Rsi

[MSDeltaFlt]

My state allows a DAI without paralytic protocol, but my 911 service does not. The state will not allow us until we have complete coverage of capnography with backups for every county we serve.

And we keep growing acquiring some counties that don't have it.

 

[Carlos Danger]

Intubation with only paralytics is bad. Sedation only is what many emergency situations need and can be successfully intubated without paralytics.

A field protocol that allows for intubation with sedation only is a bad idea, IMO. Many hold the view that sedation only is safer than sedation + NMB, but I respectfully and strongly disagree.

If a patient is sedated deeply enough to allow intubation, they will not be protecting their airway adequately, will probably not be breathing adequately if at all, and they can still cough and gag and bite and retch and vomit when you start shoving things down their throat. How is that safer than using using paralysis, where the patient cannot cough, gag, bite, or retch, you have more predictable onset and much more reliable intubating conditions, vomiting is less likely as there is no skeletal muscle tone, and the jaw and head can manipulated at will? Bottom line is that paralytics make intubating easier and quicker, and anything you can do to make intubation easier and quicker will make it safer.

Of course there may be a rare, unusual situation where someone needs to be intubated in the field, yet NMB's are absolutely contraindicated. In that case, you do the best you can with just sedation, and thankfully those scenarios are rare. I do know of a flight program that was doing this and had good results with it, but still I do not think it should be a widespread practice. Personally I would not do sedation-only intubation in emergent, non-NPO patients as a routine practice.

 

[SpecialK]

RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.

They are selected based upon competence at a three part selection process involving

(1) endorsement from their District Operations Manager stating they believe the Officer has ability to pass,
(2) an hour long online exam testing knowledge of the Clinical Practice Guidelines, pharmacology (all medicines within ALS scope), core anatomy and physiology and core pathophysiology, and
(3) a number of assessment stations around assessment, patient management, leadership, clinical decision making and airway/ventilation/failed intubation management; specifically
(a) Simulation – Each person will be a team leader for a scenario involving a critical patient. These scenarios are not particular to RSI, but test ALS skills, knowledge and decision making,
(b) Mini simulation – Each person will be given a scenario with a patient that is not obviously time critical. These will test assessment, differential diagnosis and decision making, and
(c) OSCEs – Each person will undergo about six short skill and/or knowledge assessments (referred to as OSCEs). These will last 5-10 minutes each and are not scenario based. Examples of these OSCEs could include demonstrating a failed intubation drill, cricothyroidotomy, or answering some questions relating to capnography.

If the Officer is successful at all components they are placed on the RSI course which is a learning package consisting of online workshops and some material on DVD plus practical. It has been designed by the Clinical Director who is an Anaesthetist/Intensivist supported by the National Medical Advisor who is an Emergency Physician.

Each RSI or potential RSI must be debriefed with the Clinical Director or Medical Advisor.

Indication for RSI is GCS < 10 with airway or ventilatory compromise and most patients will either have traumatic brain injury or be post-cardiac arrest but others can be stroke, poisoning, DKA (noting a significantly altered level of consciousness with somebody who has DKA is very unlikely), postictal or status epilepticus etc.

Medicine regimen is fentanyl and either midazolam or ketamine and suxamethonium. Post-intubation regimen is vecuronium, morphine and midazolam. There is talk of moving to rocuronium only in 2014.

There is a limit of two attempts and you must be able to visualise vocal cords within 15 seconds of beginning laryngoscopy and intubate within 30 seconds. A bougie is mandatory. Failed intubations are salvaged with an LMA.

To date we have performed over 500 RSI with (my understanding) no surgical airway and near 98% success rate.

RSI can be done properly and safely in Paramedic hands provided it is a small, highly trained and very select group who get adequate ongoing exposure.

These places that just tube people by shovelling midazolam into their drip until they are obtunded enough to accept a tube or just etomidate people into submission should be tried for crimes against humanity.

 

[Craig Alan Evans]

We have been performing RSIs for the last 10-12 years. I can't remember exactly. Every RSI is reviewed by our team of medical directors and they give immediate feedback to the crew. We have every paramedic visit the OR annually sometimes every 2 years to get experience and guidance under an anesthesiologist. So far the program has been very successful with no issues.

 

[MSDeltaFlt]

Intubation with only paralytics is bad. Sedation only is what many emergency situations need and can be successfully intubated without paralytics.

