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RSI vs. Pharmacologicaly Induced intubation

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In my system we use Etomidate and Versed in order to facilitate intubation. Can anyone tell me why a system would choose one over the over as in RSI vs. PII?

Thanks

Scott

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Both can be used in either, the difference is in RSI one uses a paralytic agent, after the sedative agent. Pharmacologically induced is used without the paralytics and part of the problem is laryngospasms, as well the ability to arouse and have movements.

R/r 911

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A "silver bullet" drug would be a nice. While we are on this topic, has anybody seen any research on the use of the new alpha 2 blockers as a single agent med for intubation? I heard of talk about the potential for these meds as single agents for intubation at an airway confrence in 2005; however, I have yet to hear anything definitive. I could touch up on my Google-fu, but I figured I would pose this question in any event.

Take care,

chbare.

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The idea behind using RSI in the first place is to optimize the first view of the vocal cords. By using PAI, you may not get that optimal view that we are all striving for.

Versed and Etomidate can be used this way, but if you are already knocking a patient down that far, adding a paralytic isn't too far of a leap. It will also make life much easier for everyone, particularly the patient.

On the subject of alpha blockade, little to no discussion currently. Anesthesia occasionally considers it, but sticks with the old standbys.

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Personally, if given a choice of Versed or Etomidate, I'm taking Etomidate. Versed bottoms your BP, and I've seen too many patients where 10 mg wouldn't even slightly sedate them. Etomidate works faster, and doesn't cause the hypotension that versed does. It doesn't last very long, but once they're intubated I would use valium to keep them that way. But to facilitate the tube, I'd rather have Etomidate.

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Could be lack of trust from your medical director, or perhaps he feels your system doesn't have a call volume and skill utilization level to warrant it....just a guess....

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Could be lack of trust from your medical director, or perhaps he feels your system doesn't have a call volume and skill utilization level to warrant it....just a guess....

I think you make a great point. RSI is a skill that needs to be practiced and utilized. I used to work part time in one service that had a call volume of 500 calls and fully 1/3 of those calls were transfers for a local hospital. The level of critical patients were about 5-10%. I can count on one hand how many required any type of consideration of RSI.

Intubation is a skill that is learned and without practice that skill like any other skill will degrade in competency.

If you don't perform those skills then you lose competency, not saying that you lose the skill ability completely but your skills get rusty. RSI is really meant to be a one time deal, if you paralyze a patient and can't get the tube then what are ya gonna do??? BAG em that's what and that is not an optimal position to be in as a medic.

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The studies I've seen don't show any real improvements in prehospital intubation success rate with PAI. RSI, on the other hand, has been shown to increase overall success of intubation, from about 60-70% without it to >90% with it. Of prehospital failed intubations, inadequate relaxation is cited in over 50% of failures as a cause.

"It scares the pants off the medical director" is the reason most often cited for why some systems don't have RSI, and it's usually followed by citation of dismal prehospital intubation success rates. p3 and Ruffems are right on.

On a personal note, I like to paralyze people, because if their stomach contents do come sailing up the esophagus, I know they're not going to take a niiiccceeee big deep breath in and suck it all down in to all the remote corners of their lungs.

Etomidate is now my go-to drug for sedation in RSI and in procedural sedation as well, for all the reasons scatrat mentioned. Additionally, so many people now take benzos (recreationally or for medical reasons) or abuse alcohol that Versed doesn't work at typical doses, and I'm stuck pushing more than I'm comfortable with.

'zilla

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I work in two different pre-hospital systems, one with true RSI and one without. My full-time job happens to be the system in which I do not have use of a paralytic for intubation and it's already caused me problems on two of my intubations in the past month.

In one case we were unable to successfully intubate secondary to severe laryngospasms. Had we had access to a paralytic, intubation would have been very easy, and I'm sure much less traumatic for our patient. In my second case, I had a patient with exacerbation of COPD that went down easily enough with Etomidate, however he was in excess of 200 kgs, and already on prescribed benzos. He required a great deal of versed for tube tolerance. With a post-intubation EtCO2 of 95, I wasn't about to let him pull out his ETT. I had a good blood pressure thoughout my transport, however I dislike the pucker factor I get when giving that much versed. Had I had access to vecuronium for post-intubation with my versed and fentanyl, I may have decreased my fear of creating a very large, very hypotensive patient.

I like having the option of RSI, however I do not wear it as a badge of honor and run around intubating patients because I can. After speaking to a few physicians, I've come to understand that this is also a fear they have of creating a protocol for RSI. I've heard more then one say they don't want paramedics intubating the difficult drunk patient simply because they have the drugs to do it.

It's a difficult decision to make in a very rapid time frame. Will you intubate a patient, and how will you do it? Is it really the best decision for airway control, or is there another less invasive way that will work as well? Do you really need the paralytic? I am all about aggressive airway management. The question is how aggressive is aggressive enough to provide the best outcome for the patient we're treating?

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Could be lack of trust from your medical director, or perhaps he feels your system doesn't have a call volume and skill utilization level to warrant it....just a guess....

Agreed. I worked at one place until recently that didn't trust us with 12 lead capabilities. Certainly they wouldn't trust us with something like RSI capabilities.

...f you paralyze a patient and can't get the tube then what are ya gonna do??? BAG em that's what and that is not an optimal position to be in as a medic.

If you can't get the tube after paralysis, I'd hope you place your backup airway, combitube or LMA, and continue with your guidelines for sedation and continued paralysis (if included and allowed). While not the ideal way to secure an airway, at least there's *something* there.

I like etomidate as the initial induction agent, too. Then, for follow up sedation versed or a combination of versent and fentanyl.

-be safe

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