paramedic_32647

@ Systemet....thanks for your input! I guess what is concering to me the most is the vecuronium prior to intubation.....I would prefer Rocuronium over Vecuronium just because Roc usually only lasts about 20 mins, where Vecuronium can last up to 40 or more! It is good to have back up airways, but what if they fail!? Without a secured airway, it can be very difficult to ventilate a patient with respiratory conditions like COPD or Asthma....just seems very scary to me, but maybe I am wrong!!!!

If you are doing this to present an argument to your medical director, I recommend you tread very lightly. A lot of the latest research looks bad for prehospital RSI, and intubation in general. Is there any reason they are using versed over etomidate? Etomidate is quicker on/quicker off if things go bad. From personal experience, it works much better for sedation anyway. If you adequately sedate there is no reason to complicate things by adding more meds such as an analgesic. I'm a simple person and like to keep things simple. If someone is being RSI'd they are sick to begin with. You are now going to throw a bunch of meds at them. If they deteriorate, how will you be able to decide if it is from there underlying disease versus medication issues? I'm also not a big fan of pharmacologically assisted intubation. You either go all in, or not at all (yes, I realize there are exception, but as a general rule). If they are going to have you sedate and quasi-paralyze, why not just go all the way and make sure it is done correctly to optimize your chances of success? In that case, the sux would be a much better option as it is quick on/quick off. There are a few instances where it may not be the best option but more often it will be fine.

I am not trying to put down our medical director AT ALL! We are just a small agency and we transport to a smaller hospital. This is just to find out if anyone thinks there would be better medications to use. Most city agencies do not allow their providers to do RSI unless you are a EMS Supervisor. A little hesitant of going to our OMD. One I do not have that power, there is a chain of command. I just think by hearing other physicians/ems providers experiences with RSI will help answer some of my questions. I mean there very well could be strong reasons why our OMD set them up this way. Thanks for your input!

Yes we do have waveform capnography and the option to do a surgical airway. Yes, the Vecuronium is going to be used as the Paralytic instead of Succinylcholine.

Well actually, the OMD does not want us to use Succinocholyine. I have not see the actual protocol yet. This is just what we are being told is going to happen. I am not sure everyone understands that the low dose vecuronium is suppose to be used just to prevent fasiculations. I have read about that! Also, no hard feelings about people's opinions. I was just wondering and I have been using those websites. I am trying to do as much research as possible and when I mean research, I mean from a lot of different sources. I really do not understand the sedate, but no pain medication. I believe we should have some type of pain medication. We have long transports and our back up airways are going to be the King LT!!!!

Thanks for your input and advise!

It looks like a Junctional rhythm to me with a large BBB! Just my opinion.

I was going with either of your first two thoughts. Maybe a third Degree heartblock and the atrial waves are buried into the ventricular waves. And Idioventricular rythm was my second guess, but it kind of made be second guess that because of the QRS being so narrow. As for the Junctional Rythm, I don't want to focus on that too much because of the fact there are no definate, or indefinate P-waves, whether they be, positive. negative, or absent.

Glad this has some people thinking.

Only thing about it being a third degree block is that the patient does not sound symptomatic. Most people with a 3rd degree block are going to be symptomatic.

That is EXACTLY what I am getting at! That is why I am researching and am interested in hearing about other agencies protocols! I want to try and prove my point before something happens. There is nothing at all about any pain medication, we do not carry Fentanyl; only Morphine. So as I am understaing it is Versed, Vecuronium and Intubate....which I do not feel would be the best way about going at this at all!

Okay everyone, I would like to know everyone's opinion on trends for prehospital RSI. What your protocols are and if they work or do not work. My specific question is how would you feel if your protocol is having you use Versed and a low dose of Vecuronium for preintubation? I am doing some research and am just not sure these would be the best two choices for RSI, but I am not a doctor and there may be things I do not completely understand. I do know there are quite a few contraindications to Succinochylonine, but Vecuronium has such a long down time! Please help by replying with your thoughts!!! Thanks everyone =)