Rapid Sequence Intubation

[Devilz311]

I'm just curious to see what the different RSI protocols for various ALS projects... Medical vs Trauma, etc...

My company started using RSI almost 2 years ago, and the success rate is still in the high 90% range... Every experience I've had with it turned out pretty well... First RSI was on a severe CHF'er, getting tired pretty quick... could not tolerate the CPAP at all. Pt was intubated, and ended up walking out of the hospital a few days later.

I've also had a few good experiences with clenched trauma Pts...

Are there any other drugs out there then the usual sequence of Etomidate, defasiculating dose of Vecuronium (sometimes ordered, sometimes not), Succinylcholine, & then post-intubation management, versed & long-acting dose of Vec.

 

[VentMedic]

Pt was intubated, and ended up walking out of the hospital a few days later.

Depending on the disease process causing the CHF, most CHF pts do walk out of the hospital a few days later. CHFers' usually require only a few hours to and overnight on the ventilator. Total time in the hospital averages 3 days in many cases. Many can be treated with CPAP or BiPAP (trade name). If they required intubation for extended periods of time like several days, they probably had more going for etiology with CHF being just one symptom.

Since I have seen the very good and very bad examples of RSI in the field being brought into the ED, I have strong opinions and will let others give you their recipe. It is a subject where education should be provided and questions such as these should be answered by your medical director. Too ofter paramedics are given just one piece of information without full knowledge of why it works or why your medical director prefers that way over others. I know what my options are in my transport and hospital situations for RSI but those may not be applicable to your situations or transport times.

 

[Ops Paramedic]

RSI has only very recently been introduced here on the protocol of those holding the degree qualification (I have not seen this protocol published, but my info is from a reliable source)..

Currently we (ALS) have the synergistic use of Dormicum (Midozolam) and Morphine in patient who might fit the RSI scenario, and sometimes it is only with the experience of the practitioner that the tube will pass, a student/less experienced practitioner might fail. These meds will not do the trick, and the entire procedure can most likely cause more harm than good. So as an ALS provider, should you need RSI, you will have to try and get hold of one of the Drs on the road, or you will have to call the heli.

Somehow though, we manage, i just hope the patient does too.

 

[tydek07]

Heres our protocol:

NOTTA

 

[fma08]

only PAI at our place, 2.5 Versed... thats about it.

 

[firecoins]

we don't use paralytics here. We get along fine w/o. We can get the tunes w/o the paralytics.

 

[Flight-LP]

I'm just curious to see what the different RSI protocols for various ALS projects... Medical vs Trauma, etc...

My company started using RSI almost 2 years ago, and the success rate is still in the high 90% range... Every experience I've had with it turned out pretty well... First RSI was on a severe CHF'er, getting tired pretty quick... could not tolerate the CPAP at all. Pt was intubated, and ended up walking out of the hospital a few days later.

I've also had a few good experiences with clenched trauma Pts...

Are there any other drugs out there then the usual sequence of Etomidate, defasiculating dose of Vecuronium (sometimes ordered, sometimes not), Succinylcholine, & then post-intubation management, versed & long-acting dose of Vec.

Congratulations on your successes with this procedure, but it is Rapid Sequence Induction, not Intubation. There is nothing rapid about the intubation as this procedure start to finish averages about 5-7 minutes. Sorry for being petty, but it makes me wonder when the procedure isn't even titled correctly........................

I've been using paralytics for over a decade, just as Vent said, i've seen good and bad. Some medics use them just to use them, others are scared to go near them. Our current protocol is Etomidate, Sux (if needed and not contraindicated), intubation, then Versed and Vec as needed. I've used most of the NMBA's out there, personally I prefer Zemeron for induction. None of the Acetylcholine or Potassium issues, it has a rapid onset close to Sux, and it lasts a lot longer so the need for a second paralytic is rarely present.

As far as success rates go, the paralytic should have no bearing on decreasing the overall tube placement rate. If it does, then you have issues that need to be addressed with your QI/QA program. The key when using these drugs isn't are we successful in placing the tube, rather did we instigate any adverse effects, i.e. malignant hyperthermia, transient hypoxia, and hyperkalemia. You must know these drugs inside and out right down to their action at the cellular level. Anything less and you have no business even touching the vial.

Also, do you have a 100% chart review on every intubation? Nothing improves skills and education better than in depth peer review and critique. A quality QI/QA program does wonders for a professional EMS agency................

 

[Flight-LP]

only PAI at our place, 2.5 Versed... thats about it.

That sux (no pun intended!).....................

Half as@!ng it does little for your patient or your sanity. You should inquire with your medical director as to why he/she believes a low dose of Versed will remotely afford you a secured airway in the conscious patient. My opinion is "all or nothing"................

 

[Jon]

CPAP is amazing.

Around here, Etomidate is approved, but not everyone is carrying it. PA is afraid of RSI after Dr. Wang's study showed how bad most medics are at airway manegment.

 

[firecoins]

NYC now allows for etomidate.

 

[Ridryder911]

Congratulations on your successes with this procedure, but it is Rapid Sequence Induction, not Intubation. There is nothing rapid about the intubation as this procedure start to finish averages about 5-7 minutes. Sorry for being petty, but it makes me wonder when the procedure isn't even titled correctly........................