Paralytics now are used only when needed and in the OR for obvious reasons with surgery. In the ICU the use of paralytics for intubated patients had fallen out of favor long ago with the exception of a few hard to ventilate patients or those on hypothermia protocol who will not stop shivering by other means.

A field protocol that allows for intubation with sedation only is a bad idea, IMO. Many hold the view that sedation only is safer than sedation + NMB, but I respectfully and strongly disagree.

If a patient is sedated deeply enough to allow intubation, they will not be protecting their airway adequately, will probably not be breathing adequately if at all, and they can still cough and gag and bite and retch and vomit when you start shoving things down their throat. How is that safer than using using paralysis, where the patient cannot cough, gag, bite, or retch, you have more predictable onset and much more reliable intubating conditions, vomiting is less likely as there is no skeletal muscle tone, and the jaw and head can manipulated at will? Bottom line is that paralytics make intubating easier and quicker, and anything you can do to make intubation easier and quicker will make it safer.

Of course there may be a rare, unusual situation where someone needs to be intubated in the field, yet NMB's are absolutely contraindicated. In that case, you do the best you can with just sedation, and thankfully those scenarios are rare. I do know of a flight program that was doing this and had good results with it, but still I do not think it should be a widespread practice. Personally I would not do sedation-only intubation in emergent, non-NPO patients as a routine practice.

Both of you appear to be saying the same thing. You CAN intubate without paralytics. If after giving the patient narcotics and sedatives the patient stops breathing and lises a gag reflex, why give a paralytic. Although the paralytic needs to be drawn up regardless. However, you had better NEVER paralize the patient without sedating them because thry'd be conscious. And that'd be tantamount to torture.

Where people tend to get confused when intubating is they think that it is an all or nothing scenario. That once you make the decision to intubate thst uou need to "hurry up and do it". Thst when you perform the skill that is all you do. When nothing could be further from the truth. The decision to intubate is based off of your assessment. But you don't stop assessing the patient. You continue to assess the patient throughout the entire procedure that continues far beyond confirmation of proper placement and securing.

You don't hurry up and do this. You slow your @$$ down and do it right.

There's a difference between giving a narcotic and treating pain. There's a difference berween giving a sedative and sedating your patient. And there is a huge difference between intubating and managing your patient's airway.

In my humble opinion, RSI should have sedatives as a requirement and paralytics as an option IF AND ONLY IF the patient does not need it.

 

[Jambi]

RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.

They are selected based upon competence at a three part selection process involving

(1) endorsement from their District Operations Manager stating they believe the Officer has ability to pass,
(2) an hour long online exam testing knowledge of the Clinical Practice Guidelines, pharmacology (all medicines within ALS scope), core anatomy and physiology and core pathophysiology, and
(3) a number of assessment stations around assessment, patient management, leadership, clinical decision making and airway/ventilation/failed intubation management; specifically
(a) Simulation – Each person will be a team leader for a scenario involving a critical patient. These scenarios are not particular to RSI, but test ALS skills, knowledge and decision making,
(b) Mini simulation – Each person will be given a scenario with a patient that is not obviously time critical. These will test assessment, differential diagnosis and decision making, and
(c) OSCEs – Each person will undergo about six short skill and/or knowledge assessments (referred to as OSCEs). These will last 5-10 minutes each and are not scenario based. Examples of these OSCEs could include demonstrating a failed intubation drill, cricothyroidotomy, or answering some questions relating to capnography.

If the Officer is successful at all components they are placed on the RSI course which is a learning package consisting of online workshops and some material on DVD plus practical. It has been designed by the Clinical Director who is an Anaesthetist/Intensivist supported by the National Medical Advisor who is an Emergency Physician.

Each RSI or potential RSI must be debriefed with the Clinical Director or Medical Advisor.

Indication for RSI is GCS < 10 with airway or ventilatory compromise and most patients will either have traumatic brain injury or be post-cardiac arrest but others can be stroke, poisoning, DKA (noting a significantly altered level of consciousness with somebody who has DKA is very unlikely), postictal or status epilepticus etc.

Medicine regimen is fentanyl and either midazolam or ketamine and suxamethonium. Post-intubation regimen is vecuronium, morphine and midazolam. There is talk of moving to rocuronium only in 2014.

