Ideas for RSI eduction

[medicaltransient]

When we got our Christmas bonus I asked my boss to give me some extra work. He says he wants me to give an RSI class so we can update our protocols. I think we are just going to copy the AEL protocol. Basically I am going to show the ACE SAT video on airway management and then I am going to show a power point and proctor a test. So I need Ideas for the power point. These are the things I am going to include in the test so far. I

The LEMON score.
The actual protocol
A slide for every drug
The RASS score

Does any one know a good reliable online source for pharmacology information?
Thanks for your help!

 

[NomadicMedic]

Curious, do you have RSI now?

Cuz, there's a little more to it than a PPT.

 

[FiremanMike]

To build on what DEMedic says, if you don't currently have an RSI or at least "drug assisted intubation" protocol currently in place, try to incorporate some hi-fidelity sim lab training into this process. RSI is much less about the procedure itself and much more about the decision making process that leads up to the RSI and then the ability to execute the administration of drugs, the intubation, and the ability to decisively move on to a rescue airway in the event that your intubation attempts fail.

 

[CANMAN]

I second all of the above, what is going to be your companies stance on O.R. time for live intubations or procedure for hopefully quarterly, or annual competency? What is your companies current first tube success pass rate? Do you guys have any adjuncts such as VL, bougies, etc? If instituting an RSI program for the first time there is a lot more involved then running a few slides and medics intubating Harry the Half Head half a dozen times for sign off. What is going to be your post RSI plan for sedation, ventilation management, etc? Are you strictly a field EMS program of also doing IFT? Add some more details and I will be happy to provide some more tomorrow on shift. Between the MD's on the forum, Remi, DEmedic, Chaz, FiremanMike, and others we will be able to give you some solid direction.

 

[medicaltransient]

No we don't currently have RSI. I have done it 7 times personally at a previous job. Yes we do plan to have a practical skills training. We only do EMS. We plan on instituting the bougie and king lt-d. I don't know any of our statistics for intubation and I don't know how accessible the local OR is. The protocols are going to be a copy of Air Evac Life Team;
Premedication:

1. Administer atropine 0.02mg/kg IV prophylactically to prevent bradycardia in all pediatric patients less than 4 years of age. Atropine minimum dose is 0.1 mg to avoid rebound effect.

Use ONE of the following medications: with preference in the order listed.

1. Etomidate 0.3mg/kg IV

2. Ketamine 1mg/kg IV

3. Midazolam 0.1mg/kg IV (only to be used if Etomidate and Ketamine are unavailable or contraindicated)

Neuromuscular Blockade:

Doses are applicable for both adult and pediatric patients. Use ONE of the following medications with preference in the order listed.

1. Succinylcholine 2mg/kg IV (Max single dose 200mg)

2. Rocuronium 1mg/kg IV (Max single dose 2mg/kg of ideal body weight)

POST INTUBATION MANAGEMENT

The goal of post intubation management is to safely provide and monitor adequate sedation of the intubated patient by treating pain and anxiety in the intubated patient. Before sedating the patient:

1. Confirm successful placement of an advanced airway per PRO 007. (ETT, King Airway, LMA, cricothyrotomy)

2. Initiate and continue to monitor ETCO2, SpO2, NIBP values. (arterial lines if available)

3. Establish and maintain patent and working intravenous/intraosseous access.

4. Assess and document initial level of sedation using RASS score.

5. Determine and document target level of sedation using RASS score, typically (-2 to -4)

6. Document RASS score before each time a medication is given, change in patient condition or q10 minutes.

*A RASS score must be documented on every patient. A RASS score must also be documented every time a patient receives sedation.

Is there a need for immediate sedation?

YES

NO.

Reassess RASS score at a

minimum of Q10 minutes. If

patient needs further sedation to attain target RASS score, then…

Is the patient

hemodynamically unstable?

YES NO.

Follow Post

Intubation

Medication list.

A. IV fluids wide open via pressure bag.

B. Ketamine (use with caution in patients with CHF)

ADULT- 0.5mg/kg to 1mg/kg IV. (If needed, repeat with

half of initial dose q5 -15 minute to effect).

