Rapid Sequence Intubation

[Flight-LP]

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...

Sorry, but that is a horrible excuse from your MD. If the airway can be managed by simple BLS interventions, then fine, but you show me a conscious pt. in distress that will allow you to lay him flat to ventilate with a BVM. Or an OD pt. with vomitus that is barely conscious, but has an intact gag reflex. Or the status seizure pt. that has now seized for over 10 minutes most of which without spontaneous respirations. These are the folks that need a Paramedic to take over their respiratory system. That is done through sedation and paralysis. It sounds like to me that your MD doesn't trust his medics if he is that concerned about "taking away a respiratory drive". After all, Anectine only lasts about 4-6 minutes, even if you don't get a tube, you can bag the pt without an issue.

If you wait until a pt. is "bad enough" to intubate, then you are way behind the 8 ball. This is when mistakes are made as you now have to race against time to save your patients life.
For the record, the last three pts. that I intubated have all been conscious upon our arrival and all three without a shadow of a doubt, required immediate intubation. There was no other safe or effective way to manage their airway.

I've heard a lot of excuses as to why RSI is not needed, usually it is the old myth that a naso-intubation would work just fine. I've never heard one like this before......................

 

[VentMedic]

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.

The term rapid sequence intubation is preferred over rapid sequence induction because the latter denotes the technique used by anesthesiologists for rapid airway control coincident with the initiation of anesthesia. The Anesthesiologist has many meds that can be given different routes for different types of surgeries that require rapid induction. In emergency settings, RSI should be seen not "as the initiation of anesthesia" but rather as the use of deep sedation and paralysis to facilitate endotracheal intubation.


NAEMSP is also considering the use of DAI - Drug Assisted Intubation as a catch all term.

Recommended Uniform Guidelines for Uniform Reporting of Data from Out-of-Hospital Airway Management
NAEMSP Annual Meeting (The National Association of EMS Physicians)
January 18, 2003, Panama City, Florida

http://www.naemsp.org/pdf/wangforum.pdf

http://www.naemsp.org/pdf/Recommended_Guidelines_for_Uniform_Reporting_of_Data.pdf

Should we use the term “Rapid Sequence Intubation” or “Neuromuscular Blockade Intubation?”

We prefer “Rapid-Sequence Intubation” or “RSI.” The rationale for using this term is that in the development of a prior position paper (Prehospital Rapid-Sequence Intubation), there were long debates regarding potential alternative terms to describe this technique. In fact, “Neuromuscular Blockade Assisted Intubation” (NMBI) was used as the working term throughout the position development process. However, in the end, there was clear consensus that RSI was already a widely used term with clear connotations, and that we should not try to introduce another new term.

We recognize that “RSI” has a different definition for anesthesiologists (Rapid Sequence Induction).

“RSI-facilitated intubation” has been proposed as an updated prehospital term. We welcome additional comments in this area.

 

[Street Dancer]

Our RSI protocol.

1.0mg/kg Lidocaine
.5 Atropine for

• -Hypoxia with decreased SAO2 and Increased CO2
• -Peds <12 @ 0.01mg/kg
• -HR <100

Etomidate 0.3mg/kg max 20mg
Succinylcholine 1.5 mg/kg, max of 200 mg single dose

• If suspected increased ICP give 10% wait a minute give other 90%

Intubate - Verified with CO2 waveform, maintained @ 35-45mm/hg.

Long term Paralysis

Versed 2.5-10mg prn
Vecuronium 0.1mg/kg

Missing a tube on RSI buys you a day of OR time.:sad:

 

[firecoins]

Missing a tube on RSI buys you a day of OR time.:sad:

Which is why I am not big fan of RSI, not that I have any problems with the OR.

 

[Vizior]

Which is why I am not big fan of RSI, not that I have any problems with the OR.

Because you're afraid of a medic missing a tube, you don't like RSI? Why would you dislike a treatment option just b/c of the possibility of a poor outcome? Would the result be any worse than without trying to introduce a tube?

 

[firecoins]

Because you're afraid of a medic missing a tube, you don't like RSI? Why would you dislike a treatment option just b/c of the possibility of a poor outcome? Would the result be any worse than without trying to introduce a tube?

My problem is the paralytic. Not the tube. If you intorduce a paralytic, you must be able to get the tube.

 

[Ridryder911]

My problem is the paralytic. Not the tube. If you intorduce a paralytic, you must be able to get the tube.

or..... you can bag them, and place an alternative airway in (Combitube, LMA, etc) and if need be, crich them..

