Rapid Sequence Induction

[firemedic7982]

So whilst in the middle of a late night post call smoke, My partner and I began discussing RSI, and PAI. Both of us have worked at different 911 services where either have been available, as well as available to us now.

She and I both think that RSI is sometimes easilly abused. Do you think sometimes people may be quick to RSI, or PAI in a hectic situation?

We both whollly agree that when you need to RSI, or PAI... You need to do it. Dont **** around, just do it. Buuuut... we both believe that other resources of airway management should be attempted before just jumping to RSI/ PAI.

Again... I agree that when it is needed, there is no substitute. But... Are people maybe sometimes quick to jump to "putting them down"?

What do others think?

 

[Onceamedic]

what is PAI?

 

[firemedic7982]

Pharmecutically Assisted Intubation.

.... I always learned it as RSI, some people refer to it as PAI.

 

[Amack]

Pharmecutically Assisted Intubation.

.... I always learned it as RSI, some people refer to it as PAI.

It's taught as RSI here

 

[Amack]

So whilst in the middle of a late night post call smoke, My partner and I began discussing RSI, and PAI. Both of us have worked at different 911 services where either have been available, as well as available to us now.

She and I both think that RSI is sometimes easilly abused. Do you think sometimes people may be quick to RSI, or PAI in a hectic situation?

We both whollly agree that when you need to RSI, or PAI... You need to do it. Dont **** around, just do it. Buuuut... we both believe that other resources of airway management should be attempted before just jumping to RSI/ PAI.

Again... I agree that when it is needed, there is no substitute. But... Are people maybe sometimes quick to jump to "putting them down"?

What do others think?

BLS before ALS, I say....If you are getting good air movement, and your patient is showing signs of adequate oxygenation and perfusion with just a BVM and basic airway adjunct...I will BLS that all the way to the ER. That's the problem with ALS students that go to medic school RIGHT after they finish Basic school, before the ink is dry on their cert. They don't get much exposure to BVMs on a real person let alone propper ventillation technique.

Also, when they get out into the field...the majority of what they've recently learned is from the ALS perspective, TUBES, IVs, etc. They lack a solid foundation that could have been built upon.

 

[akflightmedic]

There is a difference between RSI and PAI.

RSI involves the use of paralytics and PAI does not.

Examples:

RSI you may use succinicholine and norcuron along with other sedating (hypnotic) agents such as versed and pain medications like fetanyl or morphine.

PAI you may use fetanyl and versed to eliminate the gag reflex in order to intubate.

 

[rescuepoppy]

RSI and PAI are both tools that we have available. They are to be used by those who know how when and why to use or not use them Unfortunatley they are being pulled from some services due to the fact that they are used incorrectly or for the wrong reasons. When used correctly could be the difference between life and death. They are never tobe used as a chemical retraint for the medics convienence as they have been used by some in the past.

 

[Scott33]

Pharmecutically Assisted Intubation.

.... I always learned it as RSI, some people refer to it as PAI.

As said above - two entirely different things.

 

[MSDeltaFlt]

There is a difference between RSI and PAI.

RSI involves the use of paralytics and PAI does not.

Examples:

RSI you may use succinicholine and norcuron along with other sedating (hypnotic) agents such as versed and pain medications like fetanyl or morphine.

PAI you may use fetanyl and versed to eliminate the gag reflex in order to intubate.

Not necessarily. You have to look at the operative words in each.

The operative word on Rapid Sequence Induction (Intubation) is Sequence. You will follow the whole sequence including the use of paralytics to secure the airway regardless of pt situation.

The operative word on Pharmacology (Drug) Assisted Intubation is Assisted. If your pt stops breathing and loses his/her gag reflex after an opioite and/or sedative, then you do not have to give the paralytic.

It all boils down to what your service calls it and what you are and are not allowed to do.

In referencing the OP, yes, sometimes I also believe that RSI/DAI might be used too much. There is a trick to pt care in this field. The trick is not knowing what to do and being able to do it. That's easy. Any moron can be taught that. The trick, ladies and gentlemen, is being able to do something and knowing when and when not to do it.