PEDIATRIC - 1.5mg/kg to 2.0mg/kg IV. (If needed, repeat with half of initial dose q5 -15 minute to effect).

C. Norepinephrine infusion, titrate SBP>90 (Mix 4mg in

250ml. Starting dose 5-10mcg/minute)

Once patient is hemodynamically stable, then…

Post Intubation Management medication list

A. Fentanyl: 0.5mcg/kg to 1.5mcg/kg IV q2 minutes. (Single max dose of 200mcg)

OR

B. Morphine: 0.05mg/kg to 0.1mg/kg IV q2 minutes. (Single max dose of 10mg)

THEN

C. Midazolam: 0.02mg/kg to 0.05mg/kg IVP q2 minutes. (Single max dose of 5mg). *If unable to obtain targeted RASS score by using multiple doses of fentanyl, morphine and midazolam to sedate the patient, then consider using ketamine.* D. Ketamine:

ADULT- 0.5mg/kg to 1mg/kg IV. (If needed, repeat with half of initial dose q5 -15 minutes to effect)

PEDIATRIC- 1.5mg/kg to 2.0mg/kg

IV. (If needed, repeat with half of initial dose


Sorry this information is disheveled but I could not get it to copy in an algorithm format.

 

[medicaltransient]

Paralysis: There are very few patients that will need long acting paralytics during post intubation management. The goal of post intubation management is to safely provide and monitor adequate sedation levels by preventing pain and anxiety in the intubated patient. Paralytics do NOT provide sedation and should NEVER be used on any patient that is not properly sedated unless there is an immediate safety concern in flight.

Such as the following:

1. Immediate safety concern in which the patient will cause harm or danger to themselves.

2. Immediate safety concern in which the patient will cause harm or danger to the pilot or aircraft.

3. Immediate safety concern in which the patient will cause harm or danger to the flight crew.

-If long acting paralytics are to be administered, the doses for adult and pediatric patients are as follows:

- Rocuronium 1mg/kg IV.

- Vecuronium 0.1mg/kg IV.

 

[CANMAN]

I personally think taking one programs protocols and trying to implement those as a blanket for your program is a bad idea. I would make a bunch of changes personally to those for many reasons. I think from the sound of things you are missing some real key components and I will be happy to write up a detailed response tomorrow when I have some more time. Thanks for the additional info.

 

[Carlos Danger]

When we got our Christmas bonus I asked my boss to give me some extra work. He says he wants me to give an RSI class so we can update our protocols. I think we are just going to copy the AEL protocol. Basically I am going to show the ACE SAT video on airway management and then I am going to show a power point and proctor a test. So I need Ideas for the power point. These are the things I am going to include in the test so far.

No we don't currently have RSI. I have done it 7 times personally at a previous job. Yes we do plan to have a practical skills training. We only do EMS. We plan on instituting the bougie and king lt-d. I don't know any of our statistics for intubation and I don't know how accessible the local OR is. The protocols are going to be a copy of Air Evac Life Team;

OK, so your program wants to do RSI, but:

• Your medical director (apparently) isn't willing or able to design or teach the class.
• Your lead educator for this project will be someone who has only done the procedure himself a few times
• You don't even know if the paramedics at your service is any good at intubating
• You (apparently) aren't already training regularly in an OR, and don't know if you can get hands-on training in an OR
• Your paramedics are not already familiar with the basic adjuncts that you recognize are important to have, so they'll have to learn those at the same time that they'll be learning a critical new skill

What could possibly go wrong?

 

[FiremanMike]

Let me start by saying that AEL's RSI protocol holds a special place in my heart and as an experienced provider, I appreciated it's flexibility.

With that said, I think it's too complicated for the general population of medics, and giving that many choices will quickly lead to frustration.

My current RSI protocol is both strong and simple, able to be quickly understood by all providers and easily drawn up and administered in the heat of the moment.