Really, if you are truly competent in intubations and airway skills, having the patient RSI and paralyzed is much easier and safer for both you & the patient to intubate, than those have "gag" or performing a nasal intubation.

R/r 911

 

[fma08]

all of those situations you just mentioned can be managed without RSI, ex. Conscious pt. in resp. distress, we have CPAP now, works wonders, if it doesnt, thats where the versed comes into play, giving enough to knock em, down, then tubing, ex. OD pt, whats the one thing you always have while tubing? suction. takes care of the vomit, and again, versed to knock em down the rest of the way. ex. seizure pt, versed again, especially if they have been seizing for 10 min. not one of those scenerios did the pt. need to be paralyzed.

 

[firecoins]

Sedation does wonders. Paralytics are overkill. I don't feel endangered after usind sedatives nor do I drawbacks for the patient. I can do it safely and quickly without paralytics. We now have etomidate. Just my opinion.

 

[fma08]

i agree completely, sedation works just fine for the field, in my opinion, it is not a controlled enough environment to make paralytics a common practice, the hospital and OR's are a completely different story. and again, i'm not saying paralytics should never be used, the flight service here does field work/scene flights where they RSI, but they are specially trained people. for you're average street medic, i'd tend to lean to just sedation. it works just fine.

 

[Ridryder911]

Sedation does wonders. Paralytics are overkill. I don't feel endangered after usind sedatives nor do I drawbacks for the patient. I can do it safely and quickly without paralytics. We now have etomidate. Just my opinion.

Okay, exactly how much experience do you have with either? Have you ever seen laryngospasm occur? Have you ever had to treat and deal with an airway that this occurs in? Do you realize the risks and percentages of sedation without paralytics? Do you understand the risks of vagal stimulation, increasing ICP with intubation without paralytics?

Again, there is really a reason this is performed to begin with! This is not a matter that was devised to make it easier. It is again for the patient's sake.

Entomidate is a great medication but does not ensure prevention of gag reflex, laryngospasm, "bucking the tube". Since it is a short acting medication, to maintain level of grade of anesthesia needed for deep sedation has to be considered, the risks is hogh. Paralytic along with deep sedation is more beneficial to the patient.

Laryngospasm is a very common event, even with deep sedation. Having laryngospasm can of course has its complications.

Again, this procedure was to assure intubation to be sucessful. Extubation and reintubations of patents can only lead to problems and possibility increase of morbidity.

R/r 911

 

[Flight-LP]

Okay, exactly how much experience do you have with either?

With the posted responses and the fact that they are Paramedic students, I'd say little.....

I had a lengthy post rebutting every single word that you both wrote, but unfortunately my computer closed IE as I was posting it...............

Here's the deal...........

RSI has been STATISTICALLY PROVEN to increase probability of successful intubation vs. sedation alone. "Snowing" a pt. does nothing more than alter them with possible significant hemodynamic effects. In the aforementioned example, despite your ignorant assertation that you could have done better without RSI'ing the pt., allow me to expand on why the RSI was needed (not that a justification to you is warranted or the fact that neither of you will open your ears and actually listen to others that may know a HELL of a lot more than you)

1. CPAP was used and not tolerated, therefore you have one option left (unless you want to wait for them to go into respiratory arrest)

2. The OD just happened to be from a benzodiazepine agent, so why on earth would I want to give my pt. VERSED????????? Suction for the vomiting, that's a good one. Do you just tape the suction tip down like you would an ET tube. Why not just secure the airway?? Remember the KISS prinicple, it will save you everytime!

3. Think about this one for a moment, if the Versed isn't stopping the seizure, do you really think it is going to make intubating any easier? Why give something when it has already shown it will not work. Status seizure patients need oxygenation. These patients need airway protection that they cannot offer themselves. These patients need to stop their excessive ATP and energy utilization due to the "seizure workout". Out of all three of these, this one would probably need it most.

Right now, you should be focusing on your Paramedic education and learning to be the best that you can be. RSI is not something you should even be thinking about, especially with your current train of thought. Get your certification and some experience and when you actually start inducing (or whatever PC word is to be used these days) paralysis with these medicines, then come back and talk with us.........................

 

[fma08]

ok, next time though, give a full scenerio for each, then maybe i can make a better decision, not just OD, he's puking, status seizure of 10 min, pt. in resp. distress, and i do listen to those that know more than me, unless they are giving me attitude while doing it

 

[Ridryder911]

I do worry about such forums as these that may give the impression of those that are not even licensed/certified to give opinions on procedures, methodologies in which they are not able to perform or have very little exposure to.

