Lido for RSI?

[BLSBoy]

Had an interesting conversation in my NREMTP Prep class today.

The situation posed was a pt with a probable head injury, unable to protect his airway. He has a gag reflex, and you need to intubate.

One school of though was to use a large amount of Versed to knock the pts gag relex out, then intubate.

Another was RSI using Versed, Lido (1mg/kg) and Sux.

The first person said that Lido has shown no reduction of ICP, and giving Sux will increase the ICP. So instead of furthering the ICP, just hope that the Versed will knock out the gag reflex.

I said that Lido has shown some reduction in reducing ICP, and that relying solely on Versed was near malfeasence.

I have been studying since I got home, and have not searched, other then a quick search on here, since I will be going back to studying, and thats why I am relying on the large brain power of the group here.

 

[reaper]

We have pulled Lidocaine out of our RSI protocols. New studies show it has minimal effect on ICP.

You can try Versed only, if it does not work, give Sucs. I would be more worried with the airway at the moment, then with the small increase in ICP.

 

[Flight-LP]

Snowing a patient with a benzo is doing it half arsed and completely unacceptable. It has been statistically proven that you stand a better chance of successfully controlling an airway with the proper use of a induction agent. In fact, most agencies are now shying away from Versed and opting for Etomidate as it has minimal (if any) hemodynamic effects on the pt.............

The debate is really quite simple. Think of your basics. "A" is for airway, plain and simple. In the case of a crash airway in a pt. with intact gag, Succs is still your best bet to get them down and get them tubed. Unless your shoving in ICP transducers, you will have no idea what the ICP is doing anyways. Is Cushing's triad present? Then all the more reason to get them intubated as quick as possible.............

Lidocaine has not shown statistical value in keeping ICP down. But, by the same token, if the ICP is acceptable, then how exactly would you see the prevention of rising ICP? Again, you have no monitoring capabilities to qualify a factual account concerning their ICP. Personally, I rarely give it for TBI patients............

In my perfect little world, I would sedate with Etomidate (no hemodynamic effects), induce with Zemeron (Non depolorizing agent with rapid onset and moderate paralysis time), and maintain with Propofol (good 'ol milk of amnesia!). Sometimes RSI is an art, you have to find that perfect combination for each individual pt. Unfortunately for EMS, most have zero clue when it comes to RSI, so its availability is limited and choices of agents few.............

 

[mycrofft]

Start your chronographs.....and do no harm.

Resp embarassment: usually three minutes to start of biological death.

DEATH BY IICP: how long?
Can you tx it without a patent airway?

TIME TO HOSPITAL: how long?

Mix well and serve.

 

[mycrofft]

Flight, with all that good stuff, you ever go blowgun hunting?

.............

 

[jedirye]

Snowing a patient with a benzo is doing it half arsed and completely unacceptable.

Unfortunately not all services have the capabilities of RSI, and thus this "half assed" method is all we've got. Airway or no airway? Any medicinal help seems like a ray of light out of a dark sky...

-rye

 

[Flight-LP]

If its all you got, then its all you got. But, its still half assed. Sorry, it is what it is. No one faults you for your medical director's decisions.

But honestly, I would attempt a blind nasotracheal intubation before resorting to snowing a pt. with benzo's......................

 

[reaper]

Unfortunately not all services have the capabilities of RSI, and thus this "half assed" method is all we've got. Airway or no airway? Any medicinal help seems like a ray of light out of a dark sky...

-rye

Rye,

Where in FL are you at? Most ALS services in the state have RSI protocols. This may be something you want to talk with your MD about.

 

[VentMedic]

Rye,

Where in FL are you at? Most ALS services in the state have RSI protocols. This may be something you want to talk with your MD about.

Not all, nor should all have RSI protocols. Please see Naples FD article in the EMS news section.

As far as Lido, not enough evidence to show it does much good and not enough evidence to show it does harm. Some still have it in their protocols and some don't. We don't.

Lido is rarely if ever given before suctioning TBI pts in the ICUs. It used to be a standard many years ago but no evidence proved significant to continue the practice.

 

[boingo]

RSI is not for everyone, just because system X uses it doesn't mean it is appropriate for Y and Z.

 

[MSDeltaFlt]

Not all, nor should all have RSI protocols. Please see Naples FD article in the EMS news section.

As far as Lido, not enough evidence to show it does much good and not enough evidence to show it does harm. Some still have it in their protocols and some don't. We don't.

Lido is rarely if ever given before suctioning TBI pts in the ICUs. It used to be a standard many years ago but no evidence proved significant to continue the practice.