There is a limit of two attempts and you must be able to visualise vocal cords within 15 seconds of beginning laryngoscopy and intubate within 30 seconds. A bougie is mandatory. Failed intubations are salvaged with an LMA.

To date we have performed over 500 RSI with (my understanding) no surgical airway and near 98% success rate.

RSI can be done properly and safely in Paramedic hands provided it is a small, highly trained and very select group who get adequate ongoing exposure.

These places that just tube people by shovelling midazolam into their drip until they are obtunded enough to accept a tube or just etomidate people into submission should be tried for crimes against humanity.

This brings a tear of joy to my eye...where do you live?

 

[Medic Tim]

RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.

They are selected based upon competence at a three part selection process involving

(1) endorsement from their District Operations Manager stating they believe the Officer has ability to pass,
(2) an hour long online exam testing knowledge of the Clinical Practice Guidelines, pharmacology (all medicines within ALS scope), core anatomy and physiology and core pathophysiology, and
(3) a number of assessment stations around assessment, patient management, leadership, clinical decision making and airway/ventilation/failed intubation management; specifically
(a) Simulation – Each person will be a team leader for a scenario involving a critical patient. These scenarios are not particular to RSI, but test ALS skills, knowledge and decision making,
(b) Mini simulation – Each person will be given a scenario with a patient that is not obviously time critical. These will test assessment, differential diagnosis and decision making, and
(c) OSCEs – Each person will undergo about six short skill and/or knowledge assessments (referred to as OSCEs). These will last 5-10 minutes each and are not scenario based. Examples of these OSCEs could include demonstrating a failed intubation drill, cricothyroidotomy, or answering some questions relating to capnography.

If the Officer is successful at all components they are placed on the RSI course which is a learning package consisting of online workshops and some material on DVD plus practical. It has been designed by the Clinical Director who is an Anaesthetist/Intensivist supported by the National Medical Advisor who is an Emergency Physician.

Each RSI or potential RSI must be debriefed with the Clinical Director or Medical Advisor.

Indication for RSI is GCS < 10 with airway or ventilatory compromise and most patients will either have traumatic brain injury or be post-cardiac arrest but others can be stroke, poisoning, DKA (noting a significantly altered level of consciousness with somebody who has DKA is very unlikely), postictal or status epilepticus etc.

Medicine regimen is fentanyl and either midazolam or ketamine and suxamethonium. Post-intubation regimen is vecuronium, morphine and midazolam. There is talk of moving to rocuronium only in 2014.

There is a limit of two attempts and you must be able to visualise vocal cords within 15 seconds of beginning laryngoscopy and intubate within 30 seconds. A bougie is mandatory. Failed intubations are salvaged with an LMA.

To date we have performed over 500 RSI with (my understanding) no surgical airway and near 98% success rate.

RSI can be done properly and safely in Paramedic hands provided it is a small, highly trained and very select group who get adequate ongoing exposure.

These places that just tube people by shovelling midazolam into their drip until they are obtunded enough to accept a tube or just etomidate people into submission should be tried for crimes against humanity.

I wish my system was like this

This brings a tear of joy to my eye...where do you live?

I could be wring but I think he or she is from Australia.

 

[Carlos Danger]

If after giving the patient narcotics and sedatives the patient stops breathing and lises a gag reflex, why give a paralytic.

Because NMB's make aspiration less likely and improve intubating conditions, making first-pass success more likely.

You don't know they've lost their gag reflex until you are in the back of the oropharynx with the blade. At that point if their reflexes are still intact, it may be too late because they can wretch and vomit pretty easily.

The RSI technique was developed not just to facilitate intubation - there are other, much gentler techniques if all you need to do is place a tube - but to minimize aspiration risk in high-risk patients.

No question that the procedure shouldn't be rushed, but at the same time you really do need to minimize the time spent with the airway unprotected. That's really the whole point of the "rapid" sequence technique.

 

[DrParasite]

my former hospital based EMS agency did RSI.... my current one doesn't. The reasoning we don't is the same reason our orders from our medical control suck:we are urban and have short transport times, we have a lot of medics with high turnover so evaluating comptance is hard, and when it doubt, just load and go to the ER and the hospital will handle it. We have a lot of doc who will only give M+T orders to sick patients, instead of having our crews treat aggressively. I don't agree with it, but it's above my pay grade,

Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics. If the patient needs to be RSIed, it shouldn't be a gamble if the crew is certified to RSI or not. and I have been one quite a few calls where the patient needed to be RSIed, and was RSIed successfully.

