RSI VS Concious Sedation

[1EMT-P]

What medications do they use in Canada for PAI/RSI? What's your Medical Director's reason for not allowing sux?

[Ace844]

A Comparison of Rapid-Sequence Intubation and Etomidate-Only Intubation in the Prehospital Air Medical Setting; William P. Bozeman A1, Douglas M. Kleiner A2, Vicki Huggett A3 A1 Department of Emergency Medicine, Wake Forest University, Winston-Salem, North Carolina A2 Department of Emergency Medicine, University of Florida, Jacksonville, Florida A3 Trauma One Flight Services, Shands Jacksonville Hospital, Jacksonville, Florida]

Abstract:

Objectives. To compare laryngoscopy conditions produced by etomidate-only intubation (EOI) with those produced by rapid-sequence intubation (RSI) in the prehospital air medical setting. Methods. A prospective crossover trial design used two helicopters staffed by the same flight paramedics and nurses. Each aircraft used an EOI protocol (0.3 mg/kg) for six months. An RSI protocol using the same dose of etomidate plus succinylcholine (1.5 mg/kg) was used for the alternate six months. Laryngoscopy conditions were graded by three scales: 1) a formal Laryngoscopy Grading Scale (LGS), 2) the Percentage of Glottic Opening (POGO) score, and 3) subjective overall intubation difficulty using a Likert scale of 1 (very easy) to 5 (very difficult). Orotracheal intubation success was also recorded. Results. Forty-nine patients were intubated using the EOI (n = 24) and RSI (n = 25) protocols. Mean age was 38 years, 76% were male, and 90% were intubated for trauma. Fifteen (63%) of the 24 EOI patients required additional etomidate (n = 3) or RSI (n = 12) to allow intubation, while one (4%) of the 25 RSI patients required additional medication dosing (p < 0.0001). Laryngoscopy conditions were assessed for all patients. Good or acceptable conditions as assessed by the LGS were seen in 79% of RSI patients and 13% of EOI patients (p < 0.0001). Mean rates of POGO visualization were 60% with RSI and 12% with EOI (p < 0.0001). Mean global intubation difficulty scores were 3.0 (moderate) with RSI and 4.7 (difficult to very difficult) with EOI (p < 0.0001). Ninety-two percent of the patients undergoing RSI and 25% of the EOI patients were successfully orotracheally intubated (p < 0.0001). Conclusions. Patients receiving RSI had better laryngoscopy conditions and were easier to intubate than patients receiving EOI. Intubation success rate was higher with RSI.

Hope this helps,

ACE844

[intothis1]

Our system uses Norcuron 0.01mg/kg as a preload dose to combat the effects of the Anectine (the de-fasciculating dose), followed by Etomidate 0.3mg/kg, followed by sux at 1.5mg/kg. Once the tube is in place and verified, the other 9cc's of Norcuron is given for long term down time. We also use the B.I.Z. to make sure they're not coming up out of it. This is generally for trauma. On the medical side (strokes and such) we have the option to do sedative airways. These are our adult protocols. For kids, it's the Versed, Lido, Atropine route in addtion to the paralytics.

[Ace844]

(Acad Emerg Med Volume 13 @ Number 4 378-383,

published online before print March 10, 2006, doi: 10.1197/j.aem.2005.11.076

© 2006 Society for Academic Emergency Medicine CLINICAL INVESTIGATION

Intubating Conditions and Hemodynamic Effects of Etomidate for Rapid Sequence Intubation in the Emergency Department: An Observational Cohort Study

Peter J. Zed, BSc, BSc(Pharm), PharmD, FCSHP, Riyad B. Abu-Laban, MD, MHSc, FRCPC and David W. Harrison, MD, CCFP (EM), FRCPC

From Clinical Service Unit, Pharmaceutical Sciences (PJZ) and Department of Emergency Medicine (RBA, DWH), Vancouver General Hospital, Vancouver, British Columbia, Canada; Faculty of Pharmaceutical Sciences (PJZ) and Division of Emergency Medicine, Faculty of Medicine (PJZ, RBA, DWH), University of British Columbia, Vancouver, British Columbia, Canada; and Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute (RBA), Vancouver, British Columbia, Canada.)

