RSI Response by a doctor on another group

[Guest guest]

Below is a response that a doctor made on another forum that really

applies to the RSI discussion on here recently.

Renny Spencer

EMT-I

Paramedic student

" There is a brisk discussion on this very topic online right now

among the docs in the ACEP EMS Section. I will post here what I sent

there.

I have performed a number of intubations in the field with RSI with

my squad. Few have been trauma patients; most were respiratory

failure due to medical causes such as CHF that did not respond to

therapy. Perhaps it's our patient population of morbidly obese chain

smoking hypertensive type II diabetic vasculopaths with CHF that

prefer to call 911 only when there is a large hooded figure with a

scythe standing in the corner of the room, but we get some sick

folks. We are in the process of training the medics for RSI to see if

we can sustain the skill retention through training and periodic

retesting before we implement it. On our SWAT team, the medics are

trained and authorized to use RSI (easier to implement, since this is

a small cadre of very experienced medics with dedicated monthly

training time).

One important thing to consider when looking at those studies is the

fact that they include intubation of patients who are incompletely

relaxed, the " cowboy tube " that is undertaken with nothing but a

laryngoscope and Brutane. Not only do the paramedics get the really

bad airways, as pointed out, but we ask them to intubate patients

that we as physicians would never consider intubating without RSI. By

asking them to do so, are we not setting them up for failure? What

would our intubation success rate be as physicians without RSI?

Several studies have demonstrated the value of RSI in prehospital

settings. Whether by improving intubation conditions, or improving

training, improved airway decision-making, periodic skills

reassessment, or improvement of conditions for intubation by use of

the drugs, RSI (with appropriate oversight and training) seems to

improve intubation rates.

A 2004 study by et al found that rates of unrecognized

esophageal placement of endotracheal tubes was as high as 6%. The

standard for placement verification was auscultation by the receiving

emergency physician. This rate was lower (3% vs. 9%) when a

confirmation device, such as Esophageal Detector Device or end-tidal

CO2 detector was used. Small study size limits the scope of this

study, but the results are concerning nonetheless.

An analysis of failed intubations revealed that of the 10% of

patients who had failed intubation attempts in the field, nearly 50%

were attributable to inadequate relaxation, 20% to poor anatomy, and

10% to obstruction..[iii] Of these that could not be intubated in the

field, 41% were successfully intubated after RSI in the Emergency

Department. The estimate of " truly difficult " airways, defined as

requiring 3 or more intubation attempts in the ED, was 0.8-1.6%.

A 2003 study from the University of Pittsburgh showed an overall

intubation success rate of 90%. Patients with vital signs were

successfully intubated only 72% of the time, while patients in

cardiac arrest were successfully intubated 93% of the time. Factors

attributed to failed intubation which may be remedied through RSI

include clenched jaw (30%), combativeness (11%), inadequate

relaxation (25%), intact gag reflex (38%).[iv]

A 2005 study from Wake Forest University utilizing an air transport

service compared etomidate only intubation (EOI) to RSI.[v] This

small study, with younger (mean 38 years) mostly trauma patients

(90%) used a subjective scale to rate " adequate " conditions for

intubation. EOI produced these conditions only 13% of the time, while

RSI produced them 80% of the time. Intubation success rate was 25% in

the EOI group and 92% in the RSI group. Studies from Dickenson et al

and Wang et al showed limited success with midazolam (Versed) as a

single-line agent to facilitate intubation, citing success rates of

62-75%.[vi],[vii] This mirrors our experience with our " sedate to

intubate " protocol, which allows use of versed or etomidate to

facilitate intubation.

Alicandro reported RSI success in a paramedic air transport system to

be 90%, compared with conventional ETI success rate of 69%.[viii]

A study by Hedges et al recounted 95 occurrences of RSI in a ground

ALS system, which showed an overall success rate of 96% and no

misplaced tubes or cricothyroidotomies performed.[ix] Pace and Fuller

found success rates of 92% vs. 66% with conventional intubation.[x]

Krisanda et al reported a 94% success rate with RSI in seven ground

ALS services.[xi]

Pearson's 2003 study in the Air Medical Journal examined the impact

of implementation of an RSI protocol on number of intubation attempts

and time to successful intubation. The study, though small (140

patients) found that both the number of attempts and the time to

intubation decreased significantly once succinylcholine was added to

the drug box.[xii]

A study by Ochs and from San Diego enrolled 114 patients with

head injury who underwent RSI. 84% were intubated successfully, the

rest were managed with combitube. There was only one airway failure.

[xiii]

Wayne and Friedland's 20 year review of RSI with succinylcholine in a

ground ALS service found a success rate of 95% in their analysis of

1657 patients. Only 3 of the 74 patients where intubation was

unsuccessful required cricothyroidotomy.[xiv] This study seems to

suggest 2 things: paramedics CAN successfully perform RSI, and

paralysis + failed intubation do not necessarily equal surgical

cricothyroidotomy. If the patient can be managed with a rescue airway

or oral airway and BVM, then they don't need to be cut. This study I

think shows the value of training: medics had 20 OR intubations, and

were required to get OR time and a minimum number of tubes per year.

Some recent studies have questioned the use of RSI on specific

populations in the prehospital environment. RSI has been associated

with worse outcomes in patients with severe head injury in a landmark

study by , Hoyt et al from San Diego.[xv] A follow-up analysis

of these patients suggested the association between increased

mortality and hyperventilation.[xvi]

I agree completely that RSI is a potentially disastrous tool to have

without proper training and oversight. Our currently planned regimen

involves monthly skill time on the mannekin, quarterly retesting

(written and practical), tracking of individual paramedic intubation

rates with quarterly minimums (to be made up on mannekin testing if

inadequate), and QA review of all intubation cases. Currently, run

sheets are kicked to my inbox automatically for advanced airways,

arrests, AMI, " significant ALS care " , pediatrics, obstetrics,

refusals, and any other issue as seen fit by the QA supervisor.

Two other important factors I think must be in place when allowing

RSI: confirmation of tube placement, and backup airway devices. We've

already touched on the use of capnography, which I think is an

invaluable tool for confirming and monitoring intubation. Despite

what the studies suggest regarding the EDD, I don't think anything

else yet matches EtCO2.

As far as backup airways and adjuncts go, I'm a big believer in the

Airtraq, the Glidescope (though right now we can't afford to put them

on the trucks, this is on the wish list), the bougie, and the King LT-

D. As a matter of disclosure, I have no financial or other

conflicting interests in these products whatsoever. Medics have to

have them and be comfortable with them.

The real question we need to be asking is, how can we get our medics

into the OR to practice intubation? Many anesthesiology groups here

are shut down tight when it comes to paramedic intubation time, and

unfortunately, concerned about the liability of having a less

experienced provider perform the intubation. This leaves cadaver labs

as the most accessible solution.

So to summarize (everyone wake up, lights are coming on again,

powerpoint is coming to an end, urinals and coffee urns await you...)

1) I think that RSI does belong in the field under the right

conditions.

2) That said, training and oversight are crucial and are the

difference between a successful RSI program and one that is

dangerous.

3) Medics should have the right tools. That includes not only the

tools to intubate successfully but the tools to manage the patient

when they can't. We can't set them up for failure and then complain

that their skills are inadequate.

'zilla

JH, MP, DicksonRL. Emergency Physician-Verified Out-

Of-Hospital Intubation: Miss rates by paramedics. Acad Emerg Med.

2004 Jun;11(6):707-709.

[ii] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7)

717-724.

[iii] Wang HE, Sweeney TA, et al. Failed Prehospital Intubations: An

analysis of emergency department courses and outcomes. Prehosp Emer

Care. 2001;5:134-141.

[iv] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7)

717-724.

[v] Bozeman WP, Kleiner DM, Hugget V. A comparison of rapid-sequence

intubation and etomidate-only intubation in the prehospital air

medical setting. Prehosp Emer Care. 2006;10:8-13.

[vi] Wang HE, O'Connor RE, Megargel RE, et al. The utilization of

midazolam as a pharmacologic adjunct to endotracheal intubation by

paramedics. Prehosp Emerg Care. 2000;4:14–8.

[vii] Dickinson ET, Cohen JE, Mechem CC. The effectiveness of

midazolam as a single pharmacologic agent to facilitate endotracheal

intubation by paramedics. Prehosp Emerg Care. 1999;3:191–3. 84.

[viii] Alicandro JM, Henry MC, Hollander JE, S, Kaufman M,

Niegelberg E. Improved success rate of out-of-hospital intubation

with rapid-sequence induction . Acad Emerg Med. 1996; 3:408.

[ix] Hedges JR, Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz B.

Succinylcholine-assisted intubations in prehospital care. Ann Emerg

Med. 1988;17:469–72.36.

[x] Pace SA, Fuller FP. Out-of-hospital use of succinylcholine by

paramedics. Acad Emerg Med. 1996;3: 407–8.

[xi] Krisanda T, Eitel D, Cooley M, et al. Succinylcholine-assisted

intubation by responding advanced life support ground units: results

of a four-year pilot study for the state of Pennsylvania. Acad Emerg

Med. 1997;4:460.

[xii] Pearson S. Comparison of intubation attempts and completion

times before and after the initiation of a rapid sequence intubation

protocol in an air medical transport program. Air Med J. 2003 Nov-

Dec;22(6):28-33.

[xiii] DP, Ochs M, Hoyt DB, D, Marshall LK, Rosen P.

Paramedic-administered neuromuscular blockade improves prehospital

intubation success in severely head-injured patients. J Trauma. 2003

Oct;55(4):713-9.

[xiv] Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-

year review. Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.

[xv] DP, Hoyt DB, Ochs M. The effect of paramedic rapid

sequence intubation on outcome in patients with severe traumatic

brain injury. J Trauma. 2003 Mar;54(3):444-53.

[xvi] DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of

factors associated with head-injury mortality after paramedic rapid

sequence intubation. J Trauma. 2005 Aug;59(2):486-90. "

[Guest guest]

Kenny Navarro,

Please forward this email to Dr. Fowler and Dr. Pepe. I believe Dr. Yamada's

invitation is still open for a combined RSI study between the BioTel agencies

and his agencies.

spenair wrote:

Below is a response that a doctor made on another forum that really

applies to the RSI discussion on here recently.

Renny Spencer

EMT-I

Paramedic student

" There is a brisk discussion on this very topic online right now

among the docs in the ACEP EMS Section. I will post here what I sent

there.

I have performed a number of intubations in the field with RSI with

my squad. Few have been trauma patients; most were respiratory

failure due to medical causes such as CHF that did not respond to

therapy. Perhaps it's our patient population of morbidly obese chain

smoking hypertensive type II diabetic vasculopaths with CHF that

prefer to call 911 only when there is a large hooded figure with a

scythe standing in the corner of the room, but we get some sick

folks. We are in the process of training the medics for RSI to see if

we can sustain the skill retention through training and periodic

retesting before we implement it. On our SWAT team, the medics are

trained and authorized to use RSI (easier to implement, since this is

a small cadre of very experienced medics with dedicated monthly

training time).