Again, this would be similar for me to criticize a surgical approach, that I have never performed or have seen a few times, even though I am not licensed to perform.

Opinions are nice and insightful, only if they can be validated from experience and education.

Maybe opinions should be limited or definitely clarified either as having clinical experience and expertise in a particular procedure or anecdotal thinking. Since we are attempting to inform, educate and present truthful information.

R/r 911

 

[eggshen]

Our answer to lack of RSI? BNTI followed by a dose of Versed. I don't know a lot about RSI so I will not speak on the subject. I do know that the State does not allow it and the waiver process is a ******* to get through. Over the last lot of years I have had great success with BNTI. Such that I feel more comfortable there than I do with a Miller in my L hand. That being said, we pasturize milk now right?

Egg

 

[VentMedic]

Saw this posted on another forum:

High-risk EMS procedure gets a low level of oversight

http://www.star-telegram.com/state_news/story/593026.html

By DANNY ROBBINS
Star-Telegram staff writer

Not long after complaining of shortness of breath at her Quinlan home, Patricia Cannon was in a Hunt County ambulance heading north toward Greenville with a drug dripping into her veins capable of paralyzing every muscle in her body.

The drug, succinylcholine, was administered by a paramedic. The intent was for Cannon, thought to be suffering from a blood clot in the lung, to be immobilized while a breathing tube was placed in her windpipe.

But something happened along the way that prevented the tube from being inserted correctly. The job wasn't done until the ambulance delivered Cannon, 41, to the emergency room at Greenville's Presbyterian Hospital. By then, her condition had worsened considerably.

An examination by the Star-Telegram found that at least two people in Texas have died and another has become permanently disabled after being deprived of oxygen during the procedure, known as Rapid Sequence Intubation.

The situation also raises larger questions about EMS in Texas, illustrating what some believe is a state system that allows paramedics with minimal training to engage in increasingly invasive procedures.

"The elephant in the room is prehospital personnel have a difficult time managing airways," said Robert Simonson, director of emergency services at Methodist Dallas Medical Center and the medical director for CareFlite and six North Texas ground EMS providers. "And they get into particular problems when they paralyze patients. That is a very unforgiving thing."

"You can become a paramedic in Texas with less than 700 contact hours, but it takes between 1,000 and 1,500 [to get a license] to cut hair," said Jay Cloud, an EMS instructor at San Jacinto College in Pasadena. "What's wrong with this picture?"

The bigger problem with intubations, according to many in EMS, is staying proficient, mainly because liability issues have made it increasingly difficult for most paramedics to work in hospital settings.

much more at:

http://www.star-telegram.com/state_news/story/593026.html

 

[fma08]

... wow, we are doing so much better now with our protocols. We are allowed a whole 10mg of Versed if need be to assist with intubation now. :angry: (note the sarcasm)

 

[mo-firemedic]

"You can become a paramedic in Texas with less than 700 contact hours, but it takes between 1,000 and 1,500 [to get a license] to cut hair," said Jay Cloud, an EMS instructor at San Jacinto College in Pasadena. "What's wrong with this picture?"

you actually have to have an IQ to get into medic school!!! well at least for the most part.

the thing with this whole argument is the way it turned into a pi$$!ng match between two or three people instead of a simple response to a question. all of the whining and moaning made me want to pull my hair out of my head. if you are old enough to be in the field than please for the sanity of the rest of us, freaking act like it.

in missouri it is called rapid sequence intubation, not that it really matters what you call it. if you are uncomfortable with your skills to control an airway, then dont rsi the patient or you can still paralyze the patient and secure with a combitube, king airway or LMA. we have this thing called a paramedic's discretion. it is up to the medic in charge of the patient at that time who has been trained in rsi to make that decision!!! follow your protocols and when in doubt call your med control doc. thats what your service pays him for!

 

[rhan101277]

Well many med control doctors allow paramedics to use this drug and some don't. I think it could help people who have gag reflex to get a secure airway.

If you don't get the tube, then just bag them and monitor SpO2 and waveform capnography to ensure proper respirations, it isn't that hard.

If you have to put in a rescue airway.

 

[rhan101277]

Article previously discussed doesn't show up now, but I found a new one.

http://www.jems.com/news_and_articl..._Procedure_Gets_a_Low_Level_of_Oversight.html