Address for correspondence and reprints: Peter J. Zed, BSc, BSc(Pharm), PharmD, FCSHP, CSU Pharmaceutical Sciences, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, British Columbia, Canada V5Z 1M9. Fax: 604-875-5267; e-mail: zed@interchange.ubc.ca.

Objectives: To describe and analyze the intubating conditions and hemodynamic effects of etomidate in patients undergoing rapid sequence intubation (RSI) in the emergency department.

Methods: The authors conducted a prospective observational study of all patients who received etomidate for induction of RSI over a 42-month period in a large tertiary care teaching hospital. Intubating conditions were determined by the emergency physician for both sedation and paralysis and for technical difficulty using a five-point Likert scale. Hemodynamic effects were evaluated before, after, and every five minutes for 15 minutes following administration of etomidate.

Results: Etomidate was used for induction of RSI in 522 patients, all of whom were included in the final efficacy analysis, while 491 were included in the analysis of hemodynamics. Lidocaine and fentanyl were used as pretreatment in 65.1% and 26.1% of patients, respectively, while succinylcholine was the paralytic in 94.3% of intubations. Sedation and paralysis were rated as excellent or good in 88.1% and 8.8% of patients, respectively, while technical difficulty was very easy or easy in 60.7% and 19.0% of patients, respectively. Mean (± SD) baseline systolic blood pressure (sBP), diastolic blood pressure (dBP), and heart rate were found to be 132.7 (± 35.4) mm Hg, 69.5 (± 21.2) mm Hg, and 96.1 (± 26.2) bpm, respectively. Overall, there was a clinically insignificant elevation in sBP (p < 0.0001), dBP (p = 0.0002), and heart rate (p < 0.0001) immediately postintubation. Elevations in sBP persisted at five minutes (p = 0.0230) and ten minutes (p = 0.0254) postintubation. Diastolic blood pressure and heart rate returned to baseline at five minutes after intubation and remained stable throughout the 15-minute postintubation assessment period. In the subgroup of 80 patients with a preintubation sBP < 100 mm Hg, there was a 12.1–mm Hg elevation in sBP (p < 0.0001) and a 7.3–mm Hg elevation in dBP (p = 0.0001) immediately postintubation. This elevation persisted throughout the 15-minute postintubation assessment period.

Conclusions: Etomidate appears to provide appropriate intubating conditions in a heterogeneous group of patients undergoing RSI in the emergency department. Hemodynamic stability appears to be present following administration of this agent, even in patients with low pre-RSI blood pressure. This attribute must be weighed against potential adverse effects of this agent, including adrenal suppression.

[fire911medic]

Around my area, most places use PAI as the medical directors are a bit nervous about giving the go ahead for full RSI to services, simply due to the fact that many areas are quite rural and the skill would not be used enough to warrant granting use of it, as the patients requiring it are typically flown out and the flight crews are more than capable of performing the skill with a high success rate. That seems to be biggest obstacle here, though a few select high volume services have been granted permission by the state for RSI. I think it can be a wonderful tool when needed, but it must be a constantly used or practiced skill and one must be proficient at it. I personally don't want to think about the drugs being used to knock someone down without a good knowledge of what is happening. I think we all would agree on that.

[fellinger]

There is still space available for the September Difficult Airway Course – EMS, developed by internationally recognized authors Dr. Ron Walls and Dr. Mike Murphy. Drs. Walls and Murphy are considered as two of the top authorities on difficult airway management and have been pioneers in EMS airway management for many years.

The course is being held on September 16/17, 2006 at the Radisson, Trevose. Dr. Murphy will be present both days to provide all lectures and a self-scope of his airway. In addition to being an expert in anesthesia and emergency medicine, Dr. Murphy is credited with creating one of the largest EMS Systems in the world.

Until recently this EMS specific course has only been offered on the west coast and in the southern US. Don’t miss this excellent opportunity to learn about difficult airway management and rapid sequence intubation by the man who wrote the book!

Space is still available, contact the Airway Education Center at (866) 9AIRWAY or www.theairwaysite.com for more details and to register.

Fred Ellinger, Jr., NREMT-P

Director of Clinical Affairs

Em-Star Ambulance Service, LLC

9137A Roosevelt Boulevard

Philadelphia, PA 19114

Office: (215) 969-0630

Mobile: (215) 910-0614

Fax: (215) 969-0615

Mobile 2: (267) 246-8398

[stcommodore]

Is that class an advanced provider only class? Or would medic students could attend?