 

[firemedic7982]

RSI and PAI are both tools that we have available. They are to be used by those who know how when and why to use or not use them Unfortunatley they are being pulled from some services due to the fact that they are used incorrectly or for the wrong reasons. When used correctly could be the difference between life and death. They are never tobe used as a chemical retraint for the medics convienence as they have been used by some in the past.

I have heard war stories of this being done, and frankly it appauls me that someone would do this.

I do not care what the situation is, we are not to be punitive in caring for our patient. Given the old joke of " mean pt's get a 14g."

Crap like that, and RSI'ng a combative pt. for sake of convinience is appauling.

 

[MSDeltaFlt]

I have heard war stories of this being done, and frankly it appauls me that someone would do this.

I do not care what the situation is, we are not to be punitive in caring for our patient. Given the old joke of " mean pt's get a 14g."

Crap like that, and RSI'ng a combative pt. for sake of convinience is appauling.

Yes, we all have. You and me and just about each and every other person in this field. But how can we make this better? How can we improve these situations?

There are those who say "education". And they would be correct... to a point. But it's not just education. It's creating an environment for those who are receiving the education to actually accept the education and to learn.

One way to do that is to not be judgemental. It's not what they're doing, but why they are doing it. Encourage the 14g's. For the sake of arguement, if a pt has significant injuries, they should get the largest bore their veins will hold. Even if they are rock stable. Because it's not the amount of resuscitation you can give the pt, but how fast you can give it judiciously. The key here is speed.

For the sake of the other arguement, if a pt is combative, they are coming out of "C-Spine" precautions, and you cannot guarrantee no cervical compromise, then yes, the succ should be in. I personally know an EMT-B who is living proof you can walk around the house for 3 days with a broke neck.

There may be those who disagree. I used to make this same arguement, "I'm here to save your life, not be your friend". I used to be wrong. That entire sentence was wrong. Only recently have I learned how it should have been said in the first place.

"I'm here to do more than save your life. I'm here to be more than your friend. I'm here to be your advocate."

Being an advocate sometimes means making the hard decisions that aren't very popular or very fun or very cool. It means doing the right thing.

If this reads as a rant or a tangent, I apologize. I just felt it needed posting.

 

[Sasha]

I do not care what the situation is, we are not to be punitive in caring for our patient. Given the old joke of " mean pt's get a 14g."

Crap like that, and RSI'ng a combative pt. for sake of convinience is appauling.

That's disgusting. And people like that shouldn't be in EMS.

 

[46Young]

I've been told that large depts typically won't have RSI due to QA/QI issues, such as dose calculations, or administering the paralytic first by accident(barbaric). CCEMS has RSI, and due to the numerous medication errors, the med directors(there are two) devised a reference chart which requires you to round the pt's weight in 25 lb increments. Laughable. NYC has prehospital sedation, a version of PAI I suppose, that calls for etomidate, followed by either versed or valium. Fairfax has a chemical restraint OLMC order. Punitive IV's, drunk tossing(heave ho to the stretcher from a distance), driving excessively fast with an immobilized allstate-itis pt over a bumpy rd(to go airborne), and other punishing maneuvers disgust me. Some seasoned medics would brag about piggybacking lasix to make the pt urinate u/a at the ED. I hope I didn't give anyone any ideas. Seriously.

 

[Ridryder911]

I

Crap like that, and RSI'ng a combative pt. for sake of convinience is appauling.

Apparently you have never been in a helo with a combatitive patient. Most HEMS has such orders to sedate patient for safety. Many even have to place in deep sedation for RSI because of such, as I know of one I worked at was a standing order from a correction facility that primarily handled level I violent inmates.

Before judging, as well look at many of the hospitals policies of restraining patients. Many have gone away from physical restraints to pharmacological restraining.

Yes, RSI (NOT induction but intubation) maybe over used and be inappropriate at times; then again, many of those judging may not be of the level to really have or give such an opinion. Just because someone is breathing adequately does not mean that they have a secured and patent airway. Have you ever seen aspiration?