It goes

Premedication
2mcg/kg fentanyl
2mg versed

Induction/Paralysis
1mg/kg Ketamine
1mg/kg Rocuronium

Post intubation sedation
2mcg/kg Fentanyl
2mg versed
(if you didn't notice, it's the same regimen as the premedication phase)
(q20min PRN, special training has been given to ensure everyone knows the signs of awareness in a chemically paralyzed patient)

There was quite a bit of heartburn over going to a long acting paralytic for RSI, however our medical director was able to make several points to put guys at ease;

1. The idea that giving succs would allow for the patient to start breathing again given a failed airway is based on the false premise that they'll start breathing again. He points out that we're not in a surgery center, inducing an otherwise healthy 30 year old for shoulder surgery. We RSI people who are very sick/injured and the likelihood of them resuming spontaneous adequate respirations after being down for 5 mins of succs is extremely low.
2. Throughout all of the data within the departments covered under our protocol, the incidence of a true failed airway (that is to say, not even a rescue airway could be inserted) was so extraordinarily low that it should be considered a statistical anomaly.
3. If, after knowing what we just covered, you're still uncomfortable for giving someone roc and paralyzing them for 30-45 minutes, don't give it. The fent, versed, and ketamine will likely be enough sedation to intubate them, however he does prefer we give the rocuronium if we're comfortable so as to minimize the risk of aspiration.

 

[EMT11KDL]

I personally like the fact you are using Fentanyl 2 mcg/kg. Also agree with Ketamine, but I would discuss with some more people and maybe increase your dose to 2mg/kg for induction than 1mg/kg for post intubation sedation.

Something else I would recommend you doing some research on, is High Flow Nasal Canula for about 5 mins prior to intubation. N/C Set at 15/L/Min. there is research going on both sides if it is beneficial or not, just do your own research and come up with your own opinion on the idea.

Now on another note. If you agency has not been intubating and not have an RSI protocol in place or even a Drug Assisted, there will need to be a lot of training and continuing education. Just like anything else, when something new is put on the truck everyone wants to use it, and it can be easily used inappropriately. RSI is a wonderful tool, but it does have its place.

Another thing to think about is your transport time and do you guys currently have a vent on the trucks, and do your medics know how to set up and trouble shoot the vent. Or are you guys going to Bag the patient all the way to the hospital.

3. If, after knowing what we just covered, you're still uncomfortable for giving someone roc and paralyzing them for 30-45 minutes, don't give it. The fent, versed, and ketamine will likely be enough sedation to intubate them, however he does prefer we give the rocuronium if we're comfortable so as to minimize the risk of aspiration.

If you are not comfortable using Roc, you should not be doing an RSI.

 

[FiremanMike]

Ah yes, I forgot about the high flow cannula, which we instituted this year. I don't know why it took so long for that to reach mainstream (that study was in the 60s, I believe) but it works wonderful. We perform the bulk of our pre and peri-intubation oxygenation with a cannula at 10-15lpm.. Great tool

 

[EMT11KDL]

Ah yes, I forgot about the high flow cannula, which we instituted this year. I don't know why it took so long for that to reach mainstream (that study was in the 60s, I believe) but it works wonderful. We perform the bulk of our pre and peri-intubation oxygenation with a cannula at 10-15lpm.. Great tool

it is required at my agency, and I personally like the idea and research behind it.

 

[TXmed]

There's more to RSI protocols than what is written on paper.

AEL wants to focus on oxygenation during the attempt, if the patients o2sat or SBP drop below 90 during attempt you immediately pull out and re-oxygenate. The goal is to not cause hypoxia while securing the airway. Also as far as premedication prior to induction isn't in the protocol because they found they were just drawing up to much medicine prior to intubating. And they wanted to focus more on oxygenation.

One suggestion if rsi is new to you. Hands on practice. Practice drawing up the medication , practice pushing the medication, practice pre-oxygenation, hands on practice not just talking about it.

 

[CANMAN]

OK, so your program wants to do RSI, but:

• Your medical director (apparently) isn't willing or able to design or teach the class.
• Your lead educator for this project will be someone who has only done the procedure himself a few times
• You don't even know if the paramedics at your service is any good at intubating
• You (apparently) aren't already training regularly in an OR, and don't know if you can get hands-on training in an OR
• Your paramedics are not already familiar with the basic adjuncts that you recognize are important to have, so they'll have to learn those at the same time that they'll be learning a critical new skill

What could possibly go wrong?

