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obxprnstar
10-25-2004, 21:29
Ok, so while teaching ACLS last week another instructor and myself got into a discussion with our Med Dir about RSI, specifically field RSI and a study that was recently halted (in CA IIRC) where there was a large increase of morbidity/mortality when RSI was done pre-hospital.

Help: I can't find the study, when and where was it done? When and where was it published? I know I read it recently, but have no idea where.

Also: Opinions on RSI in the field and RSI during Critical Care Tx's are welcome.

Thanks.

Glkster19
10-26-2004, 05:43
It's a great thought, but you'd better be damn good at getting tubes no matter what the circustances are. Probably why the study was halted, people getting paralyzed then BVM'd into the ED without a tube getting in. If we have a pt that messed up, usually Aero-Med is coming in, they do the RSI and we have less to worry about. They fly with Dr./RN.

I would agree with RSI pre-hosp, but I'd have to say that mandatory OR rotations every so often would be required to keep in practice.

Oh, sorry I haven't seen the article but would be interested in reading it when/if you find it.

DaleGribble
10-26-2004, 09:23
Here ya go!

http://www2.us.elsevierhealth.com/scripts/om.dll/serve?article=a126397&nav=full&from_id=a126370

I like the idea of RSI, but I've never done it, or observed it being done, so my opinion isn't based on experience.

mfackler
10-26-2004, 09:33
This doesnt have much to do with that study, but we did our own little "antidotal' (sp) study and found not only with RSI but we are attempting intubation much more then in our past Hx. We checked and some of our "missed" tubes were due to the pt no longer needing intubated. We were just attempting much earlier in the game. Thats not a bad thing.

Guess my point is you may need to look at the stats a little closer to see exactly what they mean.

TerraMedicX
10-26-2004, 13:41
Originally posted by DaleGribble
Here ya go!

http://www2.us.elsevierhealth.com/scripts/om.dll/serve?article=a126397&nav=full&from_id=a126370

I like the idea of RSI, but I've never done it, or observed it being done, so my opinion isn't based on experience.

YEP! That's the article. It's been a point of quite a bit of contention since it was published. There are a number of cities that are now conducting their own studies to see if these results can be repeated (including ALL EMS agencies in the Denver area).

This said, I am a firm believer in RSI in the prehospital setting. Airway control is the number one priority for patient care, and there are times where you just can't orally intubate a patient effectivly. Now I have nasaly intubated a few patients that REALLY needed a tube and could not take an oral tube. I feel that this technique in not only barbaric, but subject to much worse success rates than RSI. Besides, how many times have you brought a patient in to the ER and the first thing they do is RSI them (and we all know that the first thing the ER does is the last thing we should have been doing ;) )

Now I recognize that we generally get very little practice at intubations, but how many intubations a year does the average ER doc get? I agree that if RSI is used by EMS personel that they should have MANDATORY OR shifts once a month. But beyond this, I think there just needs to be a mentality shift away from ET-tubes being the ONLY way to ventilate a paralized patient. YES, the ET-tube is the golden-standard for an airway, but there is no reason that you can't ventilate the patient effectivly with an OPA and BVM. I have done this on a few patients that we simply could no intubate (it took three doctor, one of which was an anesthesiologist, two tries each to intubate this guy!!) they turn out just fine. We just need to learn to give it three or four good attempts seperated by a miniute or so of good bagging. Then we need to give it up and drop the OPA and do a really good head-tilt-chin-lift.

Sorry about all the :soap: everyone, I have a tendency to be a little long-winded and.....opinionated....:cool:
That's my take on it though.

Nate.

BTW: I don't buy that study...I can't remember exactly why right now, but I didn't.

clubsoda22
10-26-2004, 15:10
Can you give us BLS guys a little background. I'm not just an EMT, but a second year BSN nursing student who wants to go into ER or CC and hopefully flight, so i have an interest in this stuff.

DaleGribble
10-26-2004, 15:55
fackler, just from working with experienced medics who have used RSI at other agencies, I can see how you came to the conclusion that once RSI was approved, the number of intubations went up. I've been on several calls where those same medics would have used RSI and I could have gotten some damn experience at tubing folks! Without RSI, we simply can't intubate that often.

