Versed as a sole RSI agent

Doesnt matter how many calls you do a year if your providers are barely homeostasasing Parathinktheyares who got thier certification down at the local medic mill or out the Weet Bix box and have been left to rot by having to ring up on the Johnny and Roy phone evey two seconds or where the hospital is five minutes down the road.

These are the sorts of things people who are halfwy to being trusted with RSI can answer ....

Describe the sliding fillament theory of muscle contraction and synaptic transfer/release of ACh?

Explain the significance of postassium and in particular hyperkalemia in [ab]normal cardiac conduction?

Compare and contrast the factors to be considered when choosing an induction agent including physiologic presentation, side effect, mechanisim of action and duration?

Outline the quality assurance process and best practices for peer-reviewed medical audit?

Discuss the factors to be considered when assessing need for airway intervention? How might these factors be considered in context of the larger clinical picture?

... and so on and so on and that is without even considering the continuing praxis development and oversight parts of the program.
 
I have nothing againt you or your department. You solicited opinions and I responded with the best information I have.

mso_kirk said:
Perhaps I'm not explaining our demographics and circumstances well enough, but it probably doesn't matter in the long run. The person we have to convince is the doc, not the people here. ;)
Click to expand...

A famous lawyer whos name I cannot recall once said "no jury is tougher than a jury of your peers."

mso_kirk said:
We are a busy municipal department that runs over 6000 ALS calls per year in an all career department.
Click to expand...

Just to put this in perspective, one of the busiest departments I worked for had some of the worst providers I ever saw at all levels of the organization. It is still the epitomy of a skills based service.

16 ALS calls a day average in your whole service.

I must apologize, but I am not impressed by that volume unless you have only 1 vehicle on the road. I have years of experience on units that routinely saw 14 ALS calls in a shift as well as an ED that saw 94,000 patients a year.

Which brings us to: "What is considered an ALS call?" Starting an IV is an ALS call, but does not automatically mean a life threatening emergency. Giving your agency an extreme benefit, lets call 10% (double the accepted average) of your total calls "true emergencies" that is 600 a year/ 365 that is 1.64 a day divided by how many providers?

mso_kirk said:
The reason that I was comparing us to surrounding agencies is that we have tiny volunteer departments surrounding us that run 100 calls a year that have protocols 100 times more advanced than ours (including RSI and even things like placing central lines) that we don't have. In my mind, clearly we have the need and our paramedics certainly have the knowledge base and education. In fact, we've trained most of the paramedics in these outlying areas.
Click to expand...

One reason they might have more advanced protocols is they have fewer providers which allows greater oversight. They may also have a more involved medical director. A medical director more involved with EMS. There are just too many variables to make a reasonable comparison here.

mso_kirk said:
In any case, we may have a trump card, so to speak. My chief advised me today he has a lead on a new doctor in town who has expressed interest in taking over the medical oversight role. Apparently he's a former medic and has already expressed concern at what our protocols are lacking..
Click to expand...

That is probably the best thing your service could hope for. Not as desirable, but probably also beneficial, even if this doc became an assistant medical director and could devote more time to your organization.

mso_kirk said:
I guess if you can't get the top guy to give you what you want or need, you fire him and replace him with somebody who will.
Click to expand...

Perhaps what you want, I hope there is a need. Just to be the devil's advocate, what if your wants conflict with the needs of the patients and system?

You mentioned several skills, like RSI and central lines.

I can find no benefit in a field placed central line unless you are giving blood. In an emergency that requires vascular access, a peripheral line or IO is faster, safer, and has been demonstrated as beneficial.

Several years ago one of the more respectable flight services in the US removed chest tubes from its scene response protocols after an internal study demonstrated poorer outcomes than needle decompression.

Surgery was once performed in the pts home. That didn't make it best practice.

I encourage you, do not become overly engrossed in skills or procedures. By your own comments, many of your protocols are outdated. Do you think it might be a better use of effort to try and update those first before worrying about something as grand as RSI?

I am not against you or your agency, but in my not always humble opinion, advice from people who can be brutally honest or tell you why your idea is bad is much better than advice from a bunch of "go team! yes men." I recall a time when Colin Powell was the only dissenting voice for going to war in Iraq.
 
