RSI: Critical Decision Making (Advanced Provider response requested)

8jimi8

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Sorry this may be reposted, because i hit send, but the I couldn't find my thread.


So I am doing my RSI homework and reading drug profiles.

Concerning paralytics, what do you consider prior to choosing your paralytic. Do you have more than one option? Is it only a depolarizing or nondepolarizing? Do you have a choice between benzylquinolinium compounds or aminosteroidal compounds?

I see the various duration of actions, time of onset, side effects (histamine release, hypotension, tachycardia, increase in SBP, potentiation of hyperkalemia, bradycardia, increased intraocular pressure, among many others), 25% recovery times

Is it easy to make a decision because of protocols, or do you have autonomy and an excellent tool box?
 

Shishkabob

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As far as paralytics go, we just have Roc, easy choice there. If they need RSI, they get Roc.

The decision comes in pre-medication drugs such as Fent, lidocaine and nebulized lidocaine... then the sedative, which while technically is supposed to be etomidate, we have Ativan and Versed as well.



Really, the tough decision for me is deciding who gets tubed, and who can wait till we're at the hospital with more resources.
 

johnmedic

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For paralyzing agents, the only options I've worked with in the field are Succinylcholine (depolarizing) & Vecuronium (nondepolarizing) & basically the reasoning behind one vs the other is duration of effect based on transport times.
 

NomadicMedic

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We have several choices for RSI. Our paralytic choices are Succinylcholine, Roc or Vec. Obviously we stay away from Sux with patients that are or may become hyperkalemic, have eye injuries, pregnant or present with liver or kidney disease due to the decrease of plasma cholinesterase in these patients.

We also have a few sedation choices available; Versed, Ativan or Etomidate. I prefer to use at least 5mg of Versed and an analgesic like Fentanyl as my starting point for RSI.

Every RSI that we perform is reviewed by the QI team and the medical director. It's a system that gives us some freedom to make good choices based on the patient.
 

M3dicDO

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You bring up an interesting discussion. I have personally never seen Benzylisoquinonlines being used in a transport setting. It's usually been the Steriodal compounds that have been the most popular in Emergency Medicine, both in-hospital and pre-hospital.

When I worked as a critical care provider, I paralyzed patients based on one important question: Who long will I need to keep this patient paralyzed?
I used a short acting paralytic (i.e. sux) when:
  1. I was expecting a tough intubation and wanted the patient to resume breathing if intubation was not successful....just in case
  2. The receiving facility wanted the patient to not be paralyzed on arrival for a neuro exam (i.e. CVA patient)
=]
After a successful intubation, I usually gave Vecuronium to keep them paralyzed so I wouldn't have to keep worrying about the vent beeping all the time with high airway pressures. Made life a lot easier for me, especially for for the patient (with enough sedation of course ^_^)

A lot of my professors (ER docs) only use succinylcholine in the ED, and use the alternative paralytics when it's contraindicated. An attending used Pavulon on a trauma patient as the initial paralytic for RSI. It was his choice to use a super long-acting paralytic, but I wouldn't have. Sure the ED has neostigmine on hand, but why mess with worrying about reversal agents if you can't get the tube??!!

Bottom line, most critical-care protocols give medics and nurses the ability to choose paralytics based on the patient's best interest. I was able to mix and match at both my critical care transport jobs. I guess it all depends on how much your medical director lets you play with.....:wacko:
 

rhan101277

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Really, the tough decision for me is deciding who gets tubed, and who can wait till we're at the hospital with more resources.

This ......


studies show that intubated people are 8 times more likely to die than people not intubated even in the hospital. Whether this is due to MOI or something else "not fully understood". I will intubate someone if it becomes necessary, RSI or otherwise. If I can effectively bag someone and they are not vomiting and there is not tons of blood around that could be aspirated then they are getting bagged.
 

Smash

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studies show that intubated people are 8 times more likely to die than people not intubated even in the hospital. Whether this is due to MOI or something else "not fully understood". I will intubate someone if it becomes necessary, RSI or otherwise. If I can effectively bag someone and they are not vomiting and there is not tons of blood around that could be aspirated then they are getting bagged.

Would you mind posting these studies? It's a bit of a meaningless statement without some context.

RSI is not necessarily just about airway control, there are many aspects of different patient presentations that may be managed with appropriate sedation and paralysis.

As for the OP's question: it comes down to what the MD is happy with you doing. In the setting of emergent cases where RSI is considered, it typically comes down to an argument between suxamethonium or rocuronium (other stuff like cisatracurium and what not aren't very common, vecuronium... meh) So really, it's either depolarising or non-depolarising.

Proponents of depolarising will cite suxamethonium's short duration of action as a good reason to use it: if you can't intubate it wears off quickly and the patient can breath again. On the downside there are a number of potential problems: hyperkalemia in some settings, raised intra-ocular pressure (although this may not be clinically significant) and so on.