Club, what kind of info are you looking for, specifically?

This paragraph from the study explains it pretty well.

Eligible patients were oxygenated with a nonrebreather mask. If necessary, BVM ventilation was instituted before RSI to attempt to achieve an oxygen saturation value of 95% or greater. Midazolam was used as an amnestic agent if the systolic blood pressure (SBP) was 120 mm Hg or greater. Succinylcholine was used as the initial paralytic agent. Medication administration was simplified by stratifying patients into “small,” “average,” and “large” categories on the basis of estimated mass, with precalculated medication doses for each category. This also allowed for standardized dose volumes of 4, 6, or 8 mL, respectively, for both paralytic agents (Table 1).

DaleGribble
10-26-2004, 16:05
Originally posted by TerraMedicX
Now I recognize that we generally get very little practice at intubations, but how many intubations a year does the average ER doc get? I agree that if RSI is used by EMS personel that they should have MANDATORY OR shifts once a month. But beyond this, I think there just needs to be a mentality shift away from ET-tubes being the ONLY way to ventilate a paralized patient. YES, the ET-tube is the golden-standard for an airway, but there is no reason that you can't ventilate the patient effectivly with an OPA and BVM. I have done this on a few patients that we simply could no intubate (it took three doctor, one of which was an anesthesiologist, two tries each to intubate this guy!!) they turn out just fine. We just need to learn to give it three or four good attempts seperated by a miniute or so of good bagging. Then we need to give it up and drop the OPA and do a really good head-tilt-chin-lift.


I agree with the mandatory OR shifts, simply because we don't intubate that often. I've used a laryngoscope once in the last six months, and that was at inservice.

As for what happens after your three attemptsc fail, why just stick with the OPA, why not try a combitube or LMA?

TerraMedicX
10-26-2004, 20:39
Originally posted by DaleGribble
As for what happens after your three attemptsc fail, why just stick with the OPA, why not try a combitube or LMA?

Good point! I forget about these because I don't have them in either of my protocols. I used to be a big fan of LMAs, but then I had to put one in and they arn't as easy as people make them out to be!!

Nate.

obxprnstar
10-26-2004, 22:15
The LMA sucks unless you are in an OR. Combitube is the way to go, Combitube! We use standard LMA's as our backup airway (NC OEMS req's model EMS systems to have a backup) and I tried to use it once.

Let me tell you (adapatanig marcus voice from bringing out the dead) "Them things don't work on no junkies! Especially through junkie vomit!"

The one time I couldn't get the tube was on a junkie. We tried an LMA for poops and giggles, and guess what? Yeah, it didn't work. That was about two years ago and that truck is still missing that size LMA.

Our Medical Director is an Anasteseologist (or whatever) so that is a both a blessing and a curse.

SLIDER in KY
10-30-2004, 22:53
Our service just approved the Combitube and LMA's as a back-up for difficult intubations. Actually, we are a pilot program in KY for EMT's to use the Combitube. I haven't used either one yet. Fortunately, my last few intubations have been easy. No, I'm not saying I'm good, just that the tubes went well.

Ditchdoc
10-31-2004, 06:48
I see no reason why we can't do RSI in the field. This is something we have been arguing about for years now here. As stated above we other mean of ventilating patients that are hard to intubate from very simple OPA and BVM to combitube or LMA. Most ER docs around here ask the medics to intubate a patient they cannot. I've been asked to more times than I can count even with a RT standing next to the Doc.

Just my .02

:soap:

MDT
10-31-2004, 10:27
I'll interject here....

I am a VERY strong proponent of our pre-hospital folks out there. I have a great relationship with our medics. That said, I an mot convinced that RSI is a good idea in the field UNLESS you have had a butt-load of airway experience AND how to obtain a patent airway when you've had a failed RSI.
TerraMedicX, you made the comment of how many tubes do ER docs get. I do many each month. But along with that, I have a platform to obatin alternative airways if RSI fails. Pre-hospital (at least in my area) has oral, nasal endotracheal, LMA, jet-insufflation, and if it gets deep, cricothyrotomy (never seen it done in pre-hospital setting).
I have those, but also, Combitube, fiber-optic, lighted stylet, and if I get in trouble, I have an anesthesiologist I can call. There is NOTHING like taking a breathing patient, paralyzing them and then find out you can't get the airway. You'd better pray that you can bag them until the sux wears off. You guys know, it's always the 350 lbs guy, no neck and a beard who has the impossible airway.
My opinion is that unless you take an advance airway course, RSI should not be an option in the field. Place a nasal and bag.
You might check Google for Ron Walls, MD. He is the guru for airway in EM, there is an airway site (can't remember the name), but should be some good info.
I AM NOT slamming EMS or their skills, we have several medics with the skills to do RSI well, we have some I don't trust giving aspirin. Training is paramount.