Actually, Flight it is now commonly referred to as Rapid Sequence Intubation in lieu of Rapid Sequence Induction, a few years ago it was formally changed due to we do not really induce or have a license to induce anesthesia. Even physicians prefer intubation over induction; indicating speciality of anesthesia. I believe it came from pressure of CRNA/Anesthesia groups as well as liability/litigation cases.

R/r 911

 

[Ops Paramedic]

We don't have them this currently on ALS protocol. As ALS you will have to make do with Morphine & Midazolam concurrently. There is a new qualification, the B-Tech/Degree paramedic, which appareantly RSI is on their protocol. I havent' seen it published yet, as well as that register only opened last year for them.

Besides, we also recently got Lorazepam (Ativan) on protocol, which is great, but i don't think our services or practitioners are 100% equippped for the fridge drugs yet, but we are working on it!!!

 

[Ridryder911]

We don't have them this currently on ALS protocol. As ALS you will have to make do with Morphine & Midazolam concurrently. There is a new qualification, the B-Tech/Degree paramedic, which appareantly RSI is on their protocol. I havent' seen it published yet, as well as that register only opened last year for them.

Besides, we also recently got Lorazepam (Ativan) on protocol, which is great, but i don't think our services or practitioners are 100% equippped for the fridge drugs yet, but we are working on it!!!

There is a new form of Ativan, that does not require refig.; although you have to mix it. We used cold/frozen blocks that one would use to keep beverages cold, it kept the med.'s cold enough.

R/r 911

 

[Flight-LP]

Actually, Flight it is now commonly referred to as Rapid Sequence Intubation in lieu of Rapid Sequence Induction, a few years ago it was formally changed due to we do not really induce or have a license to induce anesthesia. Even physicians prefer intubation over induction; indicating speciality of anesthesia. I believe it came from pressure of CRNA/Anesthesia groups as well as liability/litigation cases.

R/r 911

I guess that trend hasn't worked its way south yet...............

Everyone around here still refers to it as induction. Interesting to know though!

 

[Ridryder911]

I guess that trend hasn't worked its way south yet...............

Everyone around here still refers to it as induction. Interesting to know though!

Yeah, I called it that for years until I was clarrified that it was a "legal issue", and seen some texts and posters describing that we were not really "placing people under for true induction"; in which I guess we would have to monitor the stage of anesthesia, etc..

R/r 911

 

[Short Bus]

That sux (no pun intended!).....................

Half as@!ng it does little for your patient or your sanity. You should inquire with your medical director as to why he/she believes a low dose of Versed will remotely afford you a secured airway in the conscious patient. My opinion is "all or nothing"................

I agree with ya here 100%. We use the Lido, Atropine, Etomidate, Sux, and the vec. Versed or more Etomidate as needed. Sooner is much better than later.

 

[fma08]

i've talked to people about it, and it seems the feeling is that while RSI is a great tool in the right hands, it is a potentially dangerous tool not to be overused, and while they wouldnt admit it, many medics would be too... excited? if thats the word... about using it, especially in a situation where it isn't warrented, or where sedation itself would be fine. He, pretty much feels that in a position where the pt. truly would even need intubation, they would be unresponsive already or in a state where it would only take minimal sedation to achieve the same results. He, and some staff feel it is better to assist ventillations rather than knock the pt's resp. drive out and need to focus our effort on breathing for him. We work pretty much only 2 man crews, Medic-Medic or Medic-Basic, so if pt's resp. drive is gone, then the man in back is stuck doing that when other tasks may need to be performed. I'm all for adding an RSI protocal, but I can completely see where the medical director is coming from. We work hard on school at learning how to properly manage an airway BLS style (bag and OPA or NPA), so we can do that effectively before even considering intubating. Plus, the vast majority of our call volume is within a 10min transport time to a hospital...

 

[Ridryder911]

The point of RSI is for those patients that are worn out or to secure an airway to prevent aspiration. Assisting them will definitely, increase teh risk as well as those such in exacrebated COPD/CHF is desparately attempting to maintain, but is slowly loosing all drive.

If one is able to RSI as well, they should have acess to transport vents. Why not? This free's up the Paramedic as well as a lot better ventilation if done properly.

R/r 911

 

[Devilz311]

Congratulations on your successes with this procedure, but it is Rapid Sequence Induction, not Intubation. There is nothing rapid about the intubation as this procedure start to finish averages about 5-7 minutes. Sorry for being petty, but it makes me wonder when the procedure isn't even titled correctly.......................

Everywhere in our policy and procedure manual, as well as every memo titles it Rapid Sequence Intubation.

Also, do you have a 100% chart review on every intubation? Nothing improves skills and education better than in depth peer review and critique. A quality QI/QA program does wonders for a professional EMS agency................

Our Clinical program has 100% QA on every single chart, not just RSI... ALS, BLS, SCTU, Non-Emergent BLS, everything is QA'd. For every RSI we do, it requires a special form to fill out, as well as every case is reviewed in depth...

 

[firecoins]

Everywhere in our policy and procedure manual, as well as every memo titles it Rapid Sequence Intubation.

Your policy and procedure policy is also incorrect. This just how EMS refers to the procedure. The correct medical name of the procedure is Rapid Sequence Induction. It is about the medication. Not the actual intubation.