the seizure that you need to continue actively treating.

Often much of the patient "fighting the ventilator", is a failure of ongoing sedation/analgesia. In my region we give aliquots ketamine or fentanyl and midazolam q 10 minutes depending on the pressure and the need. A better approach might be to run both as an infusion on a longer transport, to avoid the peaks and troughs of bolus administration.

It's much easier to assess the level of sedation if you haven't used a long-acting neuromuscular blocker. Obvious signs of being a little light would include things like tachycardia, spontaneous movement, spontaneous respirations, and respirations that interfere with ventilation.

You will still see things like tachycardia and tearing if the patient is paralysed and undersedated, but once you start seeing significant tachycardia and tearing, it's a sign that you haven't done your job properly.

 

[systemet]

Midaz usually works about 40 minutes for me. Edit In doses of 0.075mg/kg-0.15mg/kg

(forgot to list the range)

I think this is the problem I'm seeing. We're giving 0.1mg/kg (max 5mg), which is really 0.1mg/kg for anyone under 50kg, and about 0.05mg/kg for someone who's 100kg. Admittedly, we're giving this with fentanyl and there's some synergism there, but the onset seems pretty slow.

 

[Fish]

I think this is the problem I'm seeing. We're giving 0.1mg/kg (max 5mg), which is really 0.1mg/kg for anyone under 50kg, and about 0.05mg/kg for someone who's 100kg. Admittedly, we're giving this with fentanyl and there's some synergism there, but the onset seems pretty slow.

We max at 10mg, along with Fent. 5mg is pretty low.

 

[Aprz]

I believe I read somewhere that you can judge if a patient is sedate well based on their pleth waves too. I'll Google that now.

Edit: And also other things like tachycardia and movement would make sense. Not going to base it on just one thing.

 

[systemet]

I believe I read somewhere that you can judge if a patient is sedate well based on their pleth waves too. I'll Google that now.

You can see "curare notching" on capnograph waveforms, but this is just ineffective patient generated inspiration.

Edit: And also other things like tachycardia and movement would make sense. Not going to base it on just one thing.

Never thought you would. All the best.

 

[Fish]

I believe I read somewhere that you can judge if a patient is sedate well based on their pleth waves too. I'll Google that now.

Edit: And also other things like tachycardia and movement would make sense. Not going to base it on just one thing.

Bucking the tube, tearing up in the eyes, etc... lots of waysto tell.

 

[Veneficus]

I think this is the problem I'm seeing. We're giving 0.1mg/kg (max 5mg), which is really 0.1mg/kg for anyone under 50kg, and about 0.05mg/kg for someone who's 100kg. Admittedly, we're giving this with fentanyl and there's some synergism there, but the onset seems pretty slow.

I can see where such a low dose is the problem. 0.075mg at 70kg is 5.25mg, at 80 is 6mg

If you up that to even 0.1 you are almost doubling the dose.

I usually use the 0.15 when I am not mixing it as a cocktail. Fent lasts approximately just as long, but I still much prefer morphine for the longer action as well as some beneficial side effects.

 

[Veneficus]

In the above post the "doubling" refers to the amount given based on the 5mg max protocol talked about.

Thought I should clarify that.

 

[Smash]

Defasciculation sounds logical, although I've never seen it done outside of through OR. If anyone has good references on what it does to the risk of succinylcholine-induced hyperkalemia or MH, I'd love to see them.

No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux. It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.

I have to admit a personal bias in that I find bolus dosing of sedation to be a bad idea. It is far to easy to lose track of time and have unwanted peaks and troughs of analgesia and sedation, which does no-one any good.

I've said it a million times before: RSI needs to be done properly or not at all.

 

[NomadicMedic]

No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux. It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.

I have to admit a personal bias in that I find bolus dosing of sedation to be a bad idea. It is far to easy to lose track of time and have unwanted peaks and troughs of analgesia and sedation, which does no-one any good.