 

[Rialaigh]

Just to play devils advocate I know some very smart and successful medics who treat aggressively who have had RSI in their protocols for years and have never in their career deemed it necessary to RSI a patient and have never had issues otherwise intubating the patients that need it.

It is a tool like everything else. Based on current (generalization) EMS education and provider competence I am not sure it is something that is +EV for EMS as a whole.

I really applaud special K's agency

 

[JPINFV]

Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics. If the patient needs to be RSIed, it shouldn't be a gamble if the crew is certified to RSI or not. and I have been one quite a few calls where the patient needed to be RSIed, and was RSIed successfully.

Then there's the glass half full side. I'd rather take the gamble that the paramedic coming to me can RSI, but might not, than know that the paramedic can't RSI, despite having the skill to do so.

 

[the_negro_puppy]

We have a trauma Doctor that works on a fly-car. They assist higher trained medics with RSI here

 

[Clare]

The service SpecialK describes is the Order of St John New Zealand

 

[Aprz]

Intubation with only paralytics is bad. Sedation only is what many emergency situations need and can be successfully intubated without paralytics.

Paralytics now are used only when needed and in the OR for obvious reasons with surgery. In the ICU the use of paralytics for intubated patients had fallen out of favor long ago with the exception of a few hard to ventilate patients or those on hypothermia protocol who will not stop shivering by other means.

I'm talking about initially, the use of only sedation without a paralytic prior to intubation. It's very obvious why using paralytics only without sedation is a bad idea, but not the other way around. When I start the HOWTO Rapid Sequence Induction (RSI) thread, I was also looking at other sources on how to RSI, and I read that sedation-only intubation, "Facilitated Intubation", was associated with lower success rate, higher mortality rates in traumatic brain injury (TBI) patients, and a high incidence of hypotension, which would make sense why it didn't work out too well for patients with TBI. I don't know how for sure, but I suspect increase parasympathetic response and/or laryngospasm during laryngoscopy if paralytics prevent that better than sedatives (I don't know).

 

[Clipper1]

TBI might be the exception for prehospital which was the group studied. But that is not true for all medical patients.

 

[Carlos Danger]

Not for nothing, but RSI should be agency wide; either you call can do it or those that can't shouldn't be paramedics.

What is the rationale behind your "everybody or nobody" position?

Would you have those who do have the experience and judgement not be allowed to use it, just because others aren't as capable?

 

[DrParasite]

What is the rationale behind your "everybody or nobody" position?

Would you have those who do have the experience and judgement not be allowed to use it, just because others aren't as capable?

As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice. Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.

would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies? What about needle decompressions? What about d50? maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"

Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome. Think I can get a jury to feel sorry enough for your bad choices to award me a few million?

 

[Aprz]

As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice. Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.

would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies? What about needle decompressions? What about d50? maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"

Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome. Think I can get a jury to feel sorry enough for your bad choices to award me a few million?

I dunno if you could successfully sue. It's kinda the same thing with tiered response with whether the ambulance should be sent code 2 or code 3, and if they should be BLS or ALS. I think it would better to only allow the ones who can do it do it, and the ones who can't do it, not be allowed to do it. Obvious if everyone could be trained in it, that would be awesome, and probably a selling point with an agency, but I think for now since it seems to be a difficult thing for paramedics, I don't see a problem with allowing only some to do it.

 

[Clipper1]

As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice. Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.

would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies? What about needle decompressions? What about d50? maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"

Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome. Think I can get a jury to feel sorry enough for your bad choices to award me a few million?

You can try to sue but it is doubtful you will get anywhere.

I want a truck with 2 Paramedics but get one with just 1 and an EMT because of staffing issues. Can I sue? Probably not.

I want to go to the cath lab at the hospital 2 blocks further when I have chest pain but your protocol says "closest facility" which is where you take me. Can I sue? I could but you did what your protocols said. Your medical director probably had a reason for writing them.

I work for an EMS agency across town which allows me to RSI or do pericardiocentesis but moonlight at another which does not. Can I do my advanced skills "to save a life" when at the other agency? No. This has already be challenged in many cases.