Agree 100% with Remi, and he pretty much highlighted all the points that need to be corrected before moving forward with an RSI program and education. Don't take this the wrong way, but chances are if your company doesn't even know some baseline first attempt success rates for it's current provider's, and judging off the information you have provided thus far, I would venture to say they're going to be pretty poor, or certainly not inline with tacking on an RSI program without some leg work. That leg work should be heavy on involvement from your Medical Director, and should establish clear guidelines for O.R. time, and skills assessment on a frequent basis. My program has quarterly requirements for live adult and pediatric intubations, as well as simulator intubations, and has bi-annual education and competency sessions we call WISER days. This past year we had a 96.7% first tube success rate across our entire system.

What are you guys currently using for rescue airways if you do not have training on the King Airway, and use of a bougie? Tossing RSI, along with new devices such as a bougie and King airways in the provider's laps all at one time I think is a terrible idea. That is alot to train everyone up on at one time, and also gives them 0 field time to gain experience with said tools before having to use them in a difficult airway or RSI gone bad scenario.

What is the plan going to be for ventilator management post RSI? Are you hand bagging 5 minutes to most of your ED's, in which case I would question if you even need RSI, or do you have extended transport times where the patient should be getting consistent rate/volume via a mechanical ventilator?

As far as protocols go, there are 10 ways to skin a cat, and maybe other provider's will have their opinions. Based on what has been posted I would make some changes personally. I agree with alot of FiremanMike's points, however would alter the cocktails, or at least give provider's some choices. Choices are great when you have high functioning provider's who are educated and can make solid decisions. I can understand why some places take more of a blanket approach. Based on my experience I am not a fan of Versed for induction. You typically need a hefty dose, and in alot of the population we are performing an RSI on it can put you in a hypotensive situation more often then not. Where I think it works well is in conjunction with Fentanyl for post RSI sedation with stable hemodynamics. Give provider's the option of Etomidate and Ketamine. We also ditched Succs in favor of just carrying Roc and Vec. We used to carry all three. For sedation we have Fentanyl, Versed, Propofol, Ketamine bolus and drip in our protocols. Without having this statement turn into a debate, I think the concept of "waking someone up" in a diffcult airway scenario is only appropriate for an O.R. type setting, where as previously described those patient's have been through pre op screening, and are generally stable for induction. If we make the decision to take someone's airway it's because it's indicated. Waking them up is going to put us in the same S sandwich we started with and put us no better off. If you can mask ventilate you DO NOT have an airway emergency and there is no shame in oxygenating and ventilating with a BVM on the way to the hospital if you cannot successfully intubate or place a rescue airway. If you are in a bad scenario where the patient needs an airway, you cannot establish one via ETT or rescue airway, and you cannot bag and maintain Spo2 of 90 or greater and ventilate then you go to a surgical airway and call it a day. Those are your choices in my opinion.

High flow nasal cannula for apneic oxygenation is a great thing, and I am glad a bunch of people on the board are doing it in the field. We still get crazy looks from MD's and Medics when we show up, RSI, and use that tool. It's our protocol for every RSI situation. Keep in mind it can assist you slightly with pre-oxygenation coupled with a non-rebreather, BVM, or whatever the situation indicates, however it's not going to increase your numbers once drugs are on board. It's designed to prolong your period of desaturation, and I think alot of people miss that concept.

TXmed, while I agree that focusing on oxygenation is extremely important, and ideally you want to start with the best numbers possible, sometimes clinically that just isn't possible. There are times where intubations occur with less then ideal sats or blood pressure because that is the best you can achieve given what is going on. To say we aren't going to proceed with intubation for a person who might be a trauma patient with a blood pressure of 80 systolic, or stop mid attempt is kinda silly in my opinion. Those number's are certainly going to guide my drug choices, or things we do in the preparation phase such as hyper elevating a morbidly obese person with crappy sats, but they aren't always going to prevent me from pulling the trigger on RSI if that's the best we have seen after some techniques which fail to improve the situation.

