RSI Medications and Use

[TransportJockey]

For airway I have Benumoff & Hagberg's Airway Management, Manual of Emergency Airway Management, and a few others......Manual of Emergency Airway Management is a great text that I highly recommend.

I have the newest edition of the manual of emergency airway management. Great book.

 

[Carlos Danger]

Cool. Thank you for the info. We actually carry sux but everyone at my service tends to prefer Roc for the most part

Roc seems to be growing in popularity for RSI, and I'm really not sure why.

 

[TransportJockey]

Roc seems to be growing in popularity for RSI, and I'm really not sure why.

For us its due to a shortage of vec. We carried vec, roc, and sux and haven't seen any vec in months

 

[DesertMedic66]

Roc is a fairly common one for our trauma center to use

 

[Brandon O]

Roc seems to be growing in popularity for RSI, and I'm really not sure why.

If you mean versus sux, there's a feeling that the -oniums have the benefit of longer duration without the (not common but real) problems of sux such as potassium issues. People are starting to think that if you're relying on the "short halflife" of sux to rescue a failed airway, there's going to be a long line of bodies, because even sux lasts too long to sit there and wait.

If you mean versus the others in the class, ask someone who doesn't fake his way through pharm by waving his hands a lot...

 

[Handsome Robb]

Wow thank you Remi, that makes a lot more sense.

 

[Tigger]

If you mean versus sux, there's a feeling that the -oniums have the benefit of longer duration without the (not common but real) problems of sux such as potassium issues. People are starting to think that if you're relying on the "short halflife" of sux to rescue a failed airway, there's going to be a long line of bodies, because even sux lasts too long to sit there and wait.

If you mean versus the others in the class, ask someone who doesn't fake his way through pharm by waving his hands a lot...

I have never quite understood the absolute requirement for the use of sux in our RSI protocol. One of the absolute rule outs for RSI here is (straight from the protocol) "do I think I can intubuate this patient?" But if in the back of your mind you're thinking "aw well if I don't get it I can just bag em for five minutes," you're doing it wrong. I wonder if the decision to RSI would be taken more seriously if they didn't have this poorly thought out backup plan on the mind.

 

[Carlos Danger]

If you mean versus sux, there's a feeling that the -oniums have the benefit of longer duration without the (not common but real) problems of sux such as potassium issues. People are starting to think that if you're relying on the "short halflife" of sux to rescue a failed airway, there's going to be a long line of bodies, because even sux lasts too long to sit there and wait.

See, I think the exact opposite is true. No one is talking about "sitting there and waiting". From my experience, in emergency airway management, when folks encounter trouble it often either never even occurs to them to mask ventilate, or they are so afraid of the potential consequences (but what if he aspirates!?!?) that they won't do it unit the sats are in the basement. A big part of that, I know, is lack of skill and confidence in mask ventilation.

I'm aware of the argument that critical desaturation can occur before the sux wears off and spontaneous respirations resume. That's only true, however, if pre-oxygenation was unsuccessful, apneic oxygenation doesn't work, AND you are unable to get any breaths at all in with a mask. That amounts to a truly minuscule percentage of emergency airways. As long as you can get at least a handful of breaths in, most patients will be alright for the 3-4 minutes between when you discover this is a really hard intubation and when the sux wears off. This assumes that you haven't mangled the airway with repeated intubation attempts, of course. It's true that critical desaturation may occur before the sux wears off; but it absolutely will occur before long before the roc wears off.

Now, the duration of paralysis doesn't really matter in a truly emergent airway, because if someone really NEEDS their airway secured, then you are going to do it no matter what, which of course means a cric if intubation and an SGA fails. The problem with applying that reasoning routinely (and thus making a policy of using a long-acting NMB for every RSI) is that many RSI's are actually elective and not truly emergent. On the surface that may seem like semantics, but it's really not......I think there's a big difference, ethically speaking, between exposing someone to the risk of cutting their neck because you found them in a way that necessitates it, and electively choosing to put them in a position where you will have no choice but to cut their neck if your skills aren't up to what their airway requires. Also, even though roc is pretty quick at the 1.2 mg/kg dose, it still isn't as quick and predictable as sux. If you are really worried about someone being a tough airway and desaturating quickly, I'd much prefer the drug with the 30 second faster onset at the larynx.

All of this would be moot if there were a really good reason to avoid sux. But outside of a few specific populations, there isn't. I heard a podcast on Emcrit a while back where they were arguing for roc in lieu of sux for RSI, and they had all these rationalizations for why it's not more dangerous, but the only reason I remember hearing for why they wanted to avoid sux was basically "we don't want to have to remember who not to give it to". Oh, OK.

