RSI - Preperation Key to Success

[spenac]

Good RSI discussion. Since it can be the difference in life or death for our patients make sure you are prepared.

http://emedicine.medscape.com/article/1097...chealIntubation

[web:3a1e81ccd5]http://emedicine.medscape.com/article/109739-overview#MedicationsforRapidSequenceEndotrachealIntubation[/web:3a1e81ccd5]

[CBEMT]

Does giving enough Versed to knock out their gag count? We can do that if we get an order, but statewide it almost never happens. I do happen know someone who did it this year for a severe CHFer that he was losing the airway on.

[paramedicmike]

If you need to emergently manage an airway you don't have time to premedicate.

Etomidate, succs, intubate, versed, vec, fentanyl. Under ideal circumstances it should take less than two minutes to tube placement.

I don't see any discussion regarding an airway assessment. What grade airway do you have? Potential difficult airway indicators? Are you willing to paralyze a patient if you're not 100% sure you can effectively bag the patient should your airway fail?

What kind of back up airway do you have? Have it ready even if you are positive you can place the tube. Have suction ready, too.

I can, and have, RSI-ed on many occasions. It is something we review frequently. It is not for everyone and I know plenty of medics who should not have this capability.

It'll be interesting to see where this discussion goes.

-be safe

[spenac]

Mike good points. Get you combitube or other ready. Get the cric kit ready. That way if things go bad you can get patients airway.

[Dustdevil]

I am particularly intrigued by the figures quoted regarding the lifespan of good preoxygenation. I don't think anyone should take a false sense of security from them, but it is certainly a bit reassuring.

[p3medic]

Yeah, but that is healthy adults. I still think its impressive, but when you consider the patients we as prehospital providers are dealing with, I would think 1 minute is pushing it. I wouldn't go take a phone call during it (although if it were for overtime, I'd have to consider it )

[crotchitymedic1986]

1. Patients do not get brain damage because paramedics fail to intubate them, they get brain damage because paramedics fail to ventilate them.

2. Overdosing someone on versed, so that you can intubate them is very poor patient care.

[Dustdevil]

1. Patients do not get brain damage because paramedics fail to intubate them, they get brain damage because paramedics fail to ventilate them.

Excellent point. And any paramedic school that is not driving that point home is a school that sucks.

2. Overdosing someone on versed, so that you can intubate them is very poor patient care.

I have to disagree with that. We do what we can with what we are given. If that's the best you can do with what you are given, and assuming that the situation demands it, it is wholly appropriate. Of course, a lot of controversy surrounds RSI today. Not because it is dangerous, which it certainly is. But because of the EMS specific phenomenon of people performing interventions simply because they can, instead of basing such decisions on sound medical justifications. Regardless, there are indeed situations which rarely arise in the field where RSI can mean the difference between life and death. And if all you have is Versed or Fentanyl to accomplish it, I see no justification for withholding it simply because it isn't how the cookbook prescribes it. That's like refusing to do an emergency cric because you didn't have a nice, commercially pre-packaged cric tray to do it with. Neither of those decisions would be based on sound medicine, and very definitely not in your patient's best interest.

[paramedicmike]

I am particularly intrigued by the figures quoted regarding the lifespan of good preoxygenation. I don't think anyone should take a false sense of security from them, but it is certainly a bit reassuring.

No. A false sense of security shouldn't be taken from those numbers. And each patient should be assessed based on their own mechanism. As P3 noted, the numbers referenced are all based on healthy adults. Chances are you'll see sats holding longer in some trauma patients than you would in say a medical patient needing aggressive airway management. That's not hard and fast but it happens.

With regards to pharmaceutically assisted intubation (with no paralytics available) versed/fentanyl is actually an excellent combo to use. I've used this before and it works well.

Like Dust said, you use what you have. If this is what you have, then this is what you use. And one of my medical directors supports this approach.

-be safe