PAI?

[tcripp]

Was having a conversation this morning with a paramedic peer when he asked a question to which I didn't understand the question. Am posting to see if my ALS counterparts can give me some direction.

(A question from a test reads, verbatim, "Is it okay to attempt OTI after sedation if the patient appears flaccid?")

In regards to rapid sequence intubation (RSI), can one opt to not give the neruomuscular blocker if your patient is "flaccid" after giving the sedation. He called the procedure PAI (pharmacy assisted intubation), but I haven't (as of yet) been able to find a good place on the internet to get a better understanding of just why you would want to do this...and when...and the outcomes if you were to choose this route?

Of course, my answer to him was more along the lines that our protocols are "guidelines" and we can do what is best for the patient, especially if we can justify why we wouldn't give a particular drug in any treatment plan.

But, since I have yet to RSI - I have no experience to pull from.

Help?

[mobey]

PAI (pharmacy assisted intubation), but I haven't (as of yet) been able to find a good place on the internet to get a better understanding of just why you would want to do this...and when...and the outcomes if you were to choose this route?

Of course, my answer to him was more along the lines that our protocols are "guidelines" and we can do what is best for the patient, especially if we can justify why we wouldn't give a particular drug in any treatment plan.

But, since I have yet to RSI - I have no experience to pull from.

Help?

I have done what we call RSS (Rapid sequence sedation), basically the reason I chose it was because of a difficult airway. With RSS/PAI the patient is heavily sedated as to remove thier gag reflex, then a tube is passed (or attempted) while the patient is still breathing (a little). The pourpose is to remove some of the "Criticalness" from the intubation procedure. In my experience, the biggest complication is vocal cord spasm, at which point NMB is required.

I have done both a fentanyl only intubation, and a fentanyl/versed only intubation.

Let me say this though: If you attempt an PAI/RSS and fail, once you have administered the paralytic, the anatomy is VERY different. It is amazing how much a little muscle tone changes an airway.

Another tip: when passing the tube on a breathing patient, remember at some point, the tube may be pointed directly in your face and the patient will exhale. That means, if there is aspiration contents/edema/mucous, it will be coming up the tube and into your face. Ya.... I learned that the hard way! Faceshield Please!!

[tcripp]

Thanks for the feedback!

[Doczilla]

While many departments use PAI, it is, most times, a poor substitute for RSI when the department or medical director gets the heebie jeebies thinking about paralytics. Studies show it does not improve intubation success rate, whereas RSI does.

I have done PAI on occasion when knocking out the respiratory drive completely would be problematic. Most of these were extraordinarily difficult airways, such as angioedema or facial trauma, where the patient is actually moving some air on their own, bagging would be tough, and I expect the intubation attempt will take a while, such as with fiberoptic nasal intubation.

'zilla

In answer to the test question, the patient being flaccid after sedation is the desirable condition for intubation. OTI is not only okay at that point, but required.

[BCEMSmedic87]

We use RSI and our protocols are strict...only in severe respiratory distress, major trauma w/ AMS, and any other situation that warrants a rapid airway. I use etomidate, succynlcholine, and vecuronium...and in trauma w/ poss. head injury some lidocaine.

You can't justify paralyzing someone w/o sedation...they're going to feel everything you do...RSI is a privilege for intelligent medics using it appropriately...not just a cool skill for a hotshot paraGOD...

Sent from my DROIDX

[mobey]

You can't justify paralyzing someone w/o sedation...they're going to feel everything you do...RSI is a privilege for intelligent medics using it appropriately...not just a cool skill for a hotshot paraGOD...

Sent from my DROIDX

Good Gawd!! Who the hell said anything about paralyzing someone without sedation??

Hotshot paraGOD?? Sounds more like incompetent provider!

[tcripp]

You can't justify paralyzing someone w/o sedation...they're going to feel everything you do...RSI is a privilege for intelligent medics using it appropriately...not just a cool skill for a hotshot paraGOD...

You do realize, I'm asking about sedating without paralyzing? Not the other way around...

[tniuqs]

While many departments use PAI, it is, most times, a poor substitute for RSI when the department or medical director gets the heebie jeebies thinking about paralytics. Studies show it does not improve intubation success rate, whereas RSI does.

Bless you zilla Exzactly .. have you got links to studies ?