I have never quite understood the absolute requirement for the use of sux in our RSI protocol. One of the absolute rule outs for RSI here is (straight from the protocol) "do I think I can intubuate this patient?" But if in the back of your mind you're thinking "aw well if I don't get it I can just bag em for five minutes," you're doing it wrong. I wonder if the decision to RSI would be taken more seriously if they didn't have this poorly thought out backup plan on the mind.

The very FIRST question you should ask yourself when you contemplate paralyzing someone is, "can I mask ventilate this patient?" Whether or not you can intubate is moot if you can mask ventilate. Not to mention the fact that clinicians (including anesthesiologists, though they are better than anyone else) are notoriously bad at predicting difficult airways.

This is also why I think RSI in the field should be limited to truly emergent airway scenarios. When you only do a few intubations a year, you should not be giving paralytics unless it is the only way to manage the airway. We have gone waaay overboard with the "if you even consider intubation, you should do it, and if you can't get it, no biggie, just slice their neck open" thing.

 

[Brandon O]

I think what it comes down to is that you should not routinely be paralyzing people, poking around the airway, and then saying, "Oops, this was a mistake. Abort!" Between not doing it at all when you don't need to, and properly evaluating your odds beforehand, this should be vanishingly rare.

But perhaps not nonexistent, so I don't completely disagree with you. It's always nice to have yet another layer to fall back on. And part of the paradigm these folks seem to be using is that, if it's not truly do-or-die, then you probably have time to do something more controlled and elective like an awake intubation or whatever. And most of those options aren't really available in the field.

 

[Tigger]

The very FIRST question you should ask yourself when you contemplate paralyzing someone is, "can I mask ventilate this patient?" Whether or not you can intubate is moot if you can mask ventilate. Not to mention the fact that clinicians (including anesthesiologists, though they are better than anyone else) are notoriously bad at predicting difficult airways.

This is also why I think RSI in the field should be limited to truly emergent airway scenarios. When you only do a few intubations a year, you should not be giving paralytics unless it is the only way to manage the airway. We have gone waaay overboard with the "if you even consider intubation, you should do it, and if you can't get it, no biggie, just slice their neck open" thing.

That is also part of the decision making scheme, I just didn't include it.

Selection Criteria for RSI:
1. Can I get a good facial seal with the Bag-Valve-Mask?
2. Is the airway patent?
3. Do I think I can intubate this patient?
If the answers to any of the above questions are no, the patient is ruled out
as an RSI candidate.

 

[chaz90]

This is also why I think RSI in the field should be limited to truly emergent airway scenarios. When you only do a few intubations a year, you should not be giving paralytics unless it is the only way to manage the airway. We have gone waaay overboard with the "if you even consider intubation, you should do it, and if you can't get it, no biggie, just slice their neck open" thing.

Have you seen much of this attitude from providers, EMS or otherwise? I'm genuinely curious, because I don't think I've ever encountered anyone that cavalier about an emergent pre-hospital cric. Cutting is something that's always in the back of my head on critical airway calls, but the steps that would have to occur to get to that point seem rare enough that I'll likely never have to use it. Honestly, I hope the only time I would ever be in a position to perform one (and knock on wood I won't!) is if I one day find a patient already in some kind of "can't intubate/can't ventilate" scenario.

I completely agree with your statement that the first question we should be asking ourselves when considering RSI is if we can use a BVM to ventilate this patient. I use that as one of my golden rules for airway management because every single experienced airway provider and anesthesiologist that has ever taught me has emphasized that point. That being said, a cric performed out of necessity post RSI attempt would represent not only a failure to intubate the patient or place a SGA, but the fundamental failure to even properly recognize prior to pushing drugs that you can't effectively use a BVM on that patient.

How do you recommend we go about fixing this? Increased emphasis on assessment of ability to use a BVM? More practice using a BVM on a variety of patients?

 

[STXmedic]

I think there's a lot of very good discussion in some of the recent airway comments. Is there any way a mod can put these into a separate thread so it doesn't get lost in the directionless prattle?

 

[Tigger]

I think there's a lot of very good discussion in some of the recent airway comments. Is there any way a mod can put these into a separate thread so it doesn't get lost in the directionless prattle?

Ask and ye shall receive.

 

[MonkeyArrow]

Now, the duration of paralysis doesn't really matter in a truly emergent airway, because if someone really NEEDS their airway secured, then you are going to do it no matter what, which of course means a cric if intubation and an SGA fails. The problem with applying that reasoning routinely (and thus making a policy of using a long-acting NMB for every RSI) is that many RSI's are actually elective and not truly emergent. On the surface that may seem like semantics, but it's really not......I think there's a big difference, ethically speaking, between exposing someone to the risk of cutting their neck because you found them in a way that necessitates it, and electively choosing to put them in a position where you will have no choice but to cut their neck if your skills aren't up to what their airway requires. Also, even though roc is pretty quick at the 1.2 mg/kg dose, it still isn't as quick and predictable as sux. If you are really worried about someone being a tough airway and desaturating quickly, I'd much prefer the drug with the 30 second faster onset at the larynx.
.