MDT

Alpha752
10-31-2004, 10:57
Originally posted by clubsoda22
Can you give us BLS guys a little background. I'm not just an EMT, but a second year BSN nursing student who wants to go into ER or CC and hopefully flight, so i have an interest in this stuff.

Clubsoda, I dont know if this answers your question at all, but RSI is Rapid Sequence Intubation. Basically you paralize your patient with drugs in order to intubate them.

obxprnstar
10-31-2004, 12:34
I work in a system that is incredibly diverse in terms of geography (sp) The station I am at for the next 4.5 months (but who is counting) is approx 55 miles from the hospital. We have a clinic with a Doc on call witing 10mi, but the Doc only comes out when it is convienent for them, sometimes may not be as well trained as needed, etc (yet the Co pays the practice 100K a year to be on call and come out to help us). My previous station was 7mi up the road, and worst case I could always load and go a patient in any of my first due area. Down here you are on your own. Besided LMA we also have surgical cric available to us (used about 2-3 times in the last 5 years) but out in the middle of nowhere I have become a very STRONG proponent of RSI and everything else that is cutting/leading edge. But to paraphrase/re-phrase what MDT said, there are some medics that are total idiots and ruin it for the rest of us. I taught an ACLS recert two weeks ago. IMHO any field medic should not fail a recert. ACLS is the bread and butter of what we do in my agency. We had two fail it. If you failed the written, you did not get to mega code (our Med Dir was running mega-code). While it would have made the agewncy look bad to have these two run the code, hopefully it would have weeded out some of the problems.

lexmedic157
10-31-2004, 12:56
In VA we have a very limited opportunity to do conscious intubation or RSI. In order to even begin something like that you need to have your own manditory comp. evals done at minimum every quarter. Where I work, you have to tube each age range every quarter, at minimum. If you don't get the field opportunity you need to get in the OR, or the ER. Like everyone else has mentioned you need to have back-ups for your difficult airway. Combitubes are great provided you can get vascular access, we use Melker surgical trach devices which are great and cut down on bloody trachs. Also, seriously consider having gum-elastic bougies available. They're like the diameter of a 3.5-4.0 tube with a curved end and as long as you can see past the tongue, you know you're "in" when you feel the bougie run down the rings. These are a life saver, I tell you what. I'm not too familiar with the LMA thing, but hear they work good in the OR. Depending on your OMD you need to hash out what drugs to use. Remember none of this does any good if you're not positive you can get the airway. It's a long process to initiate something like this, but well worth having it available when you need it. Also consider adding some kind of verbage in your protocols about requiring another medic in the back with you. For obvious reasons you cannot do something so invasive by yourself (safely anyway). Just a thought.

obxprnstar
10-31-2004, 13:56
Our med dir has talked about us needing to have a min # of tubes a year or quarter. Somthing like 3. While I do consider myself profficiant (I suck at spelling), by no means have I gotten any more than once chance to intubate for the last two years while others have six chances in six months. It just depends on how the dice come up.

Ditchdoc
10-31-2004, 15:41
In my service we are evaluated quarterly for our skills. ET, LMA, Combi-tube if you don't pass you don't work that simple. As for medics that you wouldn't let give an aspirin, how are they still working? Is there any QA/QI? I see Paramedics do RSI all of the time on our helicopter with out a hitch. They are the same paramedics that ride the streets just the state says if they fly they can RSI. I agree on the second medic because nobody is perfect 100% of the time. For a Doc what would the minimum number of Tubes you would like to see a paramedic pass before he could do RSI? As Corey Slovis MD said I'd rather have an EMT or Paramedic controlling the airway than anyone else.

