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This thread is a long time dead. I actually cut hair in Texas now after pushing paralytics.
Rapid Sequence Intubation
- Thread starter Devilz311
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ExpatMedic0
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For an international perspective we first trialled RSI for select Intensive Care Paramedics (ALS) in Auckland during 2005-2006. The success rate was very high at about ~97% and for the last few years it has been an Auckland only skill because of the high volume of calls they recieve.
We expanded the trial during 2008 to two other areas which while not recieving as high call volume as Auckland they are very large and have the potential for long transport times, up to an hour to hospital.
This trial showed again around 97% success in over 500 patients.
RSI is now being rolled out nationwide for certian officers at Intensive Care level.
Our drugs of choice are suxamethonium and vecuronium, fentanyl and either midazolam for TBI or nuerogenic causes w/ GCS <= 10 (e.g. stroke) or ketamine for everybody else.
We expanded the trial during 2008 to two other areas which while not recieving as high call volume as Auckland they are very large and have the potential for long transport times, up to an hour to hospital.
This trial showed again around 97% success in over 500 patients.
RSI is now being rolled out nationwide for certian officers at Intensive Care level.
Our drugs of choice are suxamethonium and vecuronium, fentanyl and either midazolam for TBI or nuerogenic causes w/ GCS <= 10 (e.g. stroke) or ketamine for everybody else.
I work in 2 different services, one inner city commercial and the other rural tarnsport/ALS intercept. no RSi in the city and RSI in the woods.
where i use RSI we have very progressive med-con that QAs everything from psychs to critical patients. easy for them to do as they only sponsor like 75 or so paramedics. in 2008 we had 37 RSIs with 100% success rate. we have access to OR time anytime we feel it needed a we gives long as week or so heads up. depending on how a call is documented we actually get questioned for not using RSI on certain calls. we use sux and etomidate, with versed afterwards, no maintenance paralytic (which we have been fighting for) and have recently taken out lidocaine for ICP due to lack of evidence that it actually blunts ICP. we also have the airtrach for difficult intubations, LMA for backup and CPAP to hopefully avoid intuabtion.
in the city where i work for a well known evil empire, RSI wont even be considered for many reasons. one being short transports, a few poor paramedics, very poor QA by med-con and the company and..... we have some ED docs at one hospital that dont believe in prehospital medicine. these docs think we should go back to being a fast response meat wagon. in their defense we have had some very poor medics that dont make a good a name for prehospital medicine, but in those medics defense, QA has really only been used for punishment and not corrective action. in this area i have yet to hear of any incidents where medics were sat down and taught what and why something was wrong. its either yelling, termination, med con suspension or more often, no action taken. with that being said, i also dont know if i would want to see RSI available to all medics in this area. what 2 cities have out here have done is allow chosen medics to use RSI after an interview process with MDs and senior medics. this isnt a horrible idea but creates an inconsistent standard of care in those areas because these werent fly car intercept medics but medics in transport rigs who were usually schleppin a fer and not available during potential calls.
i have criched a trismus patient who was assesed as a potentially easy RSI/ intubation and sao2 imediately improved and airway became much more manageable however still ended up in a state i like to refer to as feed and weed. I have also had several successful nasal intubations on patients that i would have performed RSI had i had the option.
I am a believer that if you are going to do something do it all the way. i do not agree with etomidate only intubations for sveral reasons. very rarely does it provide adequit relaxation unless the pt is already obtunded and very tired. there is several documented cases of it also causing periods of trismus after administration by itself, (ill see if i can find those studies and post em here). and there is the already mentioned laryngospam
there was 1 or 2 studies done about 5 or 6 years ago that did not make a good case for field RSI by paramedics. i believe the success rate was only 85% and a lot of documented cases of dropping 02 sats druing these studies. now, i have personally witnessed some very poor RSIs in several different EDs by both seasoned attendings and residents, of small hospitals and of trauma centers some of which resulting in multiple attempts, low o2 sats, severe bradycardia and arrest. from my veiw point, few would have been considered difficult(always easy to say when the scope is not my hand) but seem to have been more due to poor skill and poor overall airway management.