Are you advocating the use of roc in emergency intubations and sux in "elective" intubations or the other way around?

Quotes around the elective because I don't think that we should be choosing to RSI patients. We RSI them because we need to in order to maintain a patent airway, in which case it is emergent (not having an airway is bad...). We're hopefully not choosing to put the patient under general anaesthesia just because...that's an elective in my opinion.

 

[Handsome Robb]

Are you advocating the use of roc in emergency intubations and sux in "elective" intubations or the other way around?

Quotes around the elective because I don't think that we should be choosing to RSI patients. We RSI them because we need to in order to maintain a patent airway, in which case it is emergent (not having an airway is bad...). We're hopefully not choosing to put the patient under general anaesthesia just because...that's an elective in my opinion.

I think there's a place for elective intubations in the prehospital environment but they're few and far between. A severely combative, head injured patient may be doing a decent job of protecting their airway and ventilating themselves but they're not helping their condition whatsoever by fighting and thrashing and driving their ICP up any higher. I definitely agree that the vast majority of these airways should be emergent rather than elective.

I was wondering where this went, glad it has it's own thread.

It would seem pertinent for any agency doing RSI to have different SGA options such as the King and LMA (iGel) comes to mind as well but I'm not aware of anyone using them prehospitally or any emergency setting. It seems like different options before "having" to cut would be a better option.

I wholeheartedly agree that you damn well better be sure you can mask ventilate a patient prior to choosing to paralyze them and take their airway, ventilation and oxygenation into your total control.

 

[Brandon O]

Bringing that back around, though. Are we talking about:

1. The patient inadequately breathing/managing their own airway who is perhaps combative and cannot be effectively bagged or managed in other ways, and needs to be "put down" to take a tube?

or

2. The sick patient who you're currently bagging, but probably should have a tube for the transport, yet is still holding on to a gag reflex?

The latter is the "elective" scenario we're discussing and probably the more plausible one, and I expect roc would work well here. You shouldn't ever have to "pull the chute" on your RSI unless you seriously screwed the pooch on your approach.

But #1 is the situation many people seem to have in mind when they advocate for sux -- thus they want something that comes on fast, and leaves fast if everything goes wrong. But I just don't know. That's exactly the patient you're going to paralyze then realize too late that you can't make anything work. I'm not sure how much consideration we should be giving to that scenario at all.

 

[Carlos Danger]

The terms "elective" and "non-elective" are not commonly used in EM and EMS, I guess because it's generally assumed that in the emergency setting, everything you do is necessary to prevent M&M and thus by definition, non-elective. IME however - and certainly this varies from agency to agency based on protocols, medical direction, and culture - many if not most prehospital RSI's actually are elective; that is, they are not done because the patient is (or is imminently expected to) experiencing respiratory failure. By far the most common indication that I have seen is suspected TBI in a trauma patient who doesn't appear to have any other serious injuries and is ventilating normally, but has a GCS less than 15 and/or a history of brief unresponsiveness. That would describe probably 75% of the prehospital RSI's that I've done or seen roll into the hospital.

Of course a good argument can be made that it's better to intubate "early" rather than waiting for the patient to decompensate, and specific indications for early intubation can be debated. It's the "they are just gonna get tubed in the ED" or the "yeah, they might need it later, so lets just do it now" situations that I'm really referring to when I use the term "elective RSI" in the context of the prehospital setting.

Have you seen much of this attitude from providers, EMS or otherwise? I'm genuinely curious, because I don't think I've ever encountered anyone that cavalier about an emergent pre-hospital cric.

Not necessarily cavalier about crics specifically, but about being unnecessarily "aggressive" with airway management in general. As a paramedic student, I was trained that the most important part of being a good paramedic was being "very aggressive" at airway management. Which really didn't mean too much at the time, because this was back well before RSI was commonly available to ground paramedics. A couple years later, when I started flying, the culture was such that you landed on a scene already planning to intubate - without even knowing the first thing about the patient - and had to be convinced not to. "Just tube 'em all and let the ED sort 'em out". We had all sorts of arguments to rationalize that approach - some decent, most not - but in reality we were probably using our very liberal airway protocols to cover for clinical weakness in some areas and to keep our egos inflated. In retrospect it is quite embarrassing that were so full of ourselves and exposed so many patients to such unnecessary risk. Unfortunately I see young paramedics and flight nurses making the same mistake I did....thinking (or convincing themselves) that they are somehow doing the right thing by dropping as many tubes as possible.