Yes, we run that amount of calls out of one station with one ambulance, although occasionally we have to use a backup rig if our first out is on a long transport.

I understand what you're saying, and RSI is probably more symbolic of much wider problems (things like having to call in to be able to give pain control, etc). We use RSI as the example, but there are a lot of smaller things that we lack that cause bigger problems. But RSI is still no small issue as we've all had it beat in to our heads since school that controlling the airway is our most important goal. If you can't do that, we were taught, you're screwed. Last year alone we identified six patients (through our own internal QA process) that we believe died because of our inability to secure an airway during a long transport. Four were drug overdoses and two were traumas.

Hopefully we can get some changes in place to improve the treatment we're able to offer our patients.
 
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mso_kirk said:
Yes, we run that amount of calls out of one station with one ambulance, although occasionally we have to use a backup rig if our first out is on a long transport.

I understand what you're saying, and RSI is probably more symbolic of much wider problems (things like having to call in to be able to give pain control, etc). We use RSI as the example, but there are a lot of smaller things that we lack that cause bigger problems. But RSI is still no small issue as we've all had it beat in to our heads since school that controlling the airway is our most important goal. If you can't do that, we were taught, you're screwed. Last year alone we identified six patients (through our own internal QA process) that we believe died because of our inability to secure an airway during a long transport. Four were drug overdoses and two were traumas.

Hopefully we can get some changes in place to improve the treatment we're able to offer our patients.
Click to expand...

6 out of 6K is a very admirable number.

If I might inquire, what were the problems in securing the airways?
 
I don't recall all of the details right now as they weren't my patients (I drive a desk these days). I remember the trauma ones. I know that one of the trauma patients had trismus of some sort and they couldn't get him relaxed enough to use a laryngoscope. The other one had significant bleeding in the airway and an intact gag. One of the drug ODs was a barbiturate patient that had enough of a gag that they couldn't intubate. Halfway in on the transport he vomited and aspirated and the resultant hypoxia led to his death several days later. Unfortunately we don't have surgical airways or combitubes either.

In my days as a street medic, I remember one patient where Anectine really saved my butt and the patient. Severe asthma and the guy just locked down within seconds. At the time we had strict orders that we had to check in with medical control before we could RSI. I couldn't reach them with the limited cell phone coverage we had at the time, so I just did it anyway (we had tried some sub-q epi but it wasn't working). He relaxed enough to get him intubated, after which time I shot some 1:1000 epi down the tube, which was an off protocol use. It opened him up like liquid Drano on a plugged sink. Medical director told me I was lucky that it all worked out because otherwise he would have gone after my license. Ah, the good old days. Now I get to sit at a desk and Monday morning quarterback everyone else's calls. :rolleyes:
 
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I forgot about the previous comment on central lines as well. Our MPD at my old department was a big believer in them. I started two in my career as a street medic (we were allowed to start sub-clavians only). One was a trauma patient we couldn't get a peripheral line in and needed to get some fluids on board. The other was a simple medical cardiac arrest that we also couldn't get a peripheral line in. I don't remember after all of these years if it made a difference or not. I know the cardiac arrest patient died and the trauma patient lived, but maybe despite my efforts for all I know.
 
mso_kirk said:
One of the drug ODs was a barbiturate patient that had enough of a gag that they couldn't intubate.
Click to expand...

Is this supposed to be a joke to mess with me?

A barbiturate OD with a gag reflex? I am not sure that is even possible.

Barbiturates:

Prolong Cl- channel openings (enhancing GABAergic transmission) (inhibitory) GABA receptors are also found on skeletal muscle and inhibit the release of Calcium from the sarcoplasmic reticulum, which reduces spastic muscle tone. (like a gag reflex)

Directly blocks glutamate (excitatory) receptors

Directly blocks Sodium Channels

At theraputic doses barbiturates are used medically to induce anesthesia and coma. At a different binding site on the same receptor and slightly different action than a benzo. (like versed)

The most commonly prescribed Barbiturate was phenobarbital for seizure disorders, so it is most likely to appear on the street. Its effects last up to days and is measured in hours.



Was this an interfacilty transport after somebody treated the OD?

There was no NPA and BVM?

This really seems off the hook.
 