 

[Carlos Danger]

The specific protocol means little, IMO. Roc vs sux, ketamine vs. etomidate, fentanyl or not, versed or not, beta blockers or not, apneic oxygenation or not.....none of it matters, really. There are many ways to do an induction correctly, and none of these drugs or techniques has been shown superior to the others except in specific scenarios. If you know what you are doing, you can make pretty much anything work. If you don't know what you are doing, even the "best" protocol is not going to cover for that.

I do have to say I honestly don't see why so many people have decided seemingly overnight that rocuronium is superior to succinylcholine for RSI. I think what annoys me the most about this debate is that the "roc rules" crowd seems to primarily rest their opinion on the fact that "if you can't intubate, sux doesn't wear off fast enough to prevent severe hypoxemia anyway", which of course is true, but is totally a red herring argument because no one who knows what they are talking about has ever argued that that is a reason to use sux.

It's OK to prefer roc, but if you want to convince others that you actually have a reasoned basis for your preference, you really need a better argument than not wanting to remember sux's contraindications, or that "you shouldn't be waking up a patient who you were trying to RSI". You use sux because it is faster and denser and more predictable, not because you think you might change your mind about the patient needing a tube.

Roc clearly has a place in RSI, such as when sux is contraindicated. Both drugs have small (but potentially significant) advantages over the other, but it is important to understand that those advantages really only matter on the margins, and it doesn't make a difference which one you use in 99.9% of cases. It's that 0.1% where you will wish you used the one you didn't. One is not clearly superior to the other. I think those folks who are totally convinced that roc is always a better choice are every bit as wrong as someone who thinks that sux is always a better choice.

 

[CANMAN]

The specific protocol means little, IMO. Roc vs sux, ketamine vs. etomidate, fentanyl or not, versed or not, beta blockers or not, apneic oxygenation or not.....none of it matters, really. There are many ways to do an induction correctly, and none of these drugs or techniques has been shown superior to the others except in specific scenarios. If you know what you are doing, you can make pretty much anything work. If you don't know what you are doing, even the "best" protocol is not going to cover for that.

I do have to say I honestly don't see why so many people have decided seemingly overnight that rocuronium is superior to succinylcholine for RSI. I think what annoys me the most about this debate is that the "roc rules" crowd seems to primarily rest their opinion on the fact that "if you can't intubate, sux doesn't wear off fast enough to prevent severe hypoxemia anyway", which of course is true, but is totally a red herring argument because no one who knows what they are talking about has ever argued that that is a reason to use sux.

It's OK to prefer roc, but if you want to convince others that you actually have a reasoned basis for your preference, you really need a better argument than not wanting to remember sux's contraindications, or that "you shouldn't be waking up a patient who you were trying to RSI". You use sux because it is faster and denser and more predictable, not because you think you might change your mind about the patient needing a tube.

Roc clearly has a place in RSI, such as when sux is contraindicated. Both drugs have small (but potentially significant) advantages over the other, but it is important to understand that those advantages really only matter on the margins, and it doesn't make a difference which one you use in 99.9% of cases. It's that 0.1% where you will wish you used the one you didn't. One is not clearly superior to the other. I think those folks who are totally convinced that roc is always a better choice are every bit as wrong as someone who thinks that sux is always a better choice.

I agree with you, I wish we still had Succs personally, however it got pulled from our protocols this last go round and thus is life. We do alot of peds where I work and the peds docs are always so anti-succs for alot of the patient population, certainly under 8 due to possibility for a undeclared neuromuscular disorder. Couple that with watching out for contraindications like a hx of malignant hyperthermia, although rare, hyperkalemia, occular trauma, I think our medical director's just went in favor of carrying less agents. I was always a succs fan, and I also believe that if you can't select the proper medication regiment then you shouldn't be perform the skill, but I enjoy where I work and challenging our medical director over something that means very little to me just isn't worth it.

 

[FiremanMike]

The specific protocol means little, IMO. Roc vs sux, ketamine vs. etomidate, fentanyl or not, versed or not, beta blockers or not, apneic oxygenation or not.....none of it matters, really. There are many ways to do an induction correctly, and none of these drugs or techniques has been shown superior to the others except in specific scenarios. If you know what you are doing, you can make pretty much anything work. If you don't know what you are doing, even the "best" protocol is not going to cover for that.

