ROSC intubation scenario

[SeeNoMore]

I don't see any reason not to RSI en route if you are going to RSI. The exception would be if you were a two person crew with no provider able to drive. You should at least have a helping hand if not a second ALS provider for RSI. I think it's also worth reiterating that intubation does not afford definite protection of the airway.

 

[SpecialK]

I don't see any reason not to RSI en route if you are going to RSI. The exception would be if you were a two person crew with no provider able to drive. You should at least have a helping hand if not a second ALS provider for RSI. I think it's also worth reiterating that intubation does not afford definite protection of the airway.

The back of an ambulance with limited space and access to the patient is not an ideal environment to perform RSI. I'd much rather RSI on-scene at the house where there is good light, lots of room to spread out equipment, can get 360° access to the patient etc. If the patient is already in the ambulance (for example meeting an RSI Officer enroute) I'd rather unload them to perform RSI so long as it is dry and daytime.

RSI always requires a dedicated, suitable assistant to the intubator. To not have such a person is a contraindication to performing the procedure. This can be somebody at any practice level however ideally (although not always possible) this should be a second ICP. If HEMS are performing RSI there will always be an ICP assisting the Doctor.

Having thought about it more, I'm still not convinced RSI if the best thing for this patient right now given her likely course and time to hospital vs. time to perform RSI. If the hospital were further away or the patient had a poorer airway or poorer oxygenation then I would very likely perform RSI. Seeking clinical advice would also not be unreasonable.

 

[SeeNoMore]

I agree that there are advantages to RSI in a non moving well lit setting, but I also think that it is acceptable to minimize out of hospital time and perform RSI en route. We routinely RSI in the back of the ambulance or helicopter (less frequently) with high first pass success rates.

 

[SpecialK]

I agree that there are advantages to RSI in a non moving well lit setting, but I also think that it is acceptable to minimize out of hospital time and perform RSI en route. We routinely RSI in the back of the ambulance or helicopter (less frequently) with high first pass success rates.

It can be done, but in practical reality, given the short amount of time it will take to unload the patient why compromise the attempt by not doing it? (provided of course it's dry and well lit - noting if on scene, the Fire Service can often rig up portable scene lights very quickly).

Helicopters are very small and provide limited space for patient treatment. I wouldn't attempt RSI in the back of a moving helicopter (or even a non-moving one!). London HEMS, for example, will anaesthetise and intubate all patients they feel might need airway intervention between scene and hospital, they do not do "awake carry-backs" of such patients.

As for minimising scene times, RSI takes approximately ten minutes. That ten minutes can be spent on scene or it can be spent on the roadside, next to, or in, a stopped ambulance so your time to hospital is going to be the same regardless. Unless there is a good reason not to do so, RSI should occur on scene, you can get them nice and settled on the ventilator (if you are mechanically ventilating them), packaged and loaded and then you only have to unload them at the other end.

The exception to this is if you are meeting an RSI Officer en-route to hospital.

 

[SeeNoMore]

I'm not so sure. There's been a lot of focus lately on ALS scene times and 10 minutes may be significant. Like I said we intubate routinely in the ambulance en route as well as in the helicopter, though this is not always preferre depending on the situation and provider.

 

[SpecialK]

I'm not so sure. There's been a lot of focus lately on ALS scene times and 10 minutes may be significant. Like I said we intubate routinely in the ambulance en route as well as in the helicopter, though this is not always preferre depending on the situation and provider.

I don't see the point in getting going to hospital only to stop and do something we could have done before we left. Scene time is important yes, but considering the "overall clinical picture" as it is said to be, I think in reality it is easier to perform RSI on scene before loading the patient provided there is not a good reason not to do so.

The exception to this is of course meeting an RSI Officer enroute.

I would not perform RSI on this patient. The time to do so, then load them, then transport to hospital is going to be about thirty minutes minimum vs. 15 minutes to hospital without it. Her airway is manageable and she is oxygenating well with normal ETCO2 so I can't see a strong reason to do so. If the hospital were 30 minutes away and her airway were a little worse then yes, or if we had to wait for a helicopter or something like that.

 

[Tigger]

Most of our RSIs happen in the back of a non-moving ambulance prior to transport. Everything is there, plenty of light, and there is a guaranteed second set of hands. Granted we have large Type I ambulances so that makes it much easier. Compared to many houses we find sick patients in I think I'd be inclined to use the ambulance if at all possible.