One important thing to consider when looking at those studies is the

fact that they include intubation of patients who are incompletely

relaxed, the " cowboy tube " that is undertaken with nothing but a

laryngoscope and Brutane. Not only do the paramedics get the really

bad airways, as pointed out, but we ask them to intubate patients

that we as physicians would never consider intubating without RSI. By

asking them to do so, are we not setting them up for failure? What

would our intubation success rate be as physicians without RSI?

Several studies have demonstrated the value of RSI in prehospital

settings. Whether by improving intubation conditions, or improving

training, improved airway decision-making, periodic skills

reassessment, or improvement of conditions for intubation by use of

the drugs, RSI (with appropriate oversight and training) seems to

improve intubation rates.

A 2004 study by et al found that rates of unrecognized

esophageal placement of endotracheal tubes was as high as 6%. The

standard for placement verification was auscultation by the receiving

emergency physician. This rate was lower (3% vs. 9%) when a

confirmation device, such as Esophageal Detector Device or end-tidal

CO2 detector was used. Small study size limits the scope of this

study, but the results are concerning nonetheless.

An analysis of failed intubations revealed that of the 10% of

patients who had failed intubation attempts in the field, nearly 50%

were attributable to inadequate relaxation, 20% to poor anatomy, and

10% to obstruction..[iii] Of these that could not be intubated in the

field, 41% were successfully intubated after RSI in the Emergency

Department. The estimate of " truly difficult " airways, defined as

requiring 3 or more intubation attempts in the ED, was 0.8-1.6%.

A 2003 study from the University of Pittsburgh showed an overall

intubation success rate of 90%. Patients with vital signs were

successfully intubated only 72% of the time, while patients in

cardiac arrest were successfully intubated 93% of the time. Factors

attributed to failed intubation which may be remedied through RSI

include clenched jaw (30%), combativeness (11%), inadequate

relaxation (25%), intact gag reflex (38%).[iv]

A 2005 study from Wake Forest University utilizing an air transport

service compared etomidate only intubation (EOI) to RSI.[v] This

small study, with younger (mean 38 years) mostly trauma patients

(90%) used a subjective scale to rate " adequate " conditions for

intubation. EOI produced these conditions only 13% of the time, while

RSI produced them 80% of the time. Intubation success rate was 25% in

the EOI group and 92% in the RSI group. Studies from Dickenson et al

and Wang et al showed limited success with midazolam (Versed) as a

single-line agent to facilitate intubation, citing success rates of

62-75%.[vi],[vii] This mirrors our experience with our " sedate to

intubate " protocol, which allows use of versed or etomidate to

facilitate intubation.

Alicandro reported RSI success in a paramedic air transport system to

be 90%, compared with conventional ETI success rate of 69%.[viii]

A study by Hedges et al recounted 95 occurrences of RSI in a ground

ALS system, which showed an overall success rate of 96% and no

misplaced tubes or cricothyroidotomies performed.[ix] Pace and Fuller

found success rates of 92% vs. 66% with conventional intubation.[x]

Krisanda et al reported a 94% success rate with RSI in seven ground

ALS services.[xi]

Pearson's 2003 study in the Air Medical Journal examined the impact

of implementation of an RSI protocol on number of intubation attempts

and time to successful intubation. The study, though small (140

patients) found that both the number of attempts and the time to

intubation decreased significantly once succinylcholine was added to

the drug box.[xii]

A study by Ochs and from San Diego enrolled 114 patients with

head injury who underwent RSI. 84% were intubated successfully, the

rest were managed with combitube. There was only one airway failure.

[xiii]

Wayne and Friedland's 20 year review of RSI with succinylcholine in a

ground ALS service found a success rate of 95% in their analysis of

1657 patients. Only 3 of the 74 patients where intubation was

unsuccessful required cricothyroidotomy.[xiv] This study seems to

suggest 2 things: paramedics CAN successfully perform RSI, and

paralysis + failed intubation do not necessarily equal surgical

cricothyroidotomy. If the patient can be managed with a rescue airway

or oral airway and BVM, then they don't need to be cut. This study I

think shows the value of training: medics had 20 OR intubations, and

were required to get OR time and a minimum number of tubes per year.

Some recent studies have questioned the use of RSI on specific

populations in the prehospital environment. RSI has been associated

with worse outcomes in patients with severe head injury in a landmark

study by , Hoyt et al from San Diego.[xv] A follow-up analysis

of these patients suggested the association between increased

mortality and hyperventilation.[xvi]

I agree completely that RSI is a potentially disastrous tool to have

without proper training and oversight. Our currently planned regimen

involves monthly skill time on the mannekin, quarterly retesting

(written and practical), tracking of individual paramedic intubation

rates with quarterly minimums (to be made up on mannekin testing if

inadequate), and QA review of all intubation cases. Currently, run

sheets are kicked to my inbox automatically for advanced airways,

arrests, AMI, " significant ALS care " , pediatrics, obstetrics,

refusals, and any other issue as seen fit by the QA supervisor.

Two other important factors I think must be in place when allowing

RSI: confirmation of tube placement, and backup airway devices. We've

already touched on the use of capnography, which I think is an

invaluable tool for confirming and monitoring intubation. Despite

what the studies suggest regarding the EDD, I don't think anything

else yet matches EtCO2.

As far as backup airways and adjuncts go, I'm a big believer in the

Airtraq, the Glidescope (though right now we can't afford to put them

on the trucks, this is on the wish list), the bougie, and the King LT-

D. As a matter of disclosure, I have no financial or other

conflicting interests in these products whatsoever. Medics have to

have them and be comfortable with them.

The real question we need to be asking is, how can we get our medics

into the OR to practice intubation? Many anesthesiology groups here

are shut down tight when it comes to paramedic intubation time, and

unfortunately, concerned about the liability of having a less

experienced provider perform the intubation. This leaves cadaver labs

as the most accessible solution.

So to summarize (everyone wake up, lights are coming on again,

powerpoint is coming to an end, urinals and coffee urns await you...)

1) I think that RSI does belong in the field under the right

conditions.

2) That said, training and oversight are crucial and are the

difference between a successful RSI program and one that is

dangerous.

3) Medics should have the right tools. That includes not only the

tools to intubate successfully but the tools to manage the patient

when they can't. We can't set them up for failure and then complain

that their skills are inadequate.

'zilla

JH, MP, DicksonRL. Emergency Physician-Verified Out-

Of-Hospital Intubation: Miss rates by paramedics. Acad Emerg Med.

2004 Jun;11(6):707-709.

[ii] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7)

717-724.

[iii] Wang HE, Sweeney TA, et al. Failed Prehospital Intubations: An

analysis of emergency department courses and outcomes. Prehosp Emer

Care. 2001;5:134-141.

[iv] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7)

717-724.

[v] Bozeman WP, Kleiner DM, Hugget V. A comparison of rapid-sequence

intubation and etomidate-only intubation in the prehospital air

medical setting. Prehosp Emer Care. 2006;10:8-13.

[vi] Wang HE, O'Connor RE, Megargel RE, et al. The utilization of

midazolam as a pharmacologic adjunct to endotracheal intubation by

paramedics. Prehosp Emerg Care. 2000;4:14–8.

[vii] Dickinson ET, Cohen JE, Mechem CC. The effectiveness of

midazolam as a single pharmacologic agent to facilitate endotracheal

intubation by paramedics. Prehosp Emerg Care. 1999;3:191–3. 84.

[viii] Alicandro JM, Henry MC, Hollander JE, S, Kaufman M,

Niegelberg E. Improved success rate of out-of-hospital intubation

with rapid-sequence induction . Acad Emerg Med. 1996; 3:408.

[ix] Hedges JR, Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz B.

Succinylcholine-assisted intubations in prehospital care. Ann Emerg

Med. 1988;17:469–72.36.

[x] Pace SA, Fuller FP. Out-of-hospital use of succinylcholine by

paramedics. Acad Emerg Med. 1996;3: 407–8.

[xi] Krisanda T, Eitel D, Cooley M, et al. Succinylcholine-assisted

intubation by responding advanced life support ground units: results

of a four-year pilot study for the state of Pennsylvania. Acad Emerg

Med. 1997;4:460.

[xii] Pearson S. Comparison of intubation attempts and completion

times before and after the initiation of a rapid sequence intubation

protocol in an air medical transport program. Air Med J. 2003 Nov-

Dec;22(6):28-33.

[xiii] DP, Ochs M, Hoyt DB, D, Marshall LK, Rosen P.

Paramedic-administered neuromuscular blockade improves prehospital

intubation success in severely head-injured patients. J Trauma. 2003

Oct;55(4):713-9.

[xiv] Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-

year review. Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.

[xv] DP, Hoyt DB, Ochs M. The effect of paramedic rapid

sequence intubation on outcome in patients with severe traumatic

brain injury. J Trauma. 2003 Mar;54(3):444-53.

[xvi] DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of

factors associated with head-injury mortality after paramedic rapid

sequence intubation. J Trauma. 2005 Aug;59(2):486-90. "

, FF/LP/NREMTP

" Live your life. Respect its brevity. "

FBFD1426@...

---------------------------------

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[Guest guest]

Here is another doctors response:

Hey all,

Doczilla asked I join the discussion. We both have been posting on

the ACEP listserver about this topic, so this is what I posted:

A few points:

1. All agencies should be using waveform capnography as the " gold

standard " to determine tube placement. With properly used waveform

capnography there should be an almost zero percent missed esophageal

intubation rate. This method of tube verification was advocated by a

position paper from the National Association of EMS Physicians in

1999. ( http://www.naemsp.org/pdf/verificationtubeplacement.pdf ) It

is a rapid and very reliable method of determining tube placement,

much better than auscultation, tube fogging, colorometric CO2

detectors, etc. Why this has not become the standard of care in both

the pre-hospital and ED settings is surprising, as if you ask our

colleagues in anesthesia, no one is intubated without waveform

capnography and it has been the standard of care in the OR for many

years.

2. I believe that the current system by which we train paramedics to

perform intubation is set up with the deck stacked against them. I

worked as an EMT for many years before becoming a physician, and all

my initial intubations were in either the OR or the ED. The first

time I had to place a tube as the physician on an ambulance I was

face down in a field with an anaphylactic patient deep in the woods

on a very bright sunny day. It was an eye opener for me how much more

difficult this was than placing a tube in the ED. Think about it --

as physicians we are accustomed to a well lit exam room, with an

adjustable bed, staff to assist us, maybe anesthesia backup. Being in

the middle of a field face down in the dirt without support staff is

a very different experience. There is an interesting article from the

Anesthesia literature in 2007 that shows that physicians that

normally work in a hospital setting, when placed with a helicopter

service, often had unrecognized esophageal intubations (no

capnography was available) http://www.anesthesia-

analgesia.org/cgi/content/abstract/104/3/619

Flash to how we train our EMS providers: we place them in a sterile

OR or ED, then once they get the " right number " of tubes send them

out into the field to get a couple of " field tubes " and then that's

it. Most never have the opportunity to come back to the ED/OR to

practice, nor do we actually train them in the environment in which

they work. Paramedic students should be getting many intubations

using airway mannequins in real field conditions (dark rooms,

bathrooms, dusty fields, etc.), and all practicing paramedics should

have the opportunity (and be mandated) to continue to practice

intubations both on airway mannequins, and back in the ED/OR to

maintain their skills.