Are you advocating the use of roc in emergency intubations and sux in "elective" intubations or the other way around?

Neither, I was just commenting on what seems to be the growing trend of routinely using rocuronium for RSI rather than succinylcholine.

There is nothing wrong with using rocuronium, of course, I just don't personally see any advantage to it over sux - unless of course sux is contraindicated for some reason. And while I would agree that sux's advantages are narrow (it's not much faster than roc, and waking up a patient after aborting an RSI attempt would admittedly be very unusual), I think that the vocal advocates of roc over sux are a little too quick to dismiss them, given the lack of roc having any clear advantages of its own.

For some interesting reading, go to PubMed and in the search box type in "rocuronium RSI". I think the aggregate of what you'll find indicates that while rocuronium provides good intubating conditions, the conditions are only as excellent as sux if you are using propofol as an induction agent. A couple studies show increased numbers of intubation attempts needed when roc was used as compared to sux.

How do you recommend we go about fixing this? Increased emphasis on assessment of ability to use a BVM? More practice using a BVM on a variety of patients?

I would actually de-emphasize the importance of airway assessment, because the assessments used are just so unreliable. When you make a decision to intubate or not intubate based on your LEMONS assessment, the reality is that there is a very high likelihood that you are making your decision based on bad or incomplete information. I'm NOT saying don't do an airway assessment - there are a few really important things that you really have to look for - I'm just saying it's very important to recognize how insensitive and non-specific those assessment tools are. After all, if someone needs their airway managed, you have to find a way to do it regardless of your airway assessment. On the contrary, if someone doesn't really need to be intubated, you don't do it just because they look "easy".

Rather, I would emphasize:

• That mask ventilation skills are absolutely critical and deserve far more training time and attention than they are typically given, both as a primary method of managing the airway and as a fall-back when intubation proves difficult.
• That RSI is an inherently risky procedure that should only be done prehospital when really necessary. Is there anyone who wouldn't rather their family member be intubated in a hospital rather than on the side of the road, given a choice? There is no elective RSI in the field.
• That an SGA is a perfectly acceptable airway management device, and in many cases may actually be preferable to an ETT
• Bag early, bag often, be conservative, go slow and methodical, be quick to place an SGA

 

[jwk]

Cisatracurium


Cisatracurium is a benzilisoquinolone; it is an isomer of atracurium and is 4x as potent. Rocuronium and vecuronium are aminosteroids. These are, to my understanding, the only 4 non-depolarizers in clinical use in the US, with atracurium being only rarely used.

The onset and duration of cis is similar to roc or vec. In order of speed of onset of an ED95 dose, it would go roc>cis>vec. Cis is also faster than vec and similar to roc at a 2x ED95 dose. Duration is also comparable between the three, with a time to 25% twitch height recovery of 30-40 min for roc and cis, and 35-45 min for vec.

The primary pharmacologic difference between the 4 is that the steroids are eliminated primarily in the biliary and renal systems (about 70-90% biliary / 10-30% renal for roc and 50-60% biliary / 40-50% renal for vec), whereas the qiunolones are eliminated by hoffman elimination in plasma, at normal physiologic ph and temperature (they will be renally excreted if not metabolized in the plasma). Also, a metabolite of the quinolines is laudanosine, a chemical with pro-convulsant properties.

Clinically, the 3 drugs are very similar. None cause significant changes in HR, BP, or histamine release. None block autonomic ganglia. Most who use them routinely will tell you that vec is the most reliable and predictable of the 3 (and is also dirt cheap), but unfortunately the slowest at onset, which limits it's usefulness to routine (non-RSI) induction and maintenance.

The only times I have used cis is for fragile renal patients. The general consensus seems to be that cis is much more expensive than the other two, without having any clinical advantages.

Cis-atracurium was developed in response to the histamine-releasing properties of atracurium - it has a far lower incidence of clinically significant histamine release, and is why atracurium has all but disappeared from the market.

However, there is another NMB you've forgotten - pancuronium or Pavulon. It's not a terribly popular drug, and one of it's major side effects is tachycardia, but it has seen some resurgence in recent years because it's cheap. It gets press somewhat frequently since it's a common ingredient in lethal injection execution cocktails in a number of states.

 

[Carlos Danger]

However, there is another NMB you've forgotten - pancuronium or Pavulon. It's not a terribly popular drug, and one of it's major side effects is tachycardia, but it has seen some resurgence in recent years because it's cheap. It gets press somewhat frequently since it's a common ingredient in lethal injection execution cocktails in a number of states.

Really - I thought that was no longer used?

 

[Nattens]

Really - I thought that was no longer used?

Our service in Victoria, Australia uses it for paralysis maintenance in RSI to good effect.