Not a joke. The patient wasn't OD'd to the point of being comatose, but semi-conscious with decreased respirations. They tried to scope him but he kept biting down enough to obscure the view. The report said they were bagging him semi-successfully but not enough to keep the sats up, but then he started vomiting like a geyser and then they had a hell of time keeping him ventilated. I had a similar case with a beta blocker overdose myself, but then again I had Anectine and was able to get the patient intubated eventually. I have no idea if they were using an NPA.
 
A couple of thoughts here.

1. Rapid Sequence Induction (and it's offspring, rapid sequence intubation) was devloped to prevent active regurgitation in the non-NPO patient during instrumentation of their airway. PERIOD. It is not for trismus or "hard tubes" (as I heard one idiot put it). The side effect/benefit is optimal intubating conditions at lower sedative doses, but it is certainly possible to snow almost anyone to the point you can intubate them. Just look out for the puke.

2. The 'barb overdose you described almost certainly puked from gastric distension related to poor BVM technique/poor laryngoscopy technique. A NG tube, couple of nasal trumpets and two people on the BVM might have been as or more effective at controling his airway. The guy with bleeding in his airway may have very well needed a cric more than RSI, is that going to be part of the bargin?

3. What are you doing wanting RSI if you don't even have appropriate rescue airways? This is a good way to start depopulating your service area.

4. What are you overall and first pass success rates? If they're not both in the 90%s (and overall better be in the high 90s), what makes you think your department is ready for RSI?

5. I'm much more impressed by a service that has adaquately pain management and sedation protocols, CPAP, strong education and QA and realizes RSI is more than they can handle than a half-@ssed RSI program. If y'all don't take airway seriously enough to have a back-up device, I suspect the latter is what your looking for.

There is no halfway here. Do it right, or kill patients.
 
What I could find on this in my anesthesia resources states that if ineffective doses of barbiturate are given, laryngospasm may be induced by an OPA, suction tip, LMA or ET tube.

Which sounds suspiciously like it was the attempt at intubating (read more so than improper bagging and gastric distension) that triggered the vomiting. More so if you consider that the neuro vomiting centers would be depressed considerably more than the respiratory centers and only local stimuli of the intact reflexes would be working.

"Ineffective dose" does not sound like an OD to me.

The same sources also state that the gag reflex will return after the duration of action of the barbiturate starts to wear off.

It is exactly the same case for succinylcholine and the nondepolarizing agents.

So the patient will still have to be further sedated to keep the tube in.

A sedative like a benzo is often used. However, a dose of barbiturate amplifies the benzo effect and duration.

So why not just cut out the middleman and add some benzo to the Barb OD and pass the tube? It would even last longer. That also makes the use of the neuromuscular blocker superfulous

I still do not see how somebody took enough barbiturate to be overdosed and still have some kind of gag reflex, because that would mean the effect of the barb was not extremely strong or wearing off.

I am also of the mind that an intact gag reflex is self protective of an airway.

If the obstruction was the tongue, just like in severe ETOH intoxication, benzo, and opioid OD, the NPA would be the device of choice. Was a manual airway maneuver used and maintained? Was the patient supine? See the issues there?

Perhaps like a benzo or opioid OD, it is just better to bag them until they come around?

To once again steal a quote from one of my lecturers,

"No one ever died from not having a plastic tube in their throat"

I agree with USALSFYRE about the guy with the bleeding airway needing a cric. If there was so much blood, the bubbling might be the only indication as to where the airway is. How does a neuromuscular block fix all the blood? Wouldn't suction be better?


Upon researching this possibility deeper from this discussion, I think RSI is definatly not something your organization should be pursuing trying to keep up with the Joneses or as a merit badge of how advanced your service is.

Sounds like your service gets along without RSI anyway.

As for central lines,

the femoral is a safer route than subclavian, there are a lot of important structures up there. Not to mention creating a potential pneumo.

Since fluids only definitively helps in stage I shock, transiently in stage II, and not at all in stage III or IV. it sounds to me like "needed to get fluids on board" might have been a conclusion based on what was thought to be true some time ago and disproven in the civilian world and 2 wars. ( by almost a decade now)

Rather than the medical director who understands a bit more, maybe it is time to look at replacing some of the providers?