The combination of training the medics in our controlled ED

environment and then sending them into a very different field

environment, coupled with the lack of continuing education/practice,

I feel is the source of many of the issues that have been raised

within this discussion. Then, factor in the lack of waveform

capnogrpahy in many places, and this just compounds the issue.

A recent article from the British Journal of Anesthesia shows

intubation to be safe and beneficial for head injured patients with

well trained providers:

http://bja.oxfordjournals.org/cgi/content/full/96/1/67 Again training

and education -- coupled with practice and good monitoring equipment -

- is the key.

3. In the San Diego study that is often quoted (The effect of

paramedic rapid sequence intubation on outcome in patients with

severe traumatic brain injury. J Trauma. 2003 Mar;54(3):444-53.), the

authors themselves noted that RSI improved paramedic success

rates: " Paramedic RSI improves intubation success rates but is

associated with an increase in mortality and decrease in 'good

outcomes' when compared with hand-matched controls. These differences

may reflect inherent inequities between the two groups, although they

appeared similar on all parameters we measured. Alternatively, the

increase in mortality may be related to inadvertent hyperventilation,

transient hypoxic episodes, and prolonged scene times associated with

the RSI procedure. "

As the authors noted in their last sentence, further analysis of the

data showed that hypertventilation and hypoxia was a large factor in

the poor outcome of the patients, not the RSI procedure itself.

(http://www.ncbi.nlm.nih.gov/pubmed/15284540 ) Well trained EMS

providers with appropriate monitoring (continous ETCO2 and SPO2) and

all available airway tools (including intubation/RSI when necessary)

is the best way to minimize these complications. In fact, if you look

at the literature from Europe (i.e. Acta Anaesthesiologica

Scandinavica. 50(10):1250-4, 2006 Nov. " Effect of pre-hospital

advanced life support with rapid sequence intubation on outcome of

severe traumatic brain injury. " ) many trauma patients were dying from

hypoxia from lack of airway control in BLS only systems, and the

introduction of ALS showed a decrease in mortality for TBI patients.

A follow up study in the Journal of Trauma in 2007 showed that if TBI

patients maintained normocapnea after intubation by medics, they did

not have an increased mortality. (

http://www.ncbi.nlm.nih.gov/pubmed/17563643 )

In addition, a study from Journal of Trauma in 2005 showed that the

use of a neuromuscular blocking agents by medics, when adjusted for

confounding variables, actually improves outcomes for patients with

TBI. ( http://www.ncbi.nlm.nih.gov/pubmed/15824647 )

Interestingly enough, there is an article in Archives of Surgery from

San Diego pre-RSI that actually shows an improvement in patient

outcome with pre-hospital intubation of head injuries (

http://archsurg.ama-assn.org/cgi/content/abstract/132/6/592 ). This

further suggests that it is not the intubation that was the issue,

but unrecognized hypoxia/hyperventilation/hypocapnea as noted.

A recent expert panel summarized this best:

" The Brain Trauma Foundation assembled a panel of experts to

interpret the existing literature regarding paramedic RSI for severe

TBI and offer guidance for EMS systems considering adding this skill

to the paramedic scope of practice. The interpretation of this panel

can be summarized as follows: (1) the existing literature regarding

paramedic RSI is inconclusive, and apparent differences in outcome

can be explained by use of different methodologies and variability in

comparison groups; (2) the use of Glasgow Coma Scale score alone to

identify TBI patients requiring RSI is limited, with additional

research needed to refine our screening criteria; (3) suboptimal RSI

technique as well as subsequent hyperventilation may account for some

of the mortality increase reported with the procedure; (4) initial

and ongoing training as well as experience with RSI appear to affect

performance; and (5) the success of a paramedic RSI program is

dependent on particular EMS and trauma system characteristics. (link:

http://www.ncbi.nlm.nih.gov/pubmed/17169868 )

4. My opinion -- backed by a recent article in Journal of Trauma-

Injury Infection & Critical Care [ " Prehospital Rapid Sequence

Intubation for Head Trauma: Conditions for a Successful Program " 60

(5):997-1001, 2006 May. ] -- is that RSI should be reserved for a

small cadre of well trained paramedics that are available for the

right cases and the sickest patients. It should not be every medic,

every patient with a GCS < 8, or every CHF'er. The conclusion from

their article is the same: " Prehospital RSI for trauma patients can

be safely and effectively performed with low rates of complication

and without significant delay in transport. This study suggests that

resources for prehospital airway management should be focused on

training, regular experience, and close monitoring of a limited group

of providers, thereby maximizing their exposure and experience with

this procedure. "

Best regards,

EMSDoc

>

> Below is a response that a doctor made on another forum that really

> applies to the RSI discussion on here recently.

> Renny Spencer

> EMT-I

> Paramedic student

>

> " There is a brisk discussion on this very topic online right now

> among the docs in the ACEP EMS Section. I will post here what I

sent

> there.

>

> I have performed a number of intubations in the field with RSI with

> my squad. Few have been trauma patients; most were respiratory

> failure due to medical causes such as CHF that did not respond to

> therapy. Perhaps it's our patient population of morbidly obese

chain

> smoking hypertensive type II diabetic vasculopaths with CHF that

> prefer to call 911 only when there is a large hooded figure with a

> scythe standing in the corner of the room, but we get some sick

> folks. We are in the process of training the medics for RSI to see

if

> we can sustain the skill retention through training and periodic

> retesting before we implement it. On our SWAT team, the medics are

> trained and authorized to use RSI (easier to implement, since this

is

> a small cadre of very experienced medics with dedicated monthly

> training time).

>

> One important thing to consider when looking at those studies is

the

> fact that they include intubation of patients who are incompletely

> relaxed, the " cowboy tube " that is undertaken with nothing but a

> laryngoscope and Brutane. Not only do the paramedics get the really

> bad airways, as pointed out, but we ask them to intubate patients

> that we as physicians would never consider intubating without RSI.

By

> asking them to do so, are we not setting them up for failure? What

> would our intubation success rate be as physicians without RSI?

>

> Several studies have demonstrated the value of RSI in prehospital

> settings. Whether by improving intubation conditions, or improving

> training, improved airway decision-making, periodic skills

> reassessment, or improvement of conditions for intubation by use of

> the drugs, RSI (with appropriate oversight and training) seems to

> improve intubation rates.

> A 2004 study by et al found that rates of unrecognized

> esophageal placement of endotracheal tubes was as high as 6%.

The

> standard for placement verification was auscultation by the

receiving

> emergency physician. This rate was lower (3% vs. 9%) when a

> confirmation device, such as Esophageal Detector Device or end-

tidal

> CO2 detector was used. Small study size limits the scope of this

> study, but the results are concerning nonetheless.

>

> An analysis of failed intubations revealed that of the 10% of

> patients who had failed intubation attempts in the field, nearly

50%

> were attributable to inadequate relaxation, 20% to poor anatomy,

and

> 10% to obstruction..[iii] Of these that could not be intubated in

the

> field, 41% were successfully intubated after RSI in the Emergency

> Department. The estimate of " truly difficult " airways, defined as

> requiring 3 or more intubation attempts in the ED, was 0.8-1.6%.

>

> A 2003 study from the University of Pittsburgh showed an overall

> intubation success rate of 90%. Patients with vital signs were

> successfully intubated only 72% of the time, while patients in

> cardiac arrest were successfully intubated 93% of the time. Factors

> attributed to failed intubation which may be remedied through RSI

> include clenched jaw (30%), combativeness (11%), inadequate

> relaxation (25%), intact gag reflex (38%).[iv]

>

> A 2005 study from Wake Forest University utilizing an air transport

> service compared etomidate only intubation (EOI) to RSI.[v] This

> small study, with younger (mean 38 years) mostly trauma patients

> (90%) used a subjective scale to rate " adequate " conditions for

> intubation. EOI produced these conditions only 13% of the time,

while

> RSI produced them 80% of the time. Intubation success rate was 25%

in

> the EOI group and 92% in the RSI group. Studies from Dickenson et

al

> and Wang et al showed limited success with midazolam (Versed) as a

> single-line agent to facilitate intubation, citing success rates of

> 62-75%.[vi],[vii] This mirrors our experience with our " sedate to

> intubate " protocol, which allows use of versed or etomidate to

> facilitate intubation.

>

> Alicandro reported RSI success in a paramedic air transport system

to

> be 90%, compared with conventional ETI success rate of 69%.[viii]

>

> A study by Hedges et al recounted 95 occurrences of RSI in a ground

> ALS system, which showed an overall success rate of 96% and no

> misplaced tubes or cricothyroidotomies performed.[ix] Pace and

Fuller

> found success rates of 92% vs. 66% with conventional intubation.[x]

> Krisanda et al reported a 94% success rate with RSI in seven ground

> ALS services.[xi]

>

> Pearson's 2003 study in the Air Medical Journal examined the impact

> of implementation of an RSI protocol on number of intubation

attempts

> and time to successful intubation. The study, though small (140

> patients) found that both the number of attempts and the time to

> intubation decreased significantly once succinylcholine was added

to

> the drug box.[xii]

>

> A study by Ochs and from San Diego enrolled 114 patients with

> head injury who underwent RSI. 84% were intubated successfully, the

> rest were managed with combitube. There was only one airway failure.

> [xiii]

>

> Wayne and Friedland's 20 year review of RSI with succinylcholine in

a

> ground ALS service found a success rate of 95% in their analysis of

> 1657 patients. Only 3 of the 74 patients where intubation was

> unsuccessful required cricothyroidotomy.[xiv] This study seems to

> suggest 2 things: paramedics CAN successfully perform RSI, and

> paralysis + failed intubation do not necessarily equal surgical

> cricothyroidotomy. If the patient can be managed with a rescue

airway

> or oral airway and BVM, then they don't need to be cut. This study

I

> think shows the value of training: medics had 20 OR intubations,

and

> were required to get OR time and a minimum number of tubes per

year.

>

> Some recent studies have questioned the use of RSI on specific

> populations in the prehospital environment. RSI has been associated

> with worse outcomes in patients with severe head injury in a

landmark

> study by , Hoyt et al from San Diego.[xv] A follow-up analysis

> of these patients suggested the association between increased

> mortality and hyperventilation.[xvi]

>

> I agree completely that RSI is a potentially disastrous tool to

have

> without proper training and oversight. Our currently planned

regimen

> involves monthly skill time on the mannekin, quarterly retesting

> (written and practical), tracking of individual paramedic

intubation

> rates with quarterly minimums (to be made up on mannekin testing if

> inadequate), and QA review of all intubation cases. Currently, run

> sheets are kicked to my inbox automatically for advanced airways,

> arrests, AMI, " significant ALS care " , pediatrics, obstetrics,

> refusals, and any other issue as seen fit by the QA supervisor.