I've said it a million times before: RSI needs to be done properly or not at all.

So you're saying we shouldn't perform sedation unless we have the ability to run the benzo as a continuous infusion?

 

[MSDeltaFlt]

No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux. It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.

I have to admit a personal bias in that I find bolus dosing of sedation to be a bad idea. It is far to easy to lose track of time and have unwanted peaks and troughs of analgesia and sedation, which does no-one any good.

I've said it a million times before: RSI needs to be done properly or not at all.

If you "lose track of time", then you've lost your situational awareness and probably shouldn't be allowed to perform this procedure. There is a difference between giving a sedative and sedating your pt as there is a difference between giving a pain med and treating pain. If you truly sedate your pt then they will be more likely to relax and stop breathing and allow intubation.

In my humble, honest opinion.

 

[Smash]

So you're saying we shouldn't perform sedation unless we have the ability to run the benzo as a continuous infusion?

Whilst I appreciate that every service, every protocol is different, I'm saying that that is my personal bias, yes. Notwithstanding Mikes comments above, even the most switched on, time conscious paramedic cannot help but give their patient varying levels of sedation and analgesia if they are relying on bolus dosing. You may get away with it if your transport time is very short, but otherwise you will almost inevitably have peaks and troughs. It may not even make any difference in the long run to the patient, but I personally feel like it is sub-optimal.
The only time I give a bolus of sedation+analgesia is immediately post the tube being passed as generally sedation and analgesia is given a little too conservatively during induction for my liking, so I like to top them up a little then start the fentanyl/midazolam infusion (or ketamine or propofol or whatever)

 

[NomadicMedic]

I'm curious how many ALS agencies, aside from CCT trucks, allow a sedation infusion. I've not seen any...

 

[jwk]

I'm curious how many ALS agencies, aside from CCT trucks, allow a sedation infusion. I've not seen any...

Why would you need it?

On a critical patient in the OR, we're going to be giving bolus doses (when we give them). If you have a critically ill patient in transport, taking the time to set up an infusion for a relatively short transport to the hospital is pointless. Inter-facility transports are a different thing.

 

[Handsome Robb]

I'm curious how many ALS agencies, aside from CCT trucks, allow a sedation infusion. I've not seen any...

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.

 

[jwk]

No references sorry, but the rationale behind a "defasciculating" dose on a non-depolariser is to avoid the post-operative myalgia that often comes with sux. It doesn't appear to work for that either, and that is the least of ones worries if you are pulling out the scary drugs.

I've said it a million times before: RSI needs to be done properly or not at all.

Anesthesia folks are +/- on using a defasciculating dose of a non-depolarizer prior to using sux. I still do, because I still think there's something to it on SOME patients, and I generally have time to give it. With other patients it doesn't seem to make any difference, and most of the literature nowadays doesn't really support it. If you're giving a non-depolarizer first, you also have to wait for it to work (3 minutes or so) and you may not have that time luxury anyway. BTW - some people will get markedly weak with just 5mg of roc. So - if your plan is for RSI because your patient is headed into that downward death spiral, I'd forget about a defasciculating dose. Then you can debate the sux or roc/vec option.

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). That being said, those are the main reasons (plus bradycardia in kids) that a lot of practitioners have totally abandoned the use of succinylcholine for any reason and have gone to roc only for RSI.

 

[NomadicMedic]

Why would you need it?

On a critical patient in the OR, we're going to be giving bolus doses (when we give them). If you have a critically ill patient in transport, taking the time to set up an infusion for a relatively short transport to the hospital is pointless. Inter-facility transports are a different thing.

Because Smash made the statement that we should not be sedating patients in the field unless we can manage the sedation via a continuous infusion. I was curious how many 911 systems allow this.

 

[Fish]

We don't set up infusions in the field, but when we take a Hemorrhagic stroke downtown that is intubated from a smaller Hospital that does not have Neuro, we run an Infusion that the ER has started.