Sorry to say, but your case for RSI is just getting worse. Perhaps the overall situation there is not as golden as it may appear because you run a lot of calls and probably why the surrounding volunteers seem more advanced?
 
Sorry mate you are going to have to keep calling on Brown and Oz in the funny orange getup to swann out the sky in thier flying contraption to come anaesthetise and intubate people.

If anybody is interested our procedure for RSI is as follows:

6.3 RAPID SEQUENCE INTUBATION (RSI)
• Indicated for patients with a GCS <10 with airway or ventilatory compromise.

• Absolute contraindications:
a. Known history or family history of malignant hyperthermia or
b. Paraplegics/quadriplegics or
c. Any muscle disorder with long term weakness or
d. Hyperkalemia strongly suspected or
e. Electronic capnography unavailable or
f. No dedicated suitable assistant (2nd AP preferred).

• Relative contraindications:
a. Age < 5 or > 75 yrs or
b. Age > 75 years with stroke or COAD as underlying cause or
c. Predicted difficult airway or
d. Less than 15 minutes to hospital or
e. Underlying cause is likely to rapidly improve e.g. GHB poisoning or post seizure.

• Preparation:
a. Assess the patient for signs of difficult intubation.
b. Prepare all equipment and brief assistant.
c. Draw up and label drugs, ensure running IV line.
d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP.
e. Pre-oxygenate for 3 minutes with 100% oxygen via manual ventilation bag.
If unable to pre-oxygenate administer 6 large breaths immediately after apnoea occurs.

• Medicines:
a. Give IV fentanyl over 1 minute, 2-3 minutes before induction.
b. Regimen 1. For all patients with neurological cause for coma
(e.g. TBI, stroke, post cardiac arrest) that do not have significant
shock - give IV midazolam and IV suxamethonium.
c. Regimen 2. For all other patients and particularly for those with
shock – give IV ketamine and IV suxamethonium.

• Intubate and confirm ETT position with capnography.
• If unable to intubate implement failed intubation drill.
• Give IV vecuronium once ETT confirmed in trachea.
• Ventilate to ETCO2 30-35 mmHg (exception – life threatening
asthma, ventilate at 6 breaths/min and ignore ETCO2).
• Give additional sedation (midazolam 1-3 mg and morphine 1-3
mg) and vecuronium as required.

RSI Drug Doses
• Fentanyl: 1mcg/kg (max 100mcg)
• Midazolam: 0.1mg/kg (max 5mg)
• Ketamine: 1.5mg/kg (max 150mg)
• Suxamethonium: 1.5mg/kg (max 150mg)
• Vecuronium: 0.1mg/kg (max 10mg)

• *Halve fentanyl and midazolam dose if: age > 60 yrs, or HR > 100/min or systolic BP < 100mmHg.
• Round the patients weight to the nearest 10 kg.
• Midazolam must be given using 1 mg/ml in a 5ml syringe.
• Ketamine must be diluted to 10 mg/ml in a 20ml syringe.
• Vecuronium must be diluted to 1 mg/ml in a 10ml syringe.
• Fentanyl in children must be diluted to 10 mcg/ml in a 10ml syringe.
• Suxamethonium in children must be diluted to 10 mg/ml in a 10ml syringe.
 
MrBrown said:
Sorry mate you are going to have to keep calling on Brown and Oz in the funny orange getup to swann out the sky in thier flying contraption to come anaesthetise and intubate people.

If anybody is interested our procedure for RSI is as follows:

6.3 RAPID SEQUENCE INTUBATION (RSI)
• Indicated for patients with a GCS <10 with airway or ventilatory compromise.

• Absolute contraindications:
a. Known history or family history of malignant hyperthermia or
b. Paraplegics/quadriplegics or
c. Any muscle disorder with long term weakness or
d. Hyperkalemia strongly suspected or
e. Electronic capnography unavailable or
f. No dedicated suitable assistant (2nd AP preferred).

• Relative contraindications:
a. Age < 5 or > 75 yrs or
b. Age > 75 years with stroke or COAD as underlying cause or
c. Predicted difficult airway or
d. Less than 15 minutes to hospital or
e. Underlying cause is likely to rapidly improve e.g. GHB poisoning or post seizure.