We have Lido in our protocols as well. Fortunately we also have a crash airway protocol where you only use Sux to put them down, then Versed and Norcuron to keep them down (used on scene flights). Thank God. The vast majority of TBI pts I've flown that needed airway control, needed it right there, right then.

Don't get me wrong. You never rush the care you give your pts. You also don't dilly dally either. If Lido works, it's going to work in how much time? A minute and a half or so? Push the sux. Put them down. Put it in. Secure it. *Get going. *Keep them down. (*)Depending on how soon you can get going, you may need to keep them down before you go.

On IFT's, we go through the whole 9 yards.

 

[bonedog]

A surgeon is what is really needed. Unless transport or extrication is long and convoluted, basic airway management may be preffered.

Benzo's can have such a deliterious effect on MAP-CVP, but what's a poor man to do? Unfortunately in the Great White North etomidate is restricted.

As a brilliant intensivist once said, I'd rather ROC than SUC.

 

[Ravemtech]

Hi Bonedog,

For your brilliant Intensivest and others who who think that rapid transport rather than RSI is the always the way to go, here is a new study that clearly shows a well trained large organisation has better patient outcome with prehospital RSI, than load and go with basic airway management. It may just be worth a read.

Objective: To determine whether paramedic rapid sequence intubation in patients with severe traumatic brain injury (TBI) improves neurologic outcomes at 6 months compared with intubation in the hospital.

Background: Severe TBI is associated with a high rate of mortality and longterm morbidity. Comatose patients with TBI routinely undergo endo-tracheal intubation to protect the airway, prevent hypoxia, and control ventilation. In many places, paramedics performintubation prior to hospital arrival. However, it is unknown whether this approach improves outcomes.

Methods: In a prospective, randomized, controlled trial, we assigned adults with severe TBI in an urban setting to either prehospital rapid sequence intubation by paramedics or transport to a hospital emergency department for intubation by physicians. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end-points were favorable versus unfavorable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge.

Results: A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%. At 6 months, the median GOSe score was 5 (interquartile range, 1–6) in patients intubated by paramedics compared with 3 (interquartile range, 1–6) in the patients intubated at hospital (P = 0.28). The proportion of patients with favorable outcome (GOSe, 5–8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% confidence interval, 1.00–1.64; P = 0.046). There were no differences in intensive care or hospital length of stay, or in survival to hospital discharge.

Conclusions: In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.
(Ann Surg 2010;252:959–965)

PS: No Lidocaine is used (protocol is Fentanyl / Midazolam then Sux. Once RSI is completed and confirmed with a range of checks including SPO2 and ETCO2, Morph/Midaz infusion and Pancuronium is used to maintain paralysis and sedation).

 

[bonedog]

Ravemtech, looks like favourable outcomes.

What method's were used to keep MAP up?

I have used small aliquot's of epi, many in our service are using phenylephrine for the same purpose's. With the deliterious effects of dropping intracerebral perfusion pressures this is paramount.

The key is well trained perficient medic's. Our service is targeted so in the large center's intubation skills are kept high. Most refer to rescue airways as the "airway of shame".

My brilliant intensivist is very much pro street intubation, and a great proponent for our practise.

 

[usalsfyre]

Ravemtech, looks like favourable outcomes.

What method's were used to keep MAP up?

I have used small aliquot's of epi, many in our service are using phenylephrine for the same purpose's. With the deliterious effects of dropping intracerebral perfusion pressures this is paramount.

The key is well trained perficient medic's. Our service is targeted so in the large center's intubation skills are kept high. Most refer to rescue airways as the "airway of shame".

My brilliant intensivist is very much pro street intubation, and a great proponent for our practise.

Using neo and ephedrine for this purpose is great, but I'm not sure "airway of shame" is a good way of looking at backup airways.

 

[Shishkabob]

Shoot, whichever airway I get, that works, is an airway of celebration.

 

[bonedog]

Using neo and ephedrine for this purpose is great, but I'm not sure "airway of shame" is a good way of looking at backup airways.

You are bang on there, a culture change is probably needed for the laryngoscope weilding warriors........brutaine is the only Rx needed for some!!!

 

[Ravemtech]

Ravemtech, looks like favourable outcomes.

What method's were used to keep MAP up?

Sorry for the delay in replying, a prefluid loading of 10 ml/kg NaCl is undertaken. Here is the link to the actual trial RSI protocol used in the study - http://www.rav.vic.gov.au/Media/docs...979e76d996.pdf

And attached is the full article.