Agian just my .02

MDT
10-31-2004, 16:36
Ditchdoc, I knew this would get into a "I'm good enought for this" kind of thing. Slovis is well respected and I think he's a good resource. There are a number of studies (recently Annals of Emergency Medicine has a couple- I'll have to dig them up if you would like to see them) about first responders and airways, some of the data was not encouraging. As I said, MANY MANY medics are extremely competent and airways are not a problem. And I'll bet you know a few who you'd rather not work on your wife or kids. Just like docs. We get residents through the ER who I wouldn't let touch my dog. Hopefully they get better, and with experience and more training, those questionable medics probably get better as well. My only caveat to RSI is you'd damned well better be able to do SOMETHING when the RSI fails. You have taken a breathing patient and now rendered him paralyzed, if your endotracheal route fails, pray to the angel on your shoulder that you can ventilate unti you get to the ED or you've just helped that person go see their maker. I face this daily in my practice, as a resident I always had an attending to bail me out. Now that I'm the attending, I don't take airways lightly. Again, this is no slam on EMS, it's just something that must be entered into with the utmost competence and experience.

MDT

Ditchdoc
10-31-2004, 19:33
MDT, It's not a "I'm good enough" thing it is a quality patient care issue. When you have a patient that is drowning on his own blood, that no amount of suction can keep up with, you can not ensure a patent airway. If you are 20 minutes or more away from a hospital this a life or death matter. RSI could help ensure an airway but we can't do it. You are right in the ER you have people you can fall back on We don't. That is why I know we need RSI. I've seen patients die because we could not get an airway. These same patients could be given a chance wth RSI. Remember we are all here for the same common goal, To Save Lives. About the studies, I've seen them. I've also seen studies that say patients in cardiac arrest have little or no chance of survival if no treatment is started within 10 minutes but we still give these patients every chance don't we?

Medic08
10-31-2004, 20:28
We are blessed with many many air medical units here in SW PA. So if someone truely needs RSI we have someone to call. Also we carry a combitube. I think with some of the medics I see around here that think they are MDs RSI could be bad. Also we ride one medic one EMT on a truck so if you can't get the tube that is it. There is no one else to try or many other options. I guess in some places it would be usefull. Not here though.

obxprnstar
10-31-2004, 22:15
It is like so many other things Medic08, it will not fit every one, every where. Some places RSI may not work, what works for a dual medic system will not work for a single medic system. Our county owns it's own medevac, but if they are out on a mission it is 60 min for the next helo. Some docs down here @ the clinic will not RSI. So while I am pro RSI, I know that I as a medic will be expected to preform to our med dir's satisfaction so many tubes, and do other training.

smokshwn
10-31-2004, 23:29
MDT,

Please don't take this the wrong way but I have never been able to understand the logic of restricting RSI based on the chance that you will not be able to place the tube. When a pt needs an airway they need an airway.

By this I mean, Pt NEEDS an airway, we cant secure airway without RSI, We utilize RSI and are unsuccessful. What changed we are still up a creek without an airway. In my service we are allowed to perform surgical airway, but many aren't.

As to the study showing increased M&M, couldn't a lot of this be attributed to more patients who may have been DOA making it to the recieving facility due to the RSI?

MDT
11-01-2004, 04:13
I think we're all saying the same thing here. It (RSI) is a skill requiring LOTS of practice. We all want the patient to come out well. If your medical director can establish competency with RSI, great. I just don't think it is something to be entered into too quickly. In my area, transport time is usually under 10 min. If my medics can't get the tube, they can usually support the airway while transporting. In rural areas, this is more problematic.

As I stated above, no slam intended.

MDT

smokshwn
11-01-2004, 18:08
No worries at all. I have been a medic on the street and I moonlight in one of our Trauma facilities. I think I get to see an interesting perspective working both places. In the clinical environment there are all kinds of safeties within the system and it allows for many more factors to be considered in the decision making process. On the street so to speak, a lot of guys don't understand how often crews perform well below standard which makes medical directors cringe at the thought of giving out more and complex procedures.

I actually work in the ER with my medical director for fire so we chuckle together quite often. In the time we were pushing for RSI we discussed some cases and I became thankful he was still letting us take vitals.

Take care, Craig