On the other hand, rocuronium takes slightly longer than sux to have an effect (although this may not be clinically significant either), but takes longer to wear off, leaving you with a non-ventilating patient. However, there are not the same concerns with the side effects like there are with sux.

BUT! While sux may wear off quickly, even healthy people will most likely still desaturate without ventilations being provided (1,2,3), so maybe the "short duration" argument is moot. Of course on the flip side, neuromuscular blockade may actually make bag-mask ventilation easier (4). Of course this is fine in your fasted patient, it may be sub-optimal in the typical "full of beer and pizza" patient we see. I'm keen to try the no desat method put forward by Dr Rich Levitan to see how well that works, it seems compelling and may remove this problem.

Rocuronium on the other hand may actually provide an increased amount of time to achieve intubation before desaturation occurs, possibly due to the lack of fasciculations with it's use (5). However, how well this translates to the critically ill patient is unclear, as this study was in elective patients.

Sooooo..... where does this leave you? Beats me, all I have is sux for initial paralysis to achieve intubation, pancuronium for ongoing paralysis! To be fair I don't have too much of a problem with sux. I think the "can't ventilate" scenario should be a relatively rare beast anyway, especially if you are judicious about who you decide to give drugs to. A lot of the problems with sux are kind of irrelevant or at least not clinically significant.

However, if I HAD to pick ONE agent, it would be rocuronium which if nothing else is versatile.

There, glad I cleared that up for you! :wacko: :unsure: :p


1. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine.
Anesthesiology. 1997 Oct;87(4):979-8

2. Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers.
Anesthesiology. 2001 May;94(5):754-9

3. Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients
Anesthesiology. 2005 Jan;102(1):35-40

4. The effect of neuromuscular blockade on mask ventilation
Anaesthesia. 2011 Mar;66(3):163-7

5. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction
Anaesthesia. 2010 Apr;65(4):358-61
 

Veneficus

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Sorry this may be reposted, because i hit send, but the I couldn't find my thread.


So I am doing my RSI homework and reading drug profiles.

Concerning paralytics, what do you consider prior to choosing your paralytic. Do you have more than one option? Is it only a depolarizing or nondepolarizing? Do you have a choice between benzylquinolinium compounds or aminosteroidal compounds?

I see the various duration of actions, time of onset, side effects (histamine release, hypotension, tachycardia, increase in SBP, potentiation of hyperkalemia, bradycardia, increased intraocular pressure, among many others), 25% recovery times

Is it easy to make a decision because of protocols, or do you have autonomy and an excellent tool box?

I have a big tool box :)

Most of the anesthesiologists tell me that there are several drugs for several purposes that do an equally good job just usually in different ways.

Provider comfort is the largest deciding factor in what drugs are usually selected in anesthesia. Next is cost.

Personally I like vecuronium, and of course substitute Roc for head injury. Why? I am comfortable with them. I know what should happen, when it is happening, and the most common problems that creep up.
 

Shishkabob

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If you make a non-depolarizing paralytic like Roc, with the short onset and duration of Succs, but none of the downsides of Succs, man... you'll make a fortune.
 

usalsfyre

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This ......


studies show that intubated people are 8 times more likely to die than people not intubated even in the hospital. Whether this is due to MOI or something else "not fully understood". I will intubate someone if it becomes necessary, RSI or otherwise. If I can effectively bag someone and they are not vomiting and there is not tons of blood around that could be aspirated then they are getting bagged.

I'd be REALLY interested in seeing this research as well and how they adjust for ISS.
 

usalsfyre

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Sorry this may be reposted, because i hit send, but the I couldn't find my thread.


So I am doing my RSI homework and reading drug profiles.

Concerning paralytics, what do you consider prior to choosing your paralytic. Do you have more than one option? Is it only a depolarizing or nondepolarizing? Do you have a choice between benzylquinolinium compounds or aminosteroidal compounds?

I see the various duration of actions, time of onset, side effects (histamine release, hypotension, tachycardia, increase in SBP, potentiation of hyperkalemia, bradycardia, increased intraocular pressure, among many others), 25% recovery times

Is it easy to make a decision because of protocols, or do you have autonomy and an excellent tool box?

Smash pretty well covered this, but I'll throw my two cents in...

There are really only three neuromuscular blockers that you will commonly see on ambulances, and I dare say, EDs, all are aminosteroids (every once in a while you might see someone get fancy with something like cisatracurium in the hepaticly impaired patient, but not often). Succinylcholine, roccuronium and vecuronium are the agents in question.

The first thing to cover is why we give a paralytic in the first place. The number #1 reason is to prevent active regurgitation in the non-NPO patient. If you paralyze them, they can't gack. Everything else, optimizing intubation conditions, release of trismus, ect is a happy side effect.

For the initial induction the common choices are succinylcholine and roccuronium. Succinylcholine has a slightly shorter onset time, but comes with a whole bag full of nasty side effects. The BIG, BIG one we're concerned about is the potasium release, followed somewhat by concerns over MH (bonus, who knows how to reverse malignant hypertermia associated with succinylcholine administration?).