I do have to say I honestly don't see why so many people have decided seemingly overnight that rocuronium is superior to succinylcholine for RSI. I think what annoys me the most about this debate is that the "roc rules" crowd seems to primarily rest their opinion on the fact that "if you can't intubate, sux doesn't wear off fast enough to prevent severe hypoxemia anyway", which of course is true, but is totally a red herring argument because no one who knows what they are talking about has ever argued that that is a reason to use sux.

It's OK to prefer roc, but if you want to convince others that you actually have a reasoned basis for your preference, you really need a better argument than not wanting to remember sux's contraindications, or that "you shouldn't be waking up a patient who you were trying to RSI". You use sux because it is faster and denser and more predictable, not because you think you might change your mind about the patient needing a tube.

Roc clearly has a place in RSI, such as when sux is contraindicated. Both drugs have small (but potentially significant) advantages over the other, but it is important to understand that those advantages really only matter on the margins, and it doesn't make a difference which one you use in 99.9% of cases. It's that 0.1% where you will wish you used the one you didn't. One is not clearly superior to the other. I think those folks who are totally convinced that roc is always a better choice are every bit as wrong as someone who thinks that sux is always a better choice.

I'm not sure if this is directed at me, but if it is, I really don't have much of a preference between roc and succs. Like you, I like either for specific situations, but also like you, I only function as a paramedic because my medical director says I can, so I use what I'm given.

If your rant is based on my medical directors explanation to our providers as to why it's not a "big deal" to give a paralytic that lasts for 30-45 minutes as opposed to one that lasts for 3-5 (which was the entire point of contention of our cohort and had nothing to do with side effects), I'll be sure to let him know that "Remi from the internet" says his explanation is dumb and that he should have approached it differently.

 

[Carlos Danger]

I'm not sure if this is directed at me

It wasn't. If it had been, I would have quoted your post. I was just commenting on a current trend.

If your rant is based on my medical directors explanation to our providers as to why it's not a "big deal" to give a paralytic that lasts for 30-45 minutes as opposed to one that lasts for 3-5 (which was the entire point of contention of our cohort and had nothing to do with side effects), I'll be sure to let him know that "Remi from the internet" says his explanation is dumb and that he should have approached it differently.

This is the second time you've threatened that recently. I would suggest that rather than taking anonymous internet posts personally, you instead look at the overall point and take it for whatever it's worth to you.

 

[FiremanMike]

It wasn't. If it had been, I would have quoted your post. I was just commenting on a current trend.

Fair enough

This is the second time you've threatened that recently. I would suggest that rather than taking anonymous internet posts personally, you instead look at the overall point and take it for whatever it's worth to you.

I would suggest you do the same?

Look Remi, you likely have a good amount of experience and points to share to help grow our knowledge base. Unfortunately, the vast majority of your message is lost because you aggressively assert a "my opinion is the only right one and if you don't agree, you're a bad provider" tone. This tends to intimidate newer folks and cause them to not want to ask questions to get clarification on things that you are saying that is likely over their head, and it tends to turn off experienced guys like myself who deal with exhausting attitudes like yours at work and don't feel like continuing it on an internet forum. I certainly hope this attitude doesn't follow you into your professional life, as I find people like that to be dangerous.

I'm not pompous enough to think that my tip will change your posting style around here, but I do hope that I can plant a seed to eventually quell your abrasiveness so that we can all learn from each other.

On a final note, as for my "threat" of invoking the almighty "Remi from the internet" during my workday, they're jokes meant to lighten the mood.

 

[STXmedic]

Not contributing anything to the topic, but

1) Remi, I really enjoy reading your posts. I don't always agree with what you say, but much of what you post stimulates my urge to research something- much in the same way Veneficus used to.

2) OP, are you still working in S. Texas? If so, which service is trying to add RSI?

Otherwise, I'll echo what others have said. Implementing RSI involves far more than a PowerPoint lecture and flexible protocols. My department implemented it on a small scale (about 20 medics) about a year ago. We had a week of lecture from several different physicians, have monthly lectures from our associate medical directors, and quarterly skills verification. That has felt like just barely enough.