>

> Two other important factors I think must be in place when allowing

> RSI: confirmation of tube placement, and backup airway devices.

We've

> already touched on the use of capnography, which I think is an

> invaluable tool for confirming and monitoring intubation. Despite

> what the studies suggest regarding the EDD, I don't think anything

> else yet matches EtCO2.

>

> As far as backup airways and adjuncts go, I'm a big believer in the

> Airtraq, the Glidescope (though right now we can't afford to put

them

> on the trucks, this is on the wish list), the bougie, and the King

LT-

> D. As a matter of disclosure, I have no financial or other

> conflicting interests in these products whatsoever. Medics have to

> have them and be comfortable with them.

>

> The real question we need to be asking is, how can we get our

medics

> into the OR to practice intubation? Many anesthesiology groups here

> are shut down tight when it comes to paramedic intubation time, and

> unfortunately, concerned about the liability of having a less

> experienced provider perform the intubation. This leaves cadaver

labs

> as the most accessible solution.

>

> So to summarize (everyone wake up, lights are coming on again,

> powerpoint is coming to an end, urinals and coffee urns await

you...)

> 1) I think that RSI does belong in the field under the right

> conditions.

> 2) That said, training and oversight are crucial and are the

> difference between a successful RSI program and one that is

> dangerous.

> 3) Medics should have the right tools. That includes not only the

> tools to intubate successfully but the tools to manage the patient

> when they can't. We can't set them up for failure and then complain

> that their skills are inadequate.

>

> 'zilla

>

> JH, MP, DicksonRL. Emergency Physician-Verified

Out-

> Of-Hospital Intubation: Miss rates by paramedics. Acad Emerg Med.

> 2004 Jun;11(6):707-709.

>

> [ii] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

> Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10

(7)

> 717-724.

>

> [iii] Wang HE, Sweeney TA, et al. Failed Prehospital Intubations:

An

> analysis of emergency department courses and outcomes. Prehosp Emer

> Care. 2001;5:134-141.

>

> [iv] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

> Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10

(7)

> 717-724.

>

> [v] Bozeman WP, Kleiner DM, Hugget V. A comparison of rapid-

sequence

> intubation and etomidate-only intubation in the prehospital air

> medical setting. Prehosp Emer Care. 2006;10:8-13.

>

> [vi] Wang HE, O'Connor RE, Megargel RE, et al. The utilization of

> midazolam as a pharmacologic adjunct to endotracheal intubation by

> paramedics. Prehosp Emerg Care. 2000;4:14–8.

>

> [vii] Dickinson ET, Cohen JE, Mechem CC. The effectiveness of

> midazolam as a single pharmacologic agent to facilitate

endotracheal

> intubation by paramedics. Prehosp Emerg Care. 1999;3:191–3. 84.

>

> [viii] Alicandro JM, Henry MC, Hollander JE, S, Kaufman M,

> Niegelberg E. Improved success rate of out-of-hospital intubation

> with rapid-sequence induction . Acad Emerg Med. 1996; 3:408.

>

> [ix] Hedges JR, Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz

B.

> Succinylcholine-assisted intubations in prehospital care. Ann Emerg

> Med. 1988;17:469–72.36.

>

> [x] Pace SA, Fuller FP. Out-of-hospital use of succinylcholine by

> paramedics. Acad Emerg Med. 1996;3: 407–8.

>

> [xi] Krisanda T, Eitel D, Cooley M, et al. Succinylcholine-assisted

> intubation by responding advanced life support ground units:

results

> of a four-year pilot study for the state of Pennsylvania. Acad

Emerg

> Med. 1997;4:460.

>

> [xii] Pearson S. Comparison of intubation attempts and completion

> times before and after the initiation of a rapid sequence

intubation

> protocol in an air medical transport program. Air Med J. 2003 Nov-

> Dec;22(6):28-33.

>

> [xiii] DP, Ochs M, Hoyt DB, D, Marshall LK, Rosen P.

> Paramedic-administered neuromuscular blockade improves prehospital

> intubation success in severely head-injured patients. J Trauma.

2003

> Oct;55(4):713-9.

>

> [xiv] Wayne MA, Friedland E. Prehospital use of succinylcholine: a

20-

> year review. Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.

>

> [xv] DP, Hoyt DB, Ochs M. The effect of paramedic rapid

> sequence intubation on outcome in patients with severe traumatic

> brain injury. J Trauma. 2003 Mar;54(3):444-53.

>

> [xvi] DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of

> factors associated with head-injury mortality after paramedic rapid

> sequence intubation. J Trauma. 2005 Aug;59(2):486-90. "

>

[Guest guest]

Hey, Renny, but any chance did you send this information and the info from your

last doctors post on to the journalist who wrote that article that started this

storm? It would be interesting to see if the journalist does a follow-up

showing the " other " side of this story...

Jane Dinsmore

To: texasems-l@...: spenair@...: Sat, 26 Apr 2008

00:31:21 +0000Subject: Re: RSI Response by a doctor on another

group

Here is another doctors response:Hey all, Doczilla asked I join the discussion.

We both have been posting on the ACEP listserver about this topic, so this is

what I posted: A few points: 1. All agencies should be using waveform

capnography as the " gold standard " to determine tube placement. With properly

used waveform capnography there should be an almost zero percent missed

esophageal intubation rate. This method of tube verification was advocated by a

position paper from the National Association of EMS Physicians in 1999. (

http://www.naemsp.org/pdf/verificationtubeplacement.pdf ) It is a rapid and very

reliable method of determining tube placement, much better than auscultation,

tube fogging, colorometric CO2 detectors, etc. Why this has not become the

standard of care in both the pre-hospital and ED settings is surprising, as if

you ask our colleagues in anesthesia, no one is intubated without waveform

capnography and it has been the standard of care in the OR for many years. 2. I

believe that the current system by which we train paramedics to perform

intubation is set up with the deck stacked against them. I worked as an EMT for

many years before becoming a physician, and all my initial intubations were in

either the OR or the ED. The first time I had to place a tube as the physician

on an ambulance I was face down in a field with an anaphylactic patient deep in

the woods on a very bright sunny day. It was an eye opener for me how much more

difficult this was than placing a tube in the ED. Think about it -- as

physicians we are accustomed to a well lit exam room, with an adjustable bed,

staff to assist us, maybe anesthesia backup. Being in the middle of a field face

down in the dirt without support staff is a very different experience. There is

an interesting article from the Anesthesia literature in 2007 that shows that

physicians that normally work in a hospital setting, when placed with a

helicopter service, often had unrecognized esophageal intubations (no

capnography was available)

http://www.anesthesia-analgesia.org/cgi/content/abstract/104/3/619 Flash to how

we train our EMS providers: we place them in a sterile OR or ED, then once they

get the " right number " of tubes send them out into the field to get a couple of

" field tubes " and then that's it. Most never have the opportunity to come back

to the ED/OR to practice, nor do we actually train them in the environment in

which they work. Paramedic students should be getting many intubations using

airway mannequins in real field conditions (dark rooms, bathrooms, dusty fields,

etc.), and all practicing paramedics should have the opportunity (and be

mandated) to continue to practice intubations both on airway mannequins, and

back in the ED/OR to maintain their skills. The combination of training the

medics in our controlled ED environment and then sending them into a very

different field environment, coupled with the lack of continuing

education/practice, I feel is the source of many of the issues that have been

raised within this discussion. Then, factor in the lack of waveform capnogrpahy

in many places, and this just compounds the issue. A recent article from the

British Journal of Anesthesia shows intubation to be safe and beneficial for

head injured patients with well trained providers:

http://bja.oxfordjournals.org/cgi/content/full/96/1/67 Again training and

education -- coupled with practice and good monitoring equipment -- is the key.

3. In the San Diego study that is often quoted (The effect of paramedic rapid

sequence intubation on outcome in patients with severe traumatic brain injury. J

Trauma. 2003 Mar;54(3):444-53.), the authors themselves noted that RSI improved

paramedic success rates: " Paramedic RSI improves intubation success rates but is

associated with an increase in mortality and decrease in 'good outcomes' when

compared with hand-matched controls. These differences may reflect inherent

inequities between the two groups, although they appeared similar on all

parameters we measured. Alternatively, the increase in mortality may be related

to inadvertent hyperventilation, transient hypoxic episodes, and prolonged scene

times associated with the RSI procedure. " As the authors noted in their last

sentence, further analysis of the data showed that hypertventilation and hypoxia

was a large factor in the poor outcome of the patients, not the RSI procedure

itself. (http://www.ncbi.nlm.nih.gov/pubmed/15284540 ) Well trained EMS

providers with appropriate monitoring (continous ETCO2 and SPO2) and all

available airway tools (including intubation/RSI when necessary) is the best way

to minimize these complications. In fact, if you look at the literature from

Europe (i.e. Acta Anaesthesiologica Scandinavica. 50(10):1250-4, 2006 Nov.

" Effect of pre-hospital advanced life support with rapid sequence intubation on

outcome of severe traumatic brain injury. " ) many trauma patients were dying from

hypoxia from lack of airway control in BLS only systems, and the introduction of

ALS showed a decrease in mortality for TBI patients. A follow up study in the

Journal of Trauma in 2007 showed that if TBI patients maintained normocapnea

after intubation by medics, they did not have an increased mortality. (

http://www.ncbi.nlm.nih.gov/pubmed/17563643 ) In addition, a study from Journal

of Trauma in 2005 showed that the use of a neuromuscular blocking agents by

medics, when adjusted for confounding variables, actually improves outcomes for

patients with TBI. ( http://www.ncbi.nlm.nih.gov/pubmed/15824647 ) Interestingly

enough, there is an article in Archives of Surgery from San Diego pre-RSI that

actually shows an improvement in patient outcome with pre-hospital intubation of

head injuries ( http://archsurg.ama-assn.org/cgi/content/abstract/132/6/592 ).