where i use RSI we have very progressive med-con that QAs everything from psychs to critical patients. easy for them to do as they only sponsor like 75 or so paramedics. in 2008 we had 37 RSIs with 100% success rate. we have access to OR time anytime we feel it needed a we gives long as week or so heads up. depending on how a call is documented we actually get questioned for not using RSI on certain calls. we use sux and etomidate, with versed afterwards, no maintenance paralytic (which we have been fighting for) and have recently taken out lidocaine for ICP due to lack of evidence that it actually blunts ICP. we also have the airtrach for difficult intubations, LMA for backup and CPAP to hopefully avoid intuabtion.
in the city where i work for a well known evil empire, RSI wont even be considered for many reasons. one being short transports, a few poor paramedics, very poor QA by med-con and the company and..... we have some ED docs at one hospital that dont believe in prehospital medicine. these docs think we should go back to being a fast response meat wagon. in their defense we have had some very poor medics that dont make a good a name for prehospital medicine, but in those medics defense, QA has really only been used for punishment and not corrective action. in this area i have yet to hear of any incidents where medics were sat down and taught what and why something was wrong. its either yelling, termination, med con suspension or more often, no action taken. with that being said, i also dont know if i would want to see RSI available to all medics in this area. what 2 cities have out here have done is allow chosen medics to use RSI after an interview process with MDs and senior medics. this isnt a horrible idea but creates an inconsistent standard of care in those areas because these werent fly car intercept medics but medics in transport rigs who were usually schleppin a fer and not available during potential calls.
i have criched a trismus patient who was assesed as a potentially easy RSI/ intubation and sao2 imediately improved and airway became much more manageable however still ended up in a state i like to refer to as feed and weed. I have also had several successful nasal intubations on patients that i would have performed RSI had i had the option.
I am a believer that if you are going to do something do it all the way. i do not agree with etomidate only intubations for sveral reasons. very rarely does it provide adequit relaxation unless the pt is already obtunded and very tired. there is several documented cases of it also causing periods of trismus after administration by itself, (ill see if i can find those studies and post em here). and there is the already mentioned laryngospam
there was 1 or 2 studies done about 5 or 6 years ago that did not make a good case for field RSI by paramedics. i believe the success rate was only 85% and a lot of documented cases of dropping 02 sats druing these studies. now, i have personally witnessed some very poor RSIs in several different EDs by both seasoned attendings and residents, of small hospitals and of trauma centers some of which resulting in multiple attempts, low o2 sats, severe bradycardia and arrest. from my veiw point, few would have been considered difficult(always easy to say when the scope is not my hand) but seem to have been more due to poor skill and poor overall airway management.
I've been doing RSII for almost 14 years. We first used versed and vecuronium. It worked, but it was a pain to have to reconstitute the vec, and it took as long as 3 minutes to work. I currently use etomidate and sux. (vec for a renal or burn patient) Onset of effects is almost instantaneous. tones...more later
part2. Now, at the service where I work we are busy, and intubate frequently enough that we are good at it. I feel confident in our ability to use paralytics because we ventilate adequately and we are not too embarrassed to roll into the ED with an OPA/BVM or LMA in place if we were unable to place the tube. I have done this more than once. I wish we had CPAP or BIPAP here. I'm told the hospitals here would not be prepared to handle it if we did, so it's on a back burner for now. I really like having the option of RSII in CVAs and head trauma. I have twice needed it to intubate burn patients and barely got the tube in due to swelling. IMHO, having RSII is better than not having it.
I think RSI is a very useful tool in the right hands. This is why we're only expanding it to select Intensive Care Paramedics as to create a better degree of skill retention per officer.
Now I do agree that it is inconsistent with say one ambo being able to RSI and another not but this is not like when we introduced ondansteron; these are not simple drugs and skills being dealt with.
Five years ago it was "never" going to be seen as standard but rather only for "selected" Paramedics (ILS) to have adrenaline, morphine and naloxone but that is being given to every officer now over the next few years.
With that in mind, in five years RSI might change too.
Now I do agree that it is inconsistent with say one ambo being able to RSI and another not but this is not like when we introduced ondansteron; these are not simple drugs and skills being dealt with.
Five years ago it was "never" going to be seen as standard but rather only for "selected" Paramedics (ILS) to have adrenaline, morphine and naloxone but that is being given to every officer now over the next few years.
With that in mind, in five years RSI might change too.
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