What's NOT (never, no way, do not pass go, ect) an approprite reason to chose succinylcholine is the short duration. More on this in my next post.

Roccuronium has an onset that is nearly that of succinylcholine without the ugly side effects. We got rid of succinylcholine a year ago in favor of it. I thought I would miss the onset. I can't say I've honestly noticed a clinically significant difference.

Vecuronuim is a longer acting med, with a longer onset time. The danger here is the patient will vomit prior to the vec taking effect (there's a reason it's nicknamed "vomidate"). It's probably not the med of choice, but if you put a gun to my head, there's still significant patient populations in which I'd choose it over succinylcholine.
 

usalsfyre

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[*]I was expecting a tough intubation and wanted the patient to resume breathing if intubation was not successful....just in case
Nope, wrong answer. WRONG, WRONG answer. You've decided the patient needs their airway protected/mechanical ventilation. So you assess them and decide they're going to be a difficult airway. Why in the Jack Stout would you paralyze them at this point? Why not use another option like awake intubation? Or simply be willing to sedate and place an alternative device if intubation fails? Or for that matter just use good manual airway manuvers, optimal positioning, suction and BVM to assist the patient. Using paralytics in this manner is asking to fail. Succinylcholine's duration of action is not short enough to NOT kill you from hypoxia. Not to mention you are now EXACTLY back where you started, but we're 7-10 minutes down the line with likely no progress towards a recieving facility. An ETT is NOT the "Gold Standard" of airway management. Oxygenation, ventilation and prevention of aspiration are. None of which an ETT inately provides. Makes easier perhaps, but all of the above can be provided by a providers hands, a BVM and a couple of suction apparatus. Attitudes like this are what get succinylcholine taken away.

After a successful intubation, I usually gave Vecuronium to keep them paralyzed so I wouldn't have to keep worrying about the vent beeping all the time with high airway pressures. Made life a lot easier for me, especially for for the patient (with enough sedation of course ^_^)

Again WRONG, WRONG answer. If you were routinely bumping high airway pressures, you almost assuredly did not have adaquately sedated and pain controled patients. The FIRST intervention if your continuely geting high airway pressures is pain control, followed by sedation. Understand that the doses that the hospital has been using may be inadaqaute in the transport environment, there's a lot more stimulus going on. I believe it was old_school recently made an excelent point about doing all you could to block out stimulus, meaning limbs are aligned, eyes lubed taped shut and hearing protection placed. Long-term neuromuscular blockade very rarely makes things "easier" for the patient. What your describing is inapproprite use of medication to make life easier on you, which is, in a word, lazy.

A lot of my professors (ER docs) only use succinylcholine in the ED, and use the alternative paralytics when it's contraindicated. An attending used Pavulon on a trauma patient as the initial paralytic for RSI. It was his choice to use a super long-acting paralytic, but I wouldn't have. Sure the ED has neostigmine on hand, but why mess with worrying about reversal agents if you can't get the tube??!!

I agree, but why not place an alternative airway in this case, and call anesthesia to for further management if called for, or let them replace it with an ETT in the OR under controled conditions? This is a better option than letting them "wake up".

Bottom line, most critical-care protocols give medics and nurses the ability to choose paralytics based on the patient's best interest. I was able to mix and match at both my critical care transport jobs. I guess it all depends on how much your medical director lets you play with.....:wacko:

Bottom line is you repeated some of the most common misconceptions that get people into trouble with paralytics. Understanding the endpoint goals here is key to best serving the patient's interest.
 
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usalsfyre

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Alternatively, problem solved if the FDA ever get round to approving Sugammadex

Ehhh, Combitubes, LMAs and King Airways have the problem pretty well whipped as it is. What's important is getting people to get over their egos enough to realize supraglotic airways aren't the "tube of shame" :rolleyes:.
 

MrBrown

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Gosh Browns loves Smash to bits, Frank Archer would be so proud! :p

We have suxamethonium followed by vecuronium and they seem to work very well, we have a close to 100% success rate with RSI.
 

NomadicMedic

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Bonus, who knows how to reverse malignant hypertermia associated with succinylcholine administration?

Dantrolene. A drug we don't carry, but should. It's cheap and has a long shelf life.

I asked a doc about it. He shrugged and said, "If you're RSIing a patient, MH is the least of their worries."
 

reaper

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Only option prehospital is active cooling and fluid challenges. Try to keep temps under control till you reach the ED.
 

usalsfyre

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Dantrolene. A drug we don't carry, but should. It's cheap and has a long shelf life.

I asked a doc about it. He shrugged and said, "If you're RSIing a patient, MH is the least of their worries."

You win $100,000. The checks in the mail. You may wanna wait till Firday to cash it :D :p

I will say MH itself can be a death sentence. MH on top of the condition your RSIing the patient for would certainly make for an uhhh "interesting" clinical course (yeah, that's it, interesting....)
 
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usalsfyre

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Very sorry if I seemed blunt before. This is one of my pet peeve issues.
 
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