mobey Posted April 8, 2009 Share Posted April 8, 2009 (edited) As a 1st year Paramedic student I am a little confused about an issue. I recently was involved in an RSI with a rural Doc. He used Versed and Sux, followed by Roc and continued Versed to keep him sedated. I have been taught in school to always use analgesic (fentanyl) when RSI'ing a patient due to the pain/possible trauma caused by the procedure itself. Obvioustly I have hit the books and net, and have found conflicting opinions on the subject. Lots of papers say "analgesic if time permits". This RSI was for CO poisoning, prior to transport to hyperbaric chamber. Side note: I fully understand the use of Paralytics and sedation, I have no question about either of those, this question is on analgesic use in non-traumatic RSI's only! Edited April 8, 2009 by mobey Link to comment Share on other sites More sharing options...
paramedicmike Posted April 8, 2009 Share Posted April 8, 2009 You've done the research so I won't go into that. I can only comment on our use. We use analgesics for all our RSIs regardless if it's trauma or medical in origin. The logic behind our using it is that even though the patient may be sedated and paralyzed it doesn't mean they can't feel pain. We also argue, like you did, that placing and maintaining a tube in the trachea can be quite an uncomfortable process for the patient. If we can minimize that discomfort, or any discomfort, and help keep them comfortable then we will. Hope this helps. -be safe Link to comment Share on other sites More sharing options...
Doczilla Posted April 8, 2009 Share Posted April 8, 2009 I'm sorry, what was your question? 'zilla Link to comment Share on other sites More sharing options...
mobey Posted April 9, 2009 Author Share Posted April 9, 2009 I'm sorry, what was your question? 'zilla Sorry Doc..... Is pain control a standard of care during RSI in the non-traumatic patient requiring RSI? Link to comment Share on other sites More sharing options...
Doczilla Posted April 9, 2009 Share Posted April 9, 2009 Not necessarily. If you have the time, you can, but many folks do not. Pain control can take the form of an IV narcotic, such as fentanyl (which I usually do) to help blunt some of the ICP rise with intubation. Others prefer tracheal lidocaine, squirted down the hole before the tube goes in. Since I'm doing more difficult airways now, usually with the glidescope, I've done the lido less often and fentanyl more often. For my crash tubes, you get Etomidate and Succ, and usually the first is being pushed as the second is being drawn up. I don't feel that strongly about it. I don't routinely push fentanyl with fracture reductions or dislocation reductions (usually just propofol or etomidate/versed). The patient has had some pain control by this point usually, but not enough to offset the pulling on the broken bone ends. So on the principle of the thing, giving fentanyl or morphine for the "pain" of intubation with adequate sedation, I don't feel that it's an absolute necessity. With regards to your scenario with the doc, I am NOT a fan of benzos like Versed as a sole agent for intubation. Too many people who take them daily for medical reasons or for fun. If pushing the paralytics at the same time you push the sedative, you have no opportunity to judge if the sedative has worked or not. With experience with procedural sedations, I get much more reliable results with etomidate. If unable to use that (though I can't think of a good reason why other than breaking the vial accidentally), I would definitely add some analgesic if using a benzo as a primary sedative agent. 'zilla Link to comment Share on other sites More sharing options...
celticcare Posted April 9, 2009 Share Posted April 9, 2009 Fentynal is used prehospitally and in hospitally here in the RSI kits. I've not seen an RSI being done yet to be honest in the heat of the moment (only induction in theatre and cardiac arrest intubation). Had a chat to an advanced paramedic friend of mine, and he is of the mindset also, that analgesia is important, as a relaxant agent and for pain relief *and yes I know the other agents are used to sedate and relax, but narcotics have that calming effect too, so hey I'd rather be calm and mellow if your sticking something down my throat........ and no wise ass comments either guys*. When I get my first one, I'll be sure to post here lol, watch this space. Link to comment Share on other sites More sharing options...
Doczilla Posted April 9, 2009 Share Posted April 9, 2009 *and yes I know the other agents are used to sedate and relax, but narcotics have that calming effect too, so hey I'd rather be calm and mellow if your sticking something down my throat........ and no wise ass comments either guys*. Link to comment Share on other sites More sharing options...
FireMedic65 Posted April 9, 2009 Share Posted April 9, 2009 Zilla, not to get off topic, but what do you suggest for those who do not have the option of RSI and need to intubate, being traumatic or non-traumatic? Link to comment Share on other sites More sharing options...
celticcare Posted April 9, 2009 Share Posted April 9, 2009 The shifty ninja strikes again Link to comment Share on other sites More sharing options...
Doczilla Posted April 9, 2009 Share Posted April 9, 2009 (edited) Zilla, not to get off topic, but what do you suggest for those who do not have the option of RSI and need to intubate, being traumatic or non-traumatic? Etomidate 0.3 mg/kg IV up to 40mg. Wait 60 seconds, and if insufficient, give the rest of the 40 mg you didn't use with the first dose. Combining agents will get you good results. 0.3 mg/kg of etomidate along with 10 mg of versed or 200 mcg of fentanyl will do quite well. If you don't carry etomidate, 10 mg versed and 200 of fentanyl. If you don't carry fentanyl, versed 10mg and 5mg of morphine. Haldol is another one to consider as an adjunct, particularly if the patient is hypotensive and you don't have a lot to work with for drugs. The above combinations are likely to result in an inability to protect the airway. That's good for tubing, but not good if you can't get the tube. But I've been able to tube a lot of folks with just 40 mg of Etomidate. The above does not include adjuncts such as atropine, lidocaine, or LTA lidocaine. And it's assuming you don't have ketamine, propofol, or methohexital. And the doses mentioned are for adults. 'zilla Edited April 9, 2009 by Doczilla Link to comment Share on other sites More sharing options...
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