R/r 911

 

[boingo]

There is a trick to pt care in this field. The trick is not knowing what to do and being able to do it. That's easy. Any moron can be taught that. The trick, ladies and gentlemen, is being able to do something and knowing when and when not to do it.

Words of wisdom.

 

[firecoins]

NYC has prehospital sedation, a version of PAI I suppose, that calls for etomidate, followed by either versed or valium.

etomidate is followed by valium once intubated.

 

[rescuepoppy]

Apparently you have never been in a helo with a combatitive patient. Most HEMS has such orders to sedate patient for safety. Many even have to place in deep sedation for RSI because of such, as I know of one I worked at was a standing order from a correction facility that primarily handled level I violent inmates.

Before judging, as well look at many of the hospitals policies of restraining patients. Many have gone away from physical restraints to pharmacological restraining.

Yes, RSI (NOT induction but intubation) maybe over used and be inappropriate at times; then again, many of those judging may not be of the level to really have or give such an opinion. Just because someone is breathing adequately does not mean that they have a secured and patent airway. Have you ever seen aspiration?

R/r 911

My statement was about the ones who have and still do use RSI as a covenience not for the safety of those concerned. If a patient needs to be RSIed for their own or the crews safety then you are doing what is best. I do not agree with "putting a patient down" just because someone does not want to listen to or deal with them.

 

[Melbourne MICA]

So whilst in the middle of a late night post call smoke, My partner and I began discussing RSI, and PAI. Both of us have worked at different 911 services where either have been available, as well as available to us now.

She and I both think that RSI is sometimes easilly abused. Do you think sometimes people may be quick to RSI, or PAI in a hectic situation?

We both whollly agree that when you need to RSI, or PAI... You need to do it. Dont **** around, just do it. Buuuut... we both believe that other resources of airway management should be attempted before just jumping to RSI/ PAI.

Again... I agree that when it is needed, there is no substitute. But... Are people maybe sometimes quick to jump to "putting them down"?

What do others think?

RSI is no laughing matter nor should it ever be.

Abuse here means a clincial breach and loss of your accreditation to do the procedure. And RSI is not a means to "put someone down" nor should it ever be used for that purpose - You can do that pharmacologically just using Midazolam for example - ie employing sedation to induce unconsciousness. We have an "agitated pt" guideline for just such a situation.

A failed intubation whilst employing paralytics in a patient with no effective ventilation options other than an RSI will lead to cardiac arrest and likely kill the pt.

It doesn't get much more serious than that.

And this is the point. There will either be indications for immediate RSI or ongoing failure of BLS/ALS alternatives leads to an indication for RSI. Nothing else.

RSI here is done according to strict procedural and clinical criteria ie indications for RSI. It is never done to "quiet down" a patient with one very specific exception - in the aeromedical setting. The flight guys can expalin why it is imperative to RSI some categories of pts for flight transport.

And the decision to use rapid sequence induction is effected to do more than just secure an airway or provide an easy option for ventilation.

In the head injured pt eg whilst RSI does provide a secured airway and controlled ventilation its principle purpose is to mitigate secondary brain injury through the ventilation component pathway whilst post induction Paralysis, Pancuronium in our case, provides control of MAP and hence ICP.

Our RSI procedure uses Fentanyl + Midazolam = anaesthesia and Suxemethonium for paralysis. ie Pain suspension, induced coma and inhibiton of reflexes and muscle relaxation. Paralysis has nothing to do with anaesthesia - give the sux only and a pt will be wide awake with intact sensory function.

EMT's who think RSI is a means to an end - usually for their convenience or laziness are asking for trouble and deserve to be stripped of their accreditation to use it.

And for MSDelta Fit. No apologies necessary. You couldn't have stated the relationship between responsibility and compassion and between professionalism and advocacy better.

Well said.B)B)

It's a pitty some out there (and here) think it's all one big yawn or joke and these deadly serious medical procedures are akin to toys.

My turn to rant.

MM