This further suggests that it is not the intubation that was the issue, but

unrecognized hypoxia/hyperventilation/hypocapnea as noted. A recent expert panel

summarized this best: " The Brain Trauma Foundation assembled a panel of experts

to interpret the existing literature regarding paramedic RSI for severe TBI and

offer guidance for EMS systems considering adding this skill to the paramedic

scope of practice. The interpretation of this panel can be summarized as

follows: (1) the existing literature regarding paramedic RSI is inconclusive,

and apparent differences in outcome can be explained by use of different

methodologies and variability in comparison groups; (2) the use of Glasgow Coma

Scale score alone to identify TBI patients requiring RSI is limited, with

additional research needed to refine our screening criteria; (3) suboptimal RSI

technique as well as subsequent hyperventilation may account for some of the

mortality increase reported with the procedure; (4) initial and ongoing training

as well as experience with RSI appear to affect performance; and (5) the success

of a paramedic RSI program is dependent on particular EMS and trauma system

characteristics. (link: http://www.ncbi.nlm.nih.gov/pubmed/17169868 ) 4. My

opinion -- backed by a recent article in Journal of Trauma-Injury Infection &

Critical Care [ " Prehospital Rapid Sequence Intubation for Head Trauma:

Conditions for a Successful Program " 60(5):997-1001, 2006 May. ] -- is that RSI

should be reserved for a small cadre of well trained paramedics that are

available for the right cases and the sickest patients. It should not be every

medic, every patient with a GCS < 8, or every CHF'er. The conclusion from their

article is the same: " Prehospital RSI for trauma patients can be safely and

effectively performed with low rates of complication and without significant

delay in transport. This study suggests that resources for prehospital airway

management should be focused on training, regular experience, and close

monitoring of a limited group of providers, thereby maximizing their exposure

and experience with this procedure. " Best regards, EMSDoc >> Below is a response

that a doctor made on another forum that really > applies to the RSI discussion

on here recently. > Renny Spencer> EMT-I> Paramedic student> > " There is a brisk

discussion on this very topic online right now > among the docs in the ACEP EMS

Section. I will post here what I sent > there. > > I have performed a number of

intubations in the field with RSI with > my squad. Few have been trauma

patients; most were respiratory > failure due to medical causes such as CHF that

did not respond to > therapy. Perhaps it's our patient population of morbidly

obese chain > smoking hypertensive type II diabetic vasculopaths with CHF that >

prefer to call 911 only when there is a large hooded figure with a > scythe

standing in the corner of the room, but we get some sick > folks. We are in the

process of training the medics for RSI to see if > we can sustain the skill

retention through training and periodic > retesting before we implement it. On

our SWAT team, the medics are > trained and authorized to use RSI (easier to

implement, since this is > a small cadre of very experienced medics with

dedicated monthly > training time). > > One important thing to consider when

looking at those studies is the > fact that they include intubation of patients

who are incompletely > relaxed, the " cowboy tube " that is undertaken with

nothing but a > laryngoscope and Brutane. Not only do the paramedics get the

really > bad airways, as pointed out, but we ask them to intubate patients >

that we as physicians would never consider intubating without RSI. By > asking

them to do so, are we not setting them up for failure? What > would our

intubation success rate be as physicians without RSI? > > Several studies have

demonstrated the value of RSI in prehospital > settings. Whether by improving

intubation conditions, or improving > training, improved airway decision-making,

periodic skills > reassessment, or improvement of conditions for intubation by

use of > the drugs, RSI (with appropriate oversight and training) seems to >

improve intubation rates. > A 2004 study by et al found that rates of

unrecognized > esophageal placement of endotracheal tubes was as high as 6%.

The > standard for placement verification was auscultation by the receiving >

emergency physician. This rate was lower (3% vs. 9%) when a > confirmation

device, such as Esophageal Detector Device or end-tidal > CO2 detector was used.

Small study size limits the scope of this > study, but the results are

concerning nonetheless. > > An analysis of failed intubations revealed that of

the 10% of > patients who had failed intubation attempts in the field, nearly

50% > were attributable to inadequate relaxation, 20% to poor anatomy, and > 10%

to obstruction..[iii] Of these that could not be intubated in the > field, 41%

were successfully intubated after RSI in the Emergency > Department. The

estimate of " truly difficult " airways, defined as > requiring 3 or more

intubation attempts in the ED, was 0.8-1.6%. > > A 2003 study from the

University of Pittsburgh showed an overall > intubation success rate of 90%.

Patients with vital signs were > successfully intubated only 72% of the time,

while patients in > cardiac arrest were successfully intubated 93% of the time.

Factors > attributed to failed intubation which may be remedied through RSI >

include clenched jaw (30%), combativeness (11%), inadequate > relaxation (25%),

intact gag reflex (38%).[iv] > > A 2005 study from Wake Forest University

utilizing an air transport > service compared etomidate only intubation (EOI) to

RSI.[v] This > small study, with younger (mean 38 years) mostly trauma patients

> (90%) used a subjective scale to rate " adequate " conditions for > intubation.

EOI produced these conditions only 13% of the time, while > RSI produced them

80% of the time. Intubation success rate was 25% in > the EOI group and 92% in

the RSI group. Studies from Dickenson et al > and Wang et al showed limited

success with midazolam (Versed) as a > single-line agent to facilitate

intubation, citing success rates of > 62-75%.[vi],[vii] This mirrors our

experience with our " sedate to > intubate " protocol, which allows use of versed

or etomidate to > facilitate intubation. > > Alicandro reported RSI success in a

paramedic air transport system to > be 90%, compared with conventional ETI

success rate of 69%.[viii] > > A study by Hedges et al recounted 95 occurrences

of RSI in a ground > ALS system, which showed an overall success rate of 96% and

no > misplaced tubes or cricothyroidotomies performed.[ix] Pace and Fuller >

found success rates of 92% vs. 66% with conventional intubation.[x] > Krisanda

et al reported a 94% success rate with RSI in seven ground > ALS services.[xi] >

> Pearson's 2003 study in the Air Medical Journal examined the impact > of

implementation of an RSI protocol on number of intubation attempts > and time to

successful intubation. The study, though small (140 > patients) found that both

the number of attempts and the time to > intubation decreased significantly once

succinylcholine was added to > the drug box.[xii] > > A study by Ochs and

from San Diego enrolled 114 patients with > head injury who underwent RSI. 84%

were intubated successfully, the > rest were managed with combitube. There was

only one airway failure.> [xiii] > > Wayne and Friedland's 20 year review of RSI

with succinylcholine in a > ground ALS service found a success rate of 95% in

their analysis of > 1657 patients. Only 3 of the 74 patients where intubation

was > unsuccessful required cricothyroidotomy.[xiv] This study seems to >

suggest 2 things: paramedics CAN successfully perform RSI, and > paralysis +

failed intubation do not necessarily equal surgical > cricothyroidotomy. If the

patient can be managed with a rescue airway > or oral airway and BVM, then they

don't need to be cut. This study I > think shows the value of training: medics

had 20 OR intubations, and > were required to get OR time and a minimum number

of tubes per year. > > Some recent studies have questioned the use of RSI on

specific > populations in the prehospital environment. RSI has been associated >

with worse outcomes in patients with severe head injury in a landmark > study by

, Hoyt et al from San Diego.[xv] A follow-up analysis > of these patients

suggested the association between increased > mortality and

hyperventilation.[xvi] > > I agree completely that RSI is a potentially

disastrous tool to have > without proper training and oversight. Our currently

planned regimen > involves monthly skill time on the mannekin, quarterly

retesting > (written and practical), tracking of individual paramedic intubation

> rates with quarterly minimums (to be made up on mannekin testing if >

inadequate), and QA review of all intubation cases. Currently, run > sheets are

kicked to my inbox automatically for advanced airways, > arrests, AMI,

" significant ALS care " , pediatrics, obstetrics, > refusals, and any other issue

as seen fit by the QA supervisor. > > Two other important factors I think must

be in place when allowing > RSI: confirmation of tube placement, and backup

airway devices. We've > already touched on the use of capnography, which I think

is an > invaluable tool for confirming and monitoring intubation. Despite > what

the studies suggest regarding the EDD, I don't think anything > else yet matches

EtCO2. > > As far as backup airways and adjuncts go, I'm a big believer in the >

Airtraq, the Glidescope (though right now we can't afford to put them > on the

trucks, this is on the wish list), the bougie, and the King LT-> D. As a matter

of disclosure, I have no financial or other > conflicting interests in these

products whatsoever. Medics have to > have them and be comfortable with them. >

> The real question we need to be asking is, how can we get our medics > into

the OR to practice intubation? Many anesthesiology groups here > are shut down

tight when it comes to paramedic intubation time, and > unfortunately, concerned

about the liability of having a less > experienced provider perform the

intubation. This leaves cadaver labs > as the most accessible solution. > > So

to summarize (everyone wake up, lights are coming on again, > powerpoint is

coming to an end, urinals and coffee urns await you...) > 1) I think that RSI

does belong in the field under the right > conditions. > 2) That said, training

and oversight are crucial and are the > difference between a successful RSI

program and one that is > dangerous. > 3) Medics should have the right tools.

That includes not only the > tools to intubate successfully but the tools to

manage the patient > when they can't. We can't set them up for failure and then

complain > that their skills are inadequate. > > 'zilla > > JH,

MP, DicksonRL. Emergency Physician-Verified Out-> Of-Hospital Intubation: Miss

rates by paramedics. Acad Emerg Med. > 2004 Jun;11(6):707-709. > > [ii] Wang HE,

Kupas DF, et al. Multivariate Predictors of Failed > Prehospital Endotracheal

Intubation. Acad. Emerg. Med. 2003 Jul;10(7) > 717-724. > > [iii] Wang HE,

Sweeney TA, et al. Failed Prehospital Intubations: An > analysis of emergency

department courses and outcomes. Prehosp Emer > Care. 2001;5:134-141. > > [iv]

Wang HE, Kupas DF, et al. Multivariate Predictors of Failed > Prehospital

Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7) > 717-724. > > [v]

Bozeman WP, Kleiner DM, Hugget V. A comparison of rapid-sequence > intubation

and etomidate-only intubation in the prehospital air > medical setting. Prehosp

Emer Care. 2006;10:8-13. > > [vi] Wang HE, O'Connor RE, Megargel RE, et al. The

utilization of > midazolam as a pharmacologic adjunct to endotracheal intubation

by > paramedics. Prehosp Emerg Care. 2000;4:14–8. > > [vii] Dickinson ET, Cohen

JE, Mechem CC. The effectiveness of > midazolam as a single pharmacologic agent

to facilitate endotracheal > intubation by paramedics. Prehosp Emerg Care.

1999;3:191–3. 84. > > [viii] Alicandro JM, Henry MC, Hollander JE, S,

Kaufman M, > Niegelberg E. Improved success rate of out-of-hospital intubation >

with rapid-sequence induction . Acad Emerg Med. 1996; 3:408. > > [ix] Hedges JR,

Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz B. > Succinylcholine-assisted

intubations in prehospital care. Ann Emerg > Med. 1988;17:469–72.36. > > [x]

Pace SA, Fuller FP. Out-of-hospital use of succinylcholine by > paramedics. Acad

Emerg Med. 1996;3: 407–8. > > [xi] Krisanda T, Eitel D, Cooley M, et al.

Succinylcholine-assisted > intubation by responding advanced life support ground

units: results > of a four-year pilot study for the state of Pennsylvania. Acad

Emerg > Med. 1997;4:460. > > [xii] Pearson S. Comparison of intubation attempts

and completion > times before and after the initiation of a rapid sequence

intubation > protocol in an air medical transport program. Air Med J. 2003 Nov->

Dec;22(6):28-33. > > [xiii] DP, Ochs M, Hoyt DB, D, Marshall LK,

Rosen P. > Paramedic-administered neuromuscular blockade improves prehospital >

intubation success in severely head-injured patients. J Trauma. 2003 >

Oct;55(4):713-9. > > [xiv] Wayne MA, Friedland E. Prehospital use of

succinylcholine: a 20-> year review. Prehosp Emerg Care. 1999

Apr-Jun;3(2):107-9. > > [xv] DP, Hoyt DB, Ochs M. The effect of paramedic

rapid > sequence intubation on outcome in patients with severe traumatic > brain

injury. J Trauma. 2003 Mar;54(3):444-53. > > [xvi] DP, Stern J, Sise MJ,

Hoyt DB. A follow-up analysis of > factors associated with head-injury mortality

after paramedic rapid > sequence intubation. J Trauma. 2005 Aug;59(2):486-90. " >

_________________________________________________________________

Express yourself wherever you are. Mobilize!

http://www.gowindowslive.com/Mobile/Landing/Messenger/Default.aspx?Locale=en-US?\

ocid=TAG_APRIL

[Guest guest]

Who are these docs? Docs, PLEASE identify yourselves. I want to talk to

you. If you're not comfortable with " coming out " on the list, write me

privately at wegandy@....

