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Intubation in 2012


BAYAMedic

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We all know that paramedic intubation is a point of contention globally. The fact it is a diminishing skill, and OR's are hard to get time in, and historically a bad percentage of recognized gut tubes are all valid points. However, I live in an area that it is common to get one to two tubes (or more) per medic per month so proficiency here, is better than some areas.

I want to open the floor to discussion on airway management and the protocols you have for RSI, Etomidate only intubation, and code only intubation. I hope we can, in this discussion, discuss drugs and sedation and doses thereof, Tools utilized: conventional, archaic and cutting edge. I would even like to discuss the supraglottic options.

I know many, if not all has been discussed in the past, but this forum hasn't had the activity as of late, so I would like to have a good old fashioned debate about this stuff. Any takers?

BAYAMedic

*edit* Typo, no content changes

Edited by BAYAMedic
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What, specifically, would you like to discuss?

I also work in a system with multiple tube opportunities per month, plentiful OR time, including opportunities to intubate pediatric patients in the OR, Decent, if not exactly progressive, RSI protocols, and plenty of tools to get the job done.

Intubation and RSI is not an issue for our service. Our first pass success rate is in the high 90s.

It doesn't seem like there's much to debate. If the system trains the medics adequately, provides opportunities for frequent practice, has a robust QI process... It works well. Systems that infrequently intubate and even more infrequently use RSI will have issues.

Sent from my iPhone using Tapatalk. Sorry for any spelling errors.

Edited by n7lxi
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Ok guys, lets start with pre-intubation meds.

My protocols give me the option for Etomidate 0.3mg/kg, or Ketamine 2mg/kg (if etomidate not available)

Anectine 2mg/kg for Induction, with Vecuronium (very rarly used) at 0.05mg/kg (Continued, detrimental agitation in the intubated patient that does not respond to midazolam and analgesia.)

Versed for post intubation sedation. 2-4mg every 5 minutes.

How many of you have rocuronium or other non-depolarizing paralytic for initial intubation? LIke wise does anyone have Propofol or other seditive in the field?

Please post if your protocol varies from mine

BAYAMedic

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At the last place I worked before school took over my life:

Etomidate or ketamine at the same doses listed,

Succinylcholine 1.5mg/kg

Intubate

Versed 0.1mg/kg

Vecuronium 0.1 mg/kg

Fentanyl 1-2 mcg/kg or morphine 0.1 mg/kg

Every RSI went through a five level QA/QI process that ended with the medical director's review. We consistently had a 98-100% first time pass rate for our airway management.

We did carry propofol but couldn't use it for post RSI sedation.

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Neuro interfacility transports. The docs at the receiving hospital to which we did most of our transfers liked that they could turn it of, wait a minute for the patient to wake up, conduct their assessment and then sedate the patient again.

Or if we were transporting someone already on propofol we could continue it.

For prehospital uses, however, it was forbidden.

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We have intubation per provider discretion, no requirements to tube if it's code blue, and I average about one tube a month more or less. No other opportunities for OR intubation practice, dubious whether or not we could get them to pass Fred the Head around, and we're saturated with a high number of paramedics (x2 per truck) plus we have two medic captains per shift who race to every critical call (and who love to intubate). No RSI.

So yeah, it's amazing that our intubation success rates are as good as they are.

Given that it's unnecessary in the vast majority of code blues, and we have increasingly more successful means of airway management for serious respiratory conditions, as well as the difficulty in trying to keep over a hundred paramedics competent in it, I wouldn't be surprised if intubation gets pulled for everyone but, say, the medic captains within the next five years.

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Given that it's unnecessary in the vast majority of code blues, and we have increasingly more successful means of airway management for serious respiratory conditions, as well as the difficulty in trying to keep over a hundred paramedics competent in it, I wouldn't be surprised if intubation gets pulled for everyone but, say, the medic captains within the next five years.

I can see this happening in more than just your system. I even understand the reasoning and logic behind it. What troubles me is that when you leave your most senior people with the ability to perform this skill those people aren't necessarily arround in the time critical incidents when it's needed.

Unfortunately, given the politics involved I see a huge fight on our hands to bring education up to the level where this isn't an issue as opposed to the easy way out of just removing the education and skill set.

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Protocol for RSI

1. IV Fentanyl (1mcg/kg) 2-3min before induction

2. It pt has shock then IV Ketamine (1.5mg/kg) and IV Suxamethonium (1..5mg/kg). If pt does not have shock then IV Midazolam (0.05mg/kg) and IV Suxamenthonium (1.5mg/kg)

3. Intubate and confirm tube placement with ETCO2

4. Give 10mg IV Vecuronium

5. Give ongoing sedation (1-3mg midazolam and 1-3mg morphine every 3-5min)

Standard Intubation

Follow steps 3-5 (only if pt not in cardiac arrest, otherwise just tube and ventilate then follow 3-5 if you get ROSC).

Only a few select people are trained for RSI so they get a lot of practice. Only issue is that they often aren't around when you need them. Everyone else gets plenty of opportunities to tube as a general rule. Either on-road or at hospital if they want. Success rate is very high.

Edited by HarryM
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Supraglottic airways, particularly the second generation devices have really shaped contemporary EMS practice IMHO. Now that we have reliable alternatives to intubation that can effectively be used by people with less education, critics of pre-hospital intubation have even more ammunition. While the visceral response to criticism is anger and denial, I believe that continued research and criticism of high risk procedures will only help us identify the efficacy, safety and educational requirements for implementing said procedures.

On a side note: I am one of three people currently performing a study comparing three of the contemporary supraglottic devices that are being used by EMS services around the United States. My hope is to have it completed by the end of this year and possibly published next year.

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