RSI Medications and Use

[NightShiftMedic]

Now, the duration of paralysis doesn't really matter in a truly emergent airway, because if someone really NEEDS their airway secured, then you are going to do it no matter what, which of course means a cric if intubation and an SGA fails. The problem with applying that reasoning routinely (and thus making a policy of using a long-acting NMB for every RSI) is that many RSI's are actually elective and not truly emergent. On the surface that may seem like semantics, but it's really not......I think there's a big difference, ethically speaking, between exposing someone to the risk of cutting their neck because you found them in a way that necessitates it, and electively choosing to put them in a position where you will have no choice but to cut their neck if your skills aren't up to what their airway requires. Also, even though roc is pretty quick at the 1.2 mg/kg dose, it still isn't as quick and predictable as sux. If you are really worried about someone being a tough airway and desaturating quickly, I'd much prefer the drug with the 30 second faster onset at the larynx.

These are really good points. In general, I would say the majority of my RSI's are elective and are done in the ED before admission or in a remote clinic before a medevac flight due to combativeness or because I question my ability to manage their airway in the confines of the aircraft. In general I prefer to use sux over roc due to the faster onset and because it's elective and thus I can bag them until it wears off if I get into trouble. If I don't think I can bag them I won't electively intubate them, end of sentence, hard stop. I prefer roc in head injuries because fasciculations from sux can cause an increase in intracranial pressure even when measures to mitigate this effect from the laryngoscopy itself are taken.

In most circumstances I try to avoid paralyzing the patient after intubating them. I feel that as long as they're adequately sedated, their pain is managed, they're breathing effectively, and the ventilator settings are appropriate for it then why not let them breathe?

We have gone waaay overboard with the "if you even consider intubation, you should do it, and if you can't get it, no biggie, just slice their neck open" thing.

This is so true. A fair amount of people I work with think this way. It's asking for trouble.

 

[jwk]

Really - I thought that was no longer used?

Still around. Like I said, it's cheap, which to some make it the preferred drug despite the unwanted side effects.

 

[usalsfyre]

It's been a while since I've been in here, and I'll only add this. If "bagging them and letting the meds wear off" is truly an acceptable option during an out-of-hospital intubation, you screwed up on patient selection.