Only about half the ALS agencies in the US do 12 Lead ECGs. Should a patient sue if he happens to have chest pain in the area where they do not have that ability? Only about half of the states allow RSI. If you cross the state line and have expectations of equal care of what you have read about some of the best EMS agenices, what happens when you find out you not all are created equal?

And, shouldn't all EMT-Bs be allowed to do glucose monitoring? Why should a patient have to wait for an ALS intercept just for a finger stick?

A doctor might have privileges to intubate had one hospital but has not been given that privilege at the hospital across the street. The person who has met the standards for intubation at that hospital will be called to intubate.

By your argument every doctor in a hospital should be neurosurgeons if the patient needed neurosurgery.

After reading the many, many posts on just this forum about how protocols differ from state to state, county to county, city to city and from one side of the street to the other with different agencies, some probably should be in court all the time. But, just like any other health care profession and facility, only those qualified should be performing the skill. Only if it is a written mandate to have an RSI qualified Paramedic on every call would there be an issue. This is seen by the expectations of a company promising an ambulance in 6 minutes or less. Most of the time it is also the EMTs or Paramedics raising the questions rather than the public because they want more staffing or to be allowed to do things they have not be trained for and may not want to put forth the effort after being trained to maintain those skills. There have also been many examples of that which intubation proficiency is one good example. Should the patients also sue when intubation privilege is removed from the skillset? Or, since it can be argued a safety issue, do they have any grounds for the suit?

 

[Carlos Danger]

As a patient, when i call an ambulance, I want an ambulance. If I need to be RSIed, and the paramedic crew can't do what is needed (but the other crew could have, if they were sent), then the service has done me a disservice. Of course, we didn't know this until a paramedic arrived and determined that RSI was needed.

would you only allow some paramedics at an agency to intubate, because intubation rates suck prehospitally according to several studies? What about needle decompressions? What about d50? maybe even 12 leads or direct admits to the cath lab? and then how do you select who gets the "full trained and can do everything" paramedics, and who gets the "everything but a potentially life saving skill?"

Or lets take the litigious concept: I need to be RSIed, but the crew you send to me can't RSI.... so I am going to sue your agency for sending a crew that couldn't help me in my time of need, when if they had sent me another one of their crews I would have had a much better outcome. Think I can get a jury to feel sorry enough for your bad choices to award me a few million?

To your second paragraph:

First of all, you are comparing apples and oranges. Pushing D50 or obtaining a 12-lead has very little in comparison to RSI, in terms of the training needed and the risk to the patient. If you can't see the difference between the gravity of RSI vs. that of obtaining a 12-lead, then I'm at a loss.

The important point you are missing is that all paramedics are simply not all the same in terms of training and experience and competency. If you haven't learned that reality yet, you will when you are more experienced.

If a medical director wanted to require his paramedics to have a certain number of year's experience before they could RSI, and a certain amount of time with the agency, and to complete a time-consuming training program first, I think that'd be pretty responsible and reasonable, and probably well in line with what the literature indicates is necessary for a successful RSI program. If he wanted to suspend RSI from individuals who don't meet certain continuing training or competency criteria, I think that's quite reasonable, too. These requirements would probably result in not all the paramedics at a given agency being able to RSI, but I don't know how you'd argue it's not a reasonable process or that it's not in the best interest of patients, or that it puts the agency at legal risk somehow.


To your last paragraph:

I'd like to see Wes weigh in on this, but I think there'd be a very slim chance you could successfully sue. If you could, it would set a precedent that every EMS agency and every hospital would essentially be responsible for following the same protocols and offering the same services, procedures, and interventions, because anyone who didn't do something that someone else did could be sued. Go to a hospital that doesn't offer the same procedure as another one? Sue 'em. Call EMS and they don't have the same drugs that another agency does? Sue 'em. Think that is good for patients? Or for the EMS profession?

Most importantly, order to successfully sue, you'd have to show damages resulting from the paramedic's action or inaction. I suppose it is plausible you could argue that damages resulted from the paramedic's inability to RSI - rather than from the disease process - but that would be an uphill battle, I think. The EMS agency's lawyers would counter-argue that much of the literature shows that prehospital RSI is unsafe and doesn't improve outcomes (it is, in reality, inconclusive at best), and therefore having it in the protocols does more harm than good and this patient would very possibly have been even more seriously injured by it. Expert witnesses will explain that paramedics in general aren't good at RSI and even when they do it right, it doesn't improve outcomes.