I need to talk to emergency docs who understand RSI in the field and who have

been there.

I live in a state where the bureaucracy suppresses RSI. I am trying to

change that. I need all the help I can get, and ONE physician's input can be

very helpful.

Gene Gandy, JD, LP

>

> Here is another doctors response:

>

> Hey all,

>

> Doczilla asked I join the discussion. We both have been posting on

> the ACEP listserver about this topic, so this is what I posted:

>

> A few points:

>

> 1. All agencies should be using waveform capnography as the " gold

> standard " to determine tube placement. With properly used waveform

> capnography there should be an almost zero percent missed esophageal

> intubation rate. This method of tube verification was advocated by a

> position paper from the National Association of EMS Physicians in

> 1999. ( http://www.naemsp.http://www.naemshttp://www.naemshttp: ) It

> is a rapid and very reliable method of determining tube placement,

> much better than auscultation, tube fogging, colorometric CO2

> detectors, etc. Why this has not become the standard of care in both

> the pre-hospital and ED settings is surprising, as if you ask our

> colleagues in anesthesia, no one is intubated without waveform

> capnography and it has been the standard of care in the OR for many

> years.

>

> 2. I believe that the current system by which we train paramedics to

> perform intubation is set up with the deck stacked against them. I

> worked as an EMT for many years before becoming a physician, and all

> my initial intubations were in either the OR or the ED. The first

> time I had to place a tube as the physician on an ambulance I was

> face down in a field with an anaphylactic patient deep in the woods

> on a very bright sunny day. It was an eye opener for me how much more

> difficult this was than placing a tube in the ED. Think about it --

> as physicians we are accustomed to a well lit exam room, with an

> adjustable bed, staff to assist us, maybe anesthesia backup. Being in

> the middle of a field face down in the dirt without support staff is

> a very different experience. There is an interesting article from the

> Anesthesia literature in 2007 that shows that physicians that

> normally work in a hospital setting, when placed with a helicopter

> service, often had unrecognized esophageal intubations (no

> capnography was available) http://www.anestheshtt

> analgesia.org/ analgesia.o analgesi analgesia

>

> Flash to how we train our EMS providers: we place them in a sterile

> OR or ED, then once they get the " right number " of tubes send them

> out into the field to get a couple of " field tubes " and then that's

> it. Most never have the opportunity to come back to the ED/OR to

> practice, nor do we actually train them in the environment in which

> they work. Paramedic students should be getting many intubations

> using airway mannequins in real field conditions (dark rooms,

> bathrooms, dusty fields, etc.), and all practicing paramedics should

> have the opportunity (and be mandated) to continue to practice

> intubations both on airway mannequins, and back in the ED/OR to

> maintain their skills.

>

> The combination of training the medics in our controlled ED

> environment and then sending them into a very different field

> environment, coupled with the lack of continuing education/practice,

> I feel is the source of many of the issues that have been raised

> within this discussion. Then, factor in the lack of waveform

> capnogrpahy in many places, and this just compounds the issue.

>

> A recent article from the British Journal of Anesthesia shows

> intubation to be safe and beneficial for head injured patients with

> well trained providers:

> http://bja.oxfordjohttp://bja.http://bja.ohttp://bjaht Again training

> and education -- coupled with practice and good monitoring equipment -

> - is the key.

>

> 3. In the San Diego study that is often quoted (The effect of

> paramedic rapid sequence intubation on outcome in patients with

> severe traumatic brain injury. J Trauma. 2003 Mar;54(3):444- severe tr

> authors themselves noted that RSI improved paramedic success

> rates: " Paramedic RSI improves intubation success rates but is

> associated with an increase in mortality and decrease in 'good

> outcomes' when compared with hand-matched controls. These differences

> may reflect inherent inequities between the two groups, although they

> appeared similar on all parameters we measured. Alternatively, the

> increase in mortality may be related to inadvertent hyperventilation,

> transient hypoxic episodes, and prolonged scene times associated with

> the RSI procedure. "

>

> As the authors noted in their last sentence, further analysis of the

> data showed that hypertventilation and hypoxia was a large factor in

> the poor outcome of the patients, not the RSI procedure itself.

> (http://www.ncbi.http://www.nhttp://www.ncbi ) Well trained EMS

> providers with appropriate monitoring (continous ETCO2 and SPO2) and

> all available airway tools (including intubation/RSI when necessary)

> is the best way to minimize these complications. In fact, if you look

> at the literature from Europe (i.e. Acta Anaesthesiologica

> Scandinavica. 50(10):1250- Scandinavica. 50(10):1250-<wbr>4, 20

> advanced life support with rapid sequence intubation on outcome of

> severe traumatic brain injury. " ) many trauma patients were dying from

> hypoxia from lack of airway control in BLS only systems, and the

> introduction of ALS showed a decrease in mortality for TBI patients.

>

> A follow up study in the Journal of Trauma in 2007 showed that if TBI

> patients maintained normocapnea after intubation by medics, they did

> not have an increased mortality. (

> http://www.ncbi.http://www.nhttp://www.ncbi )

>

> In addition, a study from Journal of Trauma in 2005 showed that the

> use of a neuromuscular blocking agents by medics, when adjusted for

> confounding variables, actually improves outcomes for patients with

> TBI. ( http://www.ncbi.http://www.nhttp://www.ncbi )

>

> Interestingly enough, there is an article in Archives of Surgery from

> San Diego pre-RSI that actually shows an improvement in patient

> outcome with pre-hospital intubation of head injuries (

> http://archsurg.http://arhttp://archsurg.http://arhttp://ar ). This

> further suggests that it is not the intubation that was the issue,

> but unrecognized hypoxia/hyperventil but unrecognized hypoxia/h

>

> A recent expert panel summarized this best:

>

> " The Brain Trauma Foundation assembled a panel of experts to

> interpret the existing literature regarding paramedic RSI for severe

> TBI and offer guidance for EMS systems considering adding this skill

> to the paramedic scope of practice. The interpretation of this panel

> can be summarized as follows: (1) the existing literature regarding

> paramedic RSI is inconclusive, and apparent differences in outcome

> can be explained by use of different methodologies and variability in

> comparison groups; (2) the use of Glasgow Coma Scale score alone to

> identify TBI patients requiring RSI is limited, with additional

> research needed to refine our screening criteria; (3) suboptimal RSI

> technique as well as subsequent hyperventilation may account for some

> of the mortality increase reported with the procedure; (4) initial

> and ongoing training as well as experience with RSI appear to affect

> performance; and (5) the success of a paramedic RSI program is

> dependent on particular EMS and trauma system characteristics. (link:

> http://www.ncbi.http://www.nhttp://www.ncbi )

>

> 4. My opinion -- backed by a recent article in Journal of Trauma-

> Injury Infection & Critical Care [ " Prehospital Rapid Sequence

> Intubation for Head Trauma: Conditions for a Successful Program " 60

> (5):997-1001, 2006 May. ] -- is that RSI should be reserved for a

> small cadre of well trained paramedics that are available for the

> right cases and the sickest patients. It should not be every medic,

> every patient with a GCS < 8, or every CHF'er. The conclusion from

> their article is the same: " Prehospital RSI for trauma patients can

> be safely and effectively performed with low rates of complication

> and without significant delay in transport. This study suggests that

> resources for prehospital airway management should be focused on

> training, regular experience, and close monitoring of a limited group

> of providers, thereby maximizing their exposure and experience with

> this procedure. "

>

> Best regards,

>

> EMSDoc

>

>

> >

> > Below is a response that a doctor made on another forum that really

> > applies to the RSI discussion on here recently.

> > Renny Spencer

> > EMT-I

> > Paramedic student

> >

> > " There is a brisk discussion on this very topic online right now

> > among the docs in the ACEP EMS Section. I will post here what I

> sent

> > there.

> >

> > I have performed a number of intubations in the field with RSI with

> > my squad. Few have been trauma patients; most were respiratory

> > failure due to medical causes such as CHF that did not respond to

> > therapy. Perhaps it's our patient population of morbidly obese

> chain

> > smoking hypertensive type II diabetic vasculopaths with CHF that

> > prefer to call 911 only when there is a large hooded figure with a

> > scythe standing in the corner of the room, but we get some sick

> > folks. We are in the process of training the medics for RSI to see

> if

> > we can sustain the skill retention through training and periodic

> > retesting before we implement it. On our SWAT team, the medics are

> > trained and authorized to use RSI (easier to implement, since this

> is

> > a small cadre of very experienced medics with dedicated monthly

> > training time).

> >

> > One important thing to consider when looking at those studies is

> the

> > fact that they include intubation of patients who are incompletely

> > relaxed, the " cowboy tube " that is undertaken with nothing but a

> > laryngoscope and Brutane. Not only do the paramedics get the really

> > bad airways, as pointed out, but we ask them to intubate patients

> > that we as physicians would never consider intubating without RSI.

> By

> > asking them to do so, are we not setting them up for failure? What

> > would our intubation success rate be as physicians without RSI?

> >

> > Several studies have demonstrated the value of RSI in prehospital

> > settings. Whether by improving intubation conditions, or improving

> > training, improved airway decision-making, periodic skills

> > reassessment, or improvement of conditions for intubation by use of

> > the drugs, RSI (with appropriate oversight and training) seems to

> > improve intubation rates.

> > A 2004 study by et al found that rates of unrecognized

> > esophageal placement of endotracheal tubes was as high as 6%.

> The

> > standard for placement verification was auscultation by the

> receiving

> > emergency physician. This rate was lower (3% vs. 9%) when a

> > confirmation device, such as Esophageal Detector Device or end-

> tidal

> > CO2 detector was used. Small study size limits the scope of this

> > study, but the results are concerning nonetheless.

> >

> > An analysis of failed intubations revealed that of the 10% of

> > patients who had failed intubation attempts in the field, nearly

> 50%

> > were attributable to inadequate relaxation, 20% to poor anatomy,

> and

> > 10% to obstruction. 10% to obstruction.<wbr>.[iii] Of these that c

> the

> > field, 41% were successfully intubated after RSI in the Emergency

> > Department. The estimate of " truly difficult " airways, defined as

> > requiring 3 or more intubation attempts in the ED, was 0.8-1.6%.

