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Rsi

Discussion in 'Firefighter/EMS Talk' started by obxprnstar, Oct 25, 2004.

  1. obxprnstar

    obxprnstar Goth Lover

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    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.
     
  2. Glkster19

    Glkster19

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    May 12, 2001
    Lansing, MI
    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.
     


  3. DaleGribble

    DaleGribble Sandwich!

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  4. 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.
     
  5. TerraMedicX

    TerraMedicX

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    Sep 26, 2004
    Boulder, CO
    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.
     
  6. clubsoda22

    clubsoda22

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    Jul 28, 2004
    SE PA
    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.
     
  7. DaleGribble

    DaleGribble Sandwich!

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    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).
     
  8. DaleGribble

    DaleGribble Sandwich!

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    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?
     
  9. TerraMedicX

    TerraMedicX

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    Sep 26, 2004
    Boulder, CO
    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.
     
  10. obxprnstar

    obxprnstar Goth Lover

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    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.
     
  11. SLIDER in KY

    SLIDER in KY Millennium Member

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    Dec 18, 1998
    KY
    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.
     
  12. Ditchdoc

    Ditchdoc

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    Aug 25, 2003
    Georgia
    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:
     
  13. MDT

    MDT Glock21Love

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    Mar 24, 2003
    Claremore, OK
    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
     
  14. Alpha752

    Alpha752

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    Aug 16, 2002
    Cleveland, Ohio
    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.
     
  15. obxprnstar

    obxprnstar Goth Lover

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    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.
     
  16. lexmedic157

    lexmedic157 Citizen

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    Jun 5, 2004
    Lex, Va.
    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.
     
  17. obxprnstar

    obxprnstar Goth Lover

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    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.
     
  18. Ditchdoc

    Ditchdoc

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    Aug 25, 2003
    Georgia
    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
     
  19. MDT

    MDT Glock21Love

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    Mar 24, 2003
    Claremore, OK
    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
     
  20. Ditchdoc

    Ditchdoc

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    Aug 25, 2003
    Georgia
    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?