RSI

[spgmedic]

Just curious. Does anyone use RSI ( Rapid Sequence Intubation ) in there service?

[Ridryder 911]

Yep... Entim., Sux's, Fentyl, Versed, Pavulon, Diprovan Gtt.

Pre- Med . Lido for ICP, Atropine for kid's

Be safe,

Ridryder 911

[shorthairedpunk]

I have only witnessed 1 RSI go smoothly, on an infant, thank god.

At ILS we dont do it, so I have only seen it in the hospital setting. It seems that it does not happen very smoothly, quite often it is performed by the flight medics prior to transport. Is RSI difficult due to the nature of the sedation? Or have I only happenned upon the difficult ones?

[Ridryder 911]

RSi, if performed correctly, is very smooth. I would not judge by seeing just 1 case. Been performing since the early 80's.

Usually, I don't RSI infants.. no teeth, etc. Neonate crews hardly ever.

Be safe,

Ridryder 911

[shorthairedpunk]

lol, i meant ive only seen one go good, ive seen it about a dozen times go bad

I just didnt know if the procedure itself made it difficult, RSI is one thing that holds me back from going further in my EMS career, I have a hard time stopping someone from breathing who was breathing, and a few of the times the person woke up and looked petrified, I know they wont remember it, but I will.

[Ridryder 911]

If you do it properly, you will successfully sedate the person before paralytics.. paralytics does not affect mentation.that is why it gets a bad rep... In-depth education, on the use of sedation infusion, neuro muscular blocking agents (NMBA), Depolarizing agents for AcH & non de-Polarizing agents. When to use & what use on specific case by case bases.

It is not a skill for the new or recent graduate Paramedic. Definitely, not any lower than that.

Be safe,

Ridryder 911

[shorthairedpunk]

I think thats a skill that should only be prehospital on a helicopter

One of the times the person woke up because of the time it took for the ER doc to authorize more of the versed (i believe), the helicopter crew had given all they could per protocol, and the intubation took about a half hour over all. This is the one that bothered me the most because it was a sever burn patient, 2.5 hours post burn, who was CAOx3 talking, and showing no signs of airway compromise (his nasal hairs werent even singed, his face was about all that didnt get any serious burn). He was intubated prior to air transport per the burn protocol for that air service.

I guess this one just bothers me because he was essentially stable, and made unstable, hypoxic (82% for 2+ minutes) with trauma to the airway from the multiple attempts at passing the tube.

[Ridryder 911]

Again proper education. Such as burns ( which Sux is sometimes contraindicated). Bird, or ground tx is tx..work both..

Be safe,

Ridryder 911

[shorthairedpunk]

educate me on the cantraindication, thats what was used in that event

[Ridryder 911]

As a an old burn center nurse & flight nurse, some services are hesitant to use sux. Sux is a negative isotope, which can cause an histamine response. Not only that post burns or crushing injuries ( > 24 hrs to 7 days )The upregulation of acetylcholine receptors (AChRs) after burns occurs at sites immediately beneath and distant from the burn; a positive correlation between AChR number and the intensity of the hyperkalemia after succinylcholine has been confirmed. The upregulation of AChRs that occurs in muscles beneath the area of the burn is as profound as after denervation and occurs as early as 72 h after burn.* Evidence for upregulation of the immature isoform has also been provided by assessment of messenger RNAs for the unit. When depolarized, the immature isoform has a prolonged open channel time, which may exaggerate the K+ efflux that occurs with depolarization. Thus, the potential for profound, denervation-type upregulation of AChRs is present as early as 3 days after burn injury when the burn-injured area is adjacent to muscle. The dramatic upregulation of AChRs on all muscles beneath the burn is also accompanied by the expression of the immature isoform of the receptor. In fact, burn injury of a single limb (8-9% body surface area) is sufficient to cause potentially lethal hyperkalemia.

The concomitant presence of immobilization with and without prolonged administration of muscle relaxants can accentuate the upregulation of AChRs. Immobilization alone can induce modest upregulation as early as 3-4 days.

Although in EMS, we will have the lack of clinical reports. Hyperkalemia before 7 days after burn injury is probably a result of the following: the previous treatment philosophy of not treating major burns aggressively with early excision and grafting did not provide the opportunity for challenge of major burns with succinylcholine within the first week; and increased awareness of the dangers of hyperkalemia with succinylcholine has resulted in its lack of use in burn patients as early as 1 week during early excision and grafting of major burns.

That is why some EMS service uses succinylcholine for burns up to 48 hr after burn injury, but it may be wise to avoid it beyond that period. Patients may be particularly vulnerable if they have been immobilized in bed because of severity of illness or concomitant disease (e.g., inhalation injury and fractures) or if they have received prolonged muscle relaxant therapy to facilitate mechanical ventilation.

I hope that answered your question.

Be safe,

Ridryder 911