> >

> > A 2003 study from the University of Pittsburgh showed an overall

> > intubation success rate of 90%. Patients with vital signs were

> > successfully intubated only 72% of the time, while patients in

> > cardiac arrest were successfully intubated 93% of the time. Factors

> > attributed to failed intubation which may be remedied through RSI

> > include clenched jaw (30%), combativeness (11%), inadequate

> > relaxation (25%), intact gag reflex (38%).[iv]

> >

> > A 2005 study from Wake Forest University utilizing an air transport

> > service compared etomidate only intubation (EOI) to RSI.[v] This

> > small study, with younger (mean 38 years) mostly trauma patients

> > (90%) used a subjective scale to rate " adequate " conditions for

> > intubation. EOI produced these conditions only 13% of the time,

> while

> > RSI produced them 80% of the time. Intubation success rate was 25%

> in

> > the EOI group and 92% in the RSI group. Studies from Dickenson et

> al

> > and Wang et al showed limited success with midazolam (Versed) as a

> > single-line agent to facilitate intubation, citing success rates of

> > 62-75%.[vi], 62-75%.[vi],<wbr>[vii] This mirrors our experience wi

> > intubate " protocol, which allows use of versed or etomidate to

> > facilitate intubation.

> >

> > Alicandro reported RSI success in a paramedic air transport system

> to

> > be 90%, compared with conventional ETI success rate of 69%.[viii]

> >

> > A study by Hedges et al recounted 95 occurrences of RSI in a ground

> > ALS system, which showed an overall success rate of 96% and no

> > misplaced tubes or cricothyroidotomies performed.[ix] Pace and

> Fuller

> > found success rates of 92% vs. 66% with conventional intubation.[ fo

> > Krisanda et al reported a 94% success rate with RSI in seven ground

> > ALS services.[xi]

> >

> > Pearson's 2003 study in the Air Medical Journal examined the impact

> > of implementation of an RSI protocol on number of intubation

> attempts

> > and time to successful intubation. The study, though small (140

> > patients) found that both the number of attempts and the time to

> > intubation decreased significantly once succinylcholine was added

> to

> > the drug box.[xii]

> >

> > A study by Ochs and from San Diego enrolled 114 patients with

> > head injury who underwent RSI. 84% were intubated successfully, the

> > rest were managed with combitube. There was only one airway failure.

> > [xiii]

> >

> > Wayne and Friedland's 20 year review of RSI with succinylcholine in

> a

> > ground ALS service found a success rate of 95% in their analysis of

> > 1657 patients. Only 3 of the 74 patients where intubation was

> > unsuccessful required cricothyroidotomy. unsuccessful required cri

> > suggest 2 things: paramedics CAN successfully perform RSI, and

> > paralysis + failed intubation do not necessarily equal surgical

> > cricothyroidotomy. If the patient can be managed with a rescue

> airway

> > or oral airway and BVM, then they don't need to be cut. This study

> I

> > think shows the value of training: medics had 20 OR intubations,

> and

> > were required to get OR time and a minimum number of tubes per

> year.

> >

> > Some recent studies have questioned the use of RSI on specific

> > populations in the prehospital environment. RSI has been associated

> > with worse outcomes in patients with severe head injury in a

> landmark

> > study by , Hoyt et al from San Diego.[xv] A follow-up analysis

> > of these patients suggested the association between increased

> > mortality and hyperventilation. morta

> >

> > I agree completely that RSI is a potentially disastrous tool to

> have

> > without proper training and oversight. Our currently planned

> regimen

> > involves monthly skill time on the mannekin, quarterly retesting

> > (written and practical), tracking of individual paramedic

> intubation

> > rates with quarterly minimums (to be made up on mannekin testing if

> > inadequate), and QA review of all intubation cases. Currently, run

> > sheets are kicked to my inbox automatically for advanced airways,

> > arrests, AMI, " significant ALS care " , pediatrics, obstetrics,

> > refusals, and any other issue as seen fit by the QA supervisor.

> >

> > Two other important factors I think must be in place when allowing

> > RSI: confirmation of tube placement, and backup airway devices.

> We've

> > already touched on the use of capnography, which I think is an

> > invaluable tool for confirming and monitoring intubation. Despite

> > what the studies suggest regarding the EDD, I don't think anything

> > else yet matches EtCO2.

> >

> > As far as backup airways and adjuncts go, I'm a big believer in the

> > Airtraq, the Glidescope (though right now we can't afford to put

> them

> > on the trucks, this is on the wish list), the bougie, and the King

> LT-

> > D. As a matter of disclosure, I have no financial or other

> > conflicting interests in these products whatsoever. Medics have to

> > have them and be comfortable with them.

> >

> > The real question we need to be asking is, how can we get our

> medics

> > into the OR to practice intubation? Many anesthesiology groups here

> > are shut down tight when it comes to paramedic intubation time, and

> > unfortunately, concerned about the liability of having a less

> > experienced provider perform the intubation. This leaves cadaver

> labs

> > as the most accessible solution.

> >

> > So to summarize (everyone wake up, lights are coming on again,

> > powerpoint is coming to an end, urinals and coffee urns await

> you...)

> > 1) I think that RSI does belong in the field under the right

> > conditions.

> > 2) That said, training and oversight are crucial and are the

> > difference between a successful RSI program and one that is

> > dangerous.

> > 3) Medics should have the right tools. That includes not only the

> > tools to intubate successfully but the tools to manage the patient

> > when they can't. We can't set them up for failure and then complain

> > that their skills are inadequate.

> >

> > 'zilla

> >

> > JH, MP, DicksonRL. Emergency Physician-Verified

> Out-

> > Of-Hospital Intubation: Miss rates by paramedics. Acad Emerg Med.

> > 2004 Jun;11(6):707- 2004

> >

> > [ii] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

> > Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10

> (7)

> > 717-724.

> >

> > [iii] Wang HE, Sweeney TA, et al. Failed Prehospital Intubations:

> An

> > analysis of emergency department courses and outcomes. Prehosp Emer

> > Care. 2001;5:134-141.

> >

> > [iv] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

> > Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10

> (7)

> > 717-724.

> >

> > [v] Bozeman WP, Kleiner DM, Hugget V. A comparison of rapid-

> sequence

> > intubation and etomidate-only intubation in the prehospital air

> > medical setting. Prehosp Emer Care. 2006;10:8-13.

> >

> > [vi] Wang HE, O'Connor RE, Megargel RE, et al. The utilization of

> > midazolam as a pharmacologic adjunct to endotracheal intubation by

> > paramedics. Prehosp Emerg Care. 2000;4:14–8.

> >

> > [vii] Dickinson ET, Cohen JE, Mechem CC. The effectiveness of

> > midazolam as a single pharmacologic agent to facilitate

> endotracheal

> > intubation by paramedics. Prehosp Emerg Care. 1999;3:191–3. 84.

> >

> > [viii] Alicandro JM, Henry MC, Hollander JE, S, Kaufman M,

> > Niegelberg E. Improved success rate of out-of-hospital intubation

> > with rapid-sequence induction . Acad Emerg Med. 1996; 3:408.

> >

> > [ix] Hedges JR, Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz

> B.

> > Succinylcholine- Succinylcholine-<wbr>assisted intubations in prehos

> > Med. 1988;17:469–72. Med

> >

> > [x] Pace SA, Fuller FP. Out-of-hospital use of succinylcholine by

> > paramedics. Acad Emerg Med. 1996;3: 407–8.

> >

> > [xi] Krisanda T, Eitel D, Cooley M, et al. Succinylcholine- [xi] Kri

> > intubation by responding advanced life support ground units:

> results

> > of a four-year pilot study for the state of Pennsylvania. Acad

> Emerg

> > Med. 1997;4:460.

> >

> > [xii] Pearson S. Comparison of intubation attempts and completion

> > times before and after the initiation of a rapid sequence

> intubation

> > protocol in an air medical transport program. Air Med J. 2003 Nov-

> > Dec;22(6):28- Dec

> >

> > [xiii] DP, Ochs M, Hoyt DB, D, Marshall LK, Rosen P.

> > Paramedic-administe Paramedic-administe<wbr>red neuromuscular block

> > intubation success in severely head-injured patients. J Trauma.

> 2003

> > Oct;55(4):713- Oc

> >

> > [xiv] Wayne MA, Friedland E. Prehospital use of succinylcholine: a

> 20-

> > year review. Prehosp Emerg Care. 1999 Apr-Jun;3(2) year re

> >

> > [xv] DP, Hoyt DB, Ochs M. The effect of paramedic rapid

> > sequence intubation on outcome in patients with severe traumatic

> > brain injury. J Trauma. 2003 Mar;54(3):444- bra

> >

> > [xvi] DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of

> > factors associated with head-injury mortality after paramedic rapid

> > sequence intubation. J Trauma. 2005 Aug;59(2):486- seq

> >

>

>

>

**************

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listings at AOL Autos.

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[Guest guest]

Excellent point. Way back in 1991 when I was going through my

paramedic course-we learned on " fred the head " and then practiced

our scenarios in the dirt-we learned blind intubation, on our head

intubations, closets you name it. I do believe they were way ahead

of their times!!!!

>

> Here is another doctors response:

>

> Hey all,

>

> Doczilla asked I join the discussion. We both have been posting on

> the ACEP listserver about this topic, so this is what I posted:

>

>

> 2. I believe that the current system by which we train paramedics

to

> perform intubation is set up with the deck stacked against them. I

> worked as an EMT for many years before becoming a physician, and

all

> my initial intubations were in either the OR or the ED. The first

> time I had to place a tube as the physician on an ambulance I was

> face down in a field with an anaphylactic patient deep in the

woods

> on a very bright sunny day. It was an eye opener for me how much

more

> difficult this was than placing a tube in the ED. Think about it --

> as physicians we are accustomed to a well lit exam room, with an

> adjustable bed, staff to assist us, maybe anesthesia backup. Being

in

> the middle of a field face down in the dirt without support staff

is

> a very different experience. There is an interesting article from

the

> Anesthesia literature in 2007 that shows that physicians that

> normally work in a hospital setting, when placed with a helicopter

> service, often had unrecognized esophageal intubations (no

> capnography was available) http://www.anesthesia-

> analgesia.org/cgi/content/abstract/104/3/619

>

> Flash to how we train our EMS providers: we place them in a

sterile

> OR or ED, then once they get the " right number " of tubes send them

> out into the field to get a couple of " field tubes " and then

that's

> it. Most never have the opportunity to come back to the ED/OR to

> practice, nor do we actually train them in the environment in

which

> they work. Paramedic students should be getting many intubations

> using airway mannequins in real field conditions (dark rooms,

> bathrooms, dusty fields, etc.), and all practicing paramedics

should

> have the opportunity (and be mandated) to continue to practice

> intubations both on airway mannequins, and back in the ED/OR to

> maintain their skills.

>

> The combination of training the medics in our controlled ED

> environment and then sending them into a very different field

> environment, coupled with the lack of continuing

education/practice,

> I feel is the source of many of the issues that have been raised

> within this discussion. Then, factor in the lack of waveform

> capnogrpahy in many places, and this just compounds the issue.