• Preparation:
a. Assess the patient for signs of difficult intubation.
b. Prepare all equipment and brief assistant.
c. Draw up and label drugs, ensure running IV line.
d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP.
e. Pre-oxygenate for 3 minutes with 100% oxygen via manual ventilation bag.
If unable to pre-oxygenate administer 6 large breaths immediately after apnoea occurs.

• Medicines:
a. Give IV fentanyl over 1 minute, 2-3 minutes before induction.
b. Regimen 1. For all patients with neurological cause for coma
(e.g. TBI, stroke, post cardiac arrest) that do not have significant
shock - give IV midazolam and IV suxamethonium.
c. Regimen 2. For all other patients and particularly for those with
shock – give IV ketamine and IV suxamethonium.

• Intubate and confirm ETT position with capnography.
• If unable to intubate implement failed intubation drill.
• Give IV vecuronium once ETT confirmed in trachea.
• Ventilate to ETCO2 30-35 mmHg (exception – life threatening
asthma, ventilate at 6 breaths/min and ignore ETCO2).
• Give additional sedation (midazolam 1-3 mg and morphine 1-3
mg) and vecuronium as required.

RSI Drug Doses
• Fentanyl: 1mcg/kg (max 100mcg)
• Midazolam: 0.1mg/kg (max 5mg)
• Ketamine: 1.5mg/kg (max 150mg)
• Suxamethonium: 1.5mg/kg (max 150mg)
• Vecuronium: 0.1mg/kg (max 10mg)

• *Halve fentanyl and midazolam dose if: age > 60 yrs, or HR > 100/min or systolic BP < 100mmHg.
• Round the patients weight to the nearest 10 kg.
• Midazolam must be given using 1 mg/ml in a 5ml syringe.
• Ketamine must be diluted to 10 mg/ml in a 20ml syringe.
• Vecuronium must be diluted to 1 mg/ml in a 10ml syringe.
• Fentanyl in children must be diluted to 10 mcg/ml in a 10ml syringe.
• Suxamethonium in children must be diluted to 10 mg/ml in a 10ml syringe.
Click to expand...

Mate you're welcome to start inducing people. But Oz is going to stick with bumped knees and hypos until he's got the brain learnin' for sick people :-)
 
Melclin said:
Mate you're welcome to start inducing people. But Oz is going to stick with bumped knees and hypos until he's got the brain learnin' for sick people :-)
Click to expand...

Thats why Browns jumpsuit says "DOCTOR" and yours ..... does not :D
 
So how much midazolam are you going to give? What about if your patient is head injured or has shock how much is your dose going to differ? Lets say your midazolam does not work and you cannot intubate them what are you going to do?

Bloody Parathinktheyares and thier bootleg ghetto drug assisted intubation
 
Brown-- only 1mcg/kg of Fent? Seems low. 1mcg/kg is more like for pain and not a pre-medication for RSI?

We pre-medicate with 3mcg/kg Fent, induce with 0.3mg/kg Etomidate, and paralyze with 1mg/kg Roc. We also have Versed and Ativan to which we can call in if we think either would be better than Etomidate.


But we have not only RSI, but also difficult airway in which we just do DAI with a sedative and not a paralytic.

Here's our RSI guideline

rsi.png
 
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Linuss, don't forget we also have awake intubation as an option. If the airway is going to be that difficult I'd much rather neb some lido and look prior to giving anything that can cause apnea.
 
Brown, if Veneficus has faith in you....well, I'll go with it. You're both awesome. Love readining your posts. Now, go back to sleep.
 
MrBrown said:
So how much midazolam are you going to give? What about if your patient is head injured or has shock how much is your dose going to differ? Lets say your midazolam does not work and you cannot intubate them what are you going to do?

Bloody Parathinktheyares and thier bootleg ghetto drug assisted intubation
Click to expand...

That is why it says "consider four factors" and is benefit > risk. Versed is contraindicated in head injury and shock so I would not even consider it
 
rhan101277 said:
Versed is contraindicated in head injury...
Click to expand...

Considering it's one of the leading agents for post-intubation sedation, I'm not sure where this is coming from. Hypotension is contraindicated in head-injury, not midaz specifically.
 
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