Did we ever determine if the patient has a gag reflex? I think I agree with those that say they would intubate but not RSI. I think by the time everything is setup and ready to go for a proper RSI we'd be awfully close to the ED doors.

 

[chaz90]

We do most of our RSIs in the back of the ambulance en route to the hospital. Granted, in every single RSI there are two paramedics in the back and one EMT, and every ambulance we work is an enormous boat like apparatus on a medium duty chassis, so we have tons of room. Most people here say they're most comfortable working on a procedure like that in the back of an ambulance since that's what we're most familiar with and it minimizes delays on scene or out of hospital.

If I'm transporting and performing an RSI en route I typically have the driver take us in non emergent or at least pull over as we push drugs and do the intubation. We also do occasional RSIs on scene as we wait for a helicopter or in the back of the ambulance prior to moving. Situation dictates all of these things, and as in most of medicine, absolutes can be dangerous.

 

[SeeNoMore]

Approx 30 percent of people have no gag reflex. If they do testing it can promote vomiting. I am still comfortable rsi ing en route. We intubate regularly with guidance from anesthesia in the OR and regularly in our practice. We have video , a bougie adjuncts , many options for induction , sedation , blood pressure support , surgical airways. I don't see the point of waiting routinely.

 

[SpecialK]

I guess I don't see the point in getting going to hospital only to stop to do something you could have done before you left.

In this specific circumstance, I don't feel it is worth delaying the overall time to reach hospital to perform something that is not absolutely needed right now.

To set up and perform RSI, load the patient and still have 15 minutes to reach hospitals means total time to reach hospital is going to be at least thirty minutes. Her oxygenation is satisfactory using an NPA and a bas mask (I'd change to an LMA) so to RSI her is only going to delay the amount of time it takes to reach hospital. If her airway and/or oxygenation were very poor and could not be managed then I'd take the extra time to perform RSI.

As we are very close to hospital and her airway and oxygenation are satisfactory I'd be comfortable just taking her to hospital.

 

[SeeNoMore]

I feel like we're having a disconnect. I'm advocating RSI en route l. No stopping. No delay. As for this patient , I can see both sides.

 

[medicsb]

I know there is data showing delays to hospital arrival are associated with poor outcomes, but that is for trauma. Taking time to secure an airway post medical arrest is not unreasonable. If there are multiple people on scene (hopefully there is for an arrest), you can set up for the RSI while the patient is being moved in order to decrease scene time. My preference was to RSI in the back of the ambulance when possible. For the actual intubation I'd have the ambulance stop as the goal was for first pass success and I don't see bouncing around in the back being any help.

 

[SeeNoMore]

Well I mean there was just that study showing ALS was worse for almost all patients than BLS and scene times were presented as a possible explanation.

 

[medicsb]

Well I mean there was just that study showing ALS was worse for almost all patients than BLS and scene times were presented as a possible explanation.

The hypotheses generated in the discussion section is the result of brainstorming for an explanation of the findings. It is not evidence. If (IF) one can intubate well, it should not matter if it is done in an ED or in the back of an ambulance in the scenario of post-cardiac arrest. Granted most systems, even those that intubate and RSI, are not actually that good at intubation, then sure maybe better to not do it at all.

 

[Gordon Miller]

How I make my determination to RSI someone are by several questions. 1. Am I taking something away they already have,if the answer to that is yes, I have to have a very good reason to proceed 2. Do they have the ability to clear secretions with out suction and swallow. 3.Is their ETCo2 35-45 measured by a cannula,it's a better indicator or respiratory status than they were breathing 8 times a min. 5.Spo2 6. GCS last due to the fact if all the other questions indicate a need for RSI it's about to be a 3 one way other the other.To me GCS is a poor indicator for the need.7. Difficult airway yes/no and time frame I have to manage this airway 5-10 min transport vs 15-60+ mins.Sometimes I don't have the option to perform an assessment this detailed and just habe to go with my gut.I don't like to do this but on one hand I don't like to
delay scene time and on the other I can't assess lung fields one were in the air. I was not on this call so I really can't answer the question,however the crew did their part well so pretty sure they made the right call.Some seem to make RSI out to be this incredibley dangerous difficult skill ,it's not that the procedure itself that's difficult.Its the decision for the need that's the difficult skill. One thing I would be worried about with this patient is knocking her B/P to nothing from the PPV.I would definitely want ensure that wasn't going to be an issue.Both the ground and air service I work for RSI.