>

>

[Guest guest]

Jane,

I have not. I did this morning send a private message to both

doctors asking them to come join this discussion. If they were to

forward it it would carry more weight. The big problem on the other

forum is we post w/o our names and contact information. I agree

about wanting to see if journalist would be big enough to present the

other side.

Renny Spencer

EMT-I

Paramedic Student

>> Below is a response

that a doctor made on another forum that really > applies to the RSI

discussion on here recently. > Renny Spencer> EMT-I> Paramedic

student> > " There is a brisk discussion on this very topic online

right now > among the docs in the ACEP EMS Section. I will post here

what I sent > there. > > I have performed a number of intubations in

the field with RSI with > my squad. Few have been trauma patients;

most were respiratory > failure due to medical causes such as CHF

that did not respond to > therapy. Perhaps it's our patient

population of morbidly obese chain > smoking hypertensive type II

diabetic vasculopaths with CHF that > prefer to call 911 only when

there is a large hooded figure with a > scythe standing in the corner

of the room, but we get some sick > folks. We are in the process of

training the medics for RSI to see if > we can sustain the skill

retention through training and periodic > retesting before we

implement it. On our SWAT team, the medics are > trained and

authorized to use RSI (easier to implement, since this is > a small

cadre of very experienced medics with dedicated monthly > training

time). > > One important thing to consider when looking at those

studies is the > fact that they include intubation of patients who

are incompletely > relaxed, the " cowboy tube " that is undertaken with

nothing but a > laryngoscope and Brutane. Not only do the paramedics

get the really > bad airways, as pointed out, but we ask them to

intubate patients > that we as physicians would never consider

intubating without RSI. By > asking them to do so, are we not setting

them up for failure? What > would our intubation success rate be as

physicians without RSI? > > Several studies have demonstrated the

value of RSI in prehospital > settings. Whether by improving

intubation conditions, or improving > training, improved airway

decision-making, periodic skills > reassessment, or improvement of

conditions for intubation by use of > the drugs, RSI (with

appropriate oversight and training) seems to > improve intubation

rates. > A 2004 study by et al found that rates of unrecognized

> esophageal placement of endotracheal tubes was as high as 6%.

The > standard for placement verification was auscultation by the

receiving > emergency physician. This rate was lower (3% vs. 9%) when

a > confirmation device, such as Esophageal Detector Device or end-

tidal > CO2 detector was used. Small study size limits the scope of

this > study, but the results are concerning nonetheless. > > An

analysis of failed intubations revealed that of the 10% of > patients

who had failed intubation attempts in the field, nearly 50% > were

attributable to inadequate relaxation, 20% to poor anatomy, and > 10%

to obstruction..[iii] Of these that could not be intubated in the >

field, 41% were successfully intubated after RSI in the Emergency >

Department. The estimate of " truly difficult " airways, defined as >

requiring 3 or more intubation attempts in the ED, was 0.8-1.6%. > >

A 2003 study from the University of Pittsburgh showed an overall >

intubation success rate of 90%. Patients with vital signs were >

successfully intubated only 72% of the time, while patients in >

cardiac arrest were successfully intubated 93% of the time. Factors >

attributed to failed intubation which may be remedied through RSI >

include clenched jaw (30%), combativeness (11%), inadequate >

relaxation (25%), intact gag reflex (38%).[iv] > > A 2005 study from

Wake Forest University utilizing an air transport > service compared

etomidate only intubation (EOI) to RSI.[v] This > small study, with

younger (mean 38 years) mostly trauma patients > (90%) used a

subjective scale to rate " adequate " conditions for > intubation. EOI

produced these conditions only 13% of the time, while > RSI produced

them 80% of the time. Intubation success rate was 25% in > the EOI

group and 92% in the RSI group. Studies from Dickenson et al > and

Wang et al showed limited success with midazolam (Versed) as a >

single-line agent to facilitate intubation, citing success rates of >

62-75%.[vi],[vii] This mirrors our experience with our " sedate to >

intubate " protocol, which allows use of versed or etomidate to >

facilitate intubation. > > Alicandro reported RSI success in a

paramedic air transport system to > be 90%, compared with

conventional ETI success rate of 69%.[viii] > > A study by Hedges et

al recounted 95 occurrences of RSI in a ground > ALS system, which

showed an overall success rate of 96% and no > misplaced tubes or

cricothyroidotomies performed.[ix] Pace and Fuller > found success

rates of 92% vs. 66% with conventional intubation.[x] > Krisanda et

al reported a 94% success rate with RSI in seven ground > ALS

services.[xi] > > Pearson's 2003 study in the Air Medical Journal

examined the impact > of implementation of an RSI protocol on number

of intubation attempts > and time to successful intubation. The

study, though small (140 > patients) found that both the number of

attempts and the time to > intubation decreased significantly once

succinylcholine was added to > the drug box.[xii] > > A study by Ochs

and from San Diego enrolled 114 patients with > head injury who

underwent RSI. 84% were intubated successfully, the > rest were

managed with combitube. There was only one airway failure.> [xiii] >

> Wayne and Friedland's 20 year review of RSI with succinylcholine in

a > ground ALS service found a success rate of 95% in their analysis

of > 1657 patients. Only 3 of the 74 patients where intubation was >

unsuccessful required cricothyroidotomy.[xiv] This study seems to >

suggest 2 things: paramedics CAN successfully perform RSI, and >

paralysis + failed intubation do not necessarily equal surgical >

cricothyroidotomy. If the patient can be managed with a rescue airway

> or oral airway and BVM, then they don't need to be cut. This study

I > think shows the value of training: medics had 20 OR intubations,

and > were required to get OR time and a minimum number of tubes per

year. > > Some recent studies have questioned the use of RSI on

specific > populations in the prehospital environment. RSI has been

associated > with worse outcomes in patients with severe head injury

in a landmark > study by , Hoyt et al from San Diego.[xv] A

follow-up analysis > of these patients suggested the association

between increased > mortality and hyperventilation.[xvi] > > I agree

completely that RSI is a potentially disastrous tool to have >

without proper training and oversight. Our currently planned regimen

> involves monthly skill time on the mannekin, quarterly retesting >

(written and practical), tracking of individual paramedic intubation

> rates with quarterly minimums (to be made up on mannekin testing if

> inadequate), and QA review of all intubation cases. Currently, run

> sheets are kicked to my inbox automatically for advanced airways, >

arrests, AMI, " significant ALS care " , pediatrics, obstetrics, >

refusals, and any other issue as seen fit by the QA supervisor. > >

Two other important factors I think must be in place when allowing >

RSI: confirmation of tube placement, and backup airway devices. We've

> already touched on the use of capnography, which I think is an >

invaluable tool for confirming and monitoring intubation. Despite >

what the studies suggest regarding the EDD, I don't think anything >

else yet matches EtCO2. > > As far as backup airways and adjuncts go,

I'm a big believer in the > Airtraq, the Glidescope (though right now

we can't afford to put them > on the trucks, this is on the wish

list), the bougie, and the King LT-> D. As a matter of disclosure, I

have no financial or other > conflicting interests in these products

whatsoever. Medics have to > have them and be comfortable with them.

> > The real question we need to be asking is, how can we get our

medics > into the OR to practice intubation? Many anesthesiology

groups here > are shut down tight when it comes to paramedic

intubation time, and > unfortunately, concerned about the liability

of having a less > experienced provider perform the intubation. This

leaves cadaver labs > as the most accessible solution. > > So to

summarize (everyone wake up, lights are coming on again, > powerpoint

is coming to an end, urinals and coffee urns await you...) > 1) I

think that RSI does belong in the field under the right > conditions.

> 2) That said, training and oversight are crucial and are the >

difference between a successful RSI program and one that is >

dangerous. > 3) Medics should have the right tools. That includes not

only the > tools to intubate successfully but the tools to manage the

patient > when they can't. We can't set them up for failure and then

complain > that their skills are inadequate. > > 'zilla > >

JH, MP, DicksonRL. Emergency Physician-Verified Out-> Of-

Hospital Intubation: Miss rates by paramedics. Acad Emerg Med. > 2004

Jun;11(6):707-709. > > [ii] Wang HE, Kupas DF, et al. Multivariate

Predictors of Failed > Prehospital Endotracheal Intubation. Acad.

Emerg. Med. 2003 Jul;10(7) > 717-724. > > [iii] Wang HE, Sweeney TA,

et al. Failed Prehospital Intubations: An > analysis of emergency

department courses and outcomes. Prehosp Emer > Care. 2001;5:134-141.

> > [iv] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed

> Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10

(7) > 717-724. > > [v] Bozeman WP, Kleiner DM, Hugget V. A comparison

of rapid-sequence > intubation and etomidate-only intubation in the

prehospital air > medical setting. Prehosp Emer Care. 2006;10:8-13. >

> [vi] Wang HE, O'Connor RE, Megargel RE, et al. The utilization of >

midazolam as a pharmacologic adjunct to endotracheal intubation by >

paramedics. Prehosp Emerg Care. 2000;4:14–8. > > [vii] Dickinson ET,

Cohen JE, Mechem CC. The effectiveness of > midazolam as a single

pharmacologic agent to facilitate endotracheal > intubation by

paramedics. Prehosp Emerg Care. 1999;3:191–3. 84. > > [viii]

Alicandro JM, Henry MC, Hollander JE, S, Kaufman M, >

Niegelberg E. Improved success rate of out-of-hospital intubation >

with rapid-sequence induction . Acad Emerg Med. 1996; 3:408. > > [ix]

Hedges JR, Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz B. >

Succinylcholine-assisted intubations in prehospital care. Ann Emerg >

Med. 1988;17:469–72.36. > > [x] Pace SA, Fuller FP. Out-of-hospital

use of succinylcholine by > paramedics. Acad Emerg Med. 1996;3: 407–

8. > > [xi] Krisanda T, Eitel D, Cooley M, et al. Succinylcholine-

assisted > intubation by responding advanced life support ground

units: results > of a four-year pilot study for the state of

Pennsylvania. Acad Emerg > Med. 1997;4:460. > > [xii] Pearson S.

Comparison of intubation attempts and completion > times before and

after the initiation of a rapid sequence intubation > protocol in an

air medical transport program. Air Med J. 2003 Nov-> Dec;22(6):28-33.

> > [xiii] DP, Ochs M, Hoyt DB, D, Marshall LK, Rosen P.

> Paramedic-administered neuromuscular blockade improves prehospital

> intubation success in severely head-injured patients. J Trauma.

2003 > Oct;55(4):713-9. > > [xiv] Wayne MA, Friedland E. Prehospital

use of succinylcholine: a 20-> year review. Prehosp Emerg Care. 1999

Apr-Jun;3(2):107-9. > > [xv] DP, Hoyt DB, Ochs M. The effect of

paramedic rapid > sequence intubation on outcome in patients with

severe traumatic > brain injury. J Trauma. 2003 Mar;54(3):444-53. > >

[xvi] DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of >

factors associated with head-injury mortality after paramedic rapid >

sequence intubation. J Trauma. 2005 Aug;59(2):486-90. " >

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