Airway management is the first priority for management of any patient therefore it is very critical to know how to manage the patient in any emergency concerning the airway. Some emergencies can be managed with just bag valve mask (BVM) ventilations done correctly to maintain saturations above 94% and some need more invasive procedures to maintain and protect the airway.
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Rapid sequence intubation (RSI) is a very critical skill. It needs a pre-hospital provider (paramedic) to have a higher level of learning and expertise. The paramedic has to be very experienced and also need to make a good judgement. Decision making is crucial on whether to RSI or not. This has to be done quickly and efficiently in order to help the patient as best as possible. The challenge surrounding the Pre-Hospital setting is whether it is good or bad for the patient.
There are a lot of facts surrounding this issue as it is not only the skill that can affect the outcomes but other factors as well. In a prehospital setting paramedics have to be properly trained. The training focuses and puts emphasis on skills and decision making. Most bad decisions have poor intubation rates. Some of the studies show it as a good skill with good outcomes and some disagree.
In the following assignment I say that pre hospital RSI is beneficial if done correctly on a patient that it is indicated for and on which the benefits outweigh the risks.
3.1 What is rapid sequence intubation (RSI)?
It is the administration of a potent sedative (sedation) and a neuromuscular blocking (NMB) agent (paralysis) for the purpose of intubating patients who have a gag reflex or who would be difficult to intubate and the benefits outweigh the risks. Neuromuscular blockade allows for easier intubation and ventilation. A muscle relaxant is given in rapid sequence with a sedative before intubation is attempted. RSI utilizes a sedative, a short term paralytic these are administered to the patient to allow the passage of an endotracheal tube (ETtube) to be placed in the patient’s trachea to allow efficient ventilation to the patient. For bradycardic patients, especially children, atropine is used. Lidocaine for patients with increased intracranial pressure (ICP).
Routine: to introduce anaesthesia and neuromuscular blockade in preparation for intubation. (Usually done in hospitals by physicians, anaesthetists or specialists in a controlled environment)
Emergency: to produce neuromuscular blockade to facilitate placement of an endotracheal tube in those patients in which the airway could not be otherwise managed.
Indications for RSI
Trauma patients with a GCS of 9 or less with a gag reflex
Trauma patients with significant facial trauma and poor airway management
Seizures resulting in status epilepticus unresponsive to benzodiazepines.
Hypoxic and combative, unable to intubate by regular means,
Trauma with seizures or trismus
Closed head injury or major stroke with unconsciousness.
Burnt patients with airway burns and a compromised airway
Respiratory exhaustion such as severe asthma, coronary heart failure (CHF) or chronic obstructive pulmonary disease (COPD) with hypoxia.
Overdoses with altered mental status where there is a loss of airway.
It makes it easier to intubate, reduces intracranial pressure (ICP) associated with intubation and it is short acting. Improves oxygenation.
3.2 What does the literature say?
I will be looking at different articles written by different people to see whether prehospital RSI is beneficial or not. If not, how can it be improved.
In the article, Spaite et al, rapid sequence intubation of patients with severe head injuries in the out-of-hospital setting. The application of recording oximeters was used to evaluate the oxygen saturation and pulse rate. 57% of these trauma victims demonstrated desaturation during out of hospital rapid sequence intubation. Among those who experienced desaturation, 84% had initial oxygen saturations in the normal range with the utilization of basic airway skills alone. In addition, nearly 1 in 5 patients experienced bradycardia during desaturation. It is also noted that, in 84% of patients who experienced desaturation, the paramedics who were doing the RSI described the performance as easy.
In this article, Spaite et al, pre hospital RSI is not supported as it is said to have a high motarlity rate and a decrease in good outcomes. It also says that much less is known about the safety and effectiveness of out-of-hospital rapid sequence intubation. One of the most common things of the majority of the previous reports of out-of-hospital rapid sequence intubation is the lack or minor reporting of significant complications. Spaite also says that EMS has less studies evaluating the implementation of new treatments and procedures that report extremely low complication rates. The lack of complications stated may be resulting from practitioners not documenting the complications in order to protect themselves or from the lack of capturing all the patient information that is required.
According to the article, Lockey D et al, there is no good evidence that pre hospital RSI improves outcome in trauma patients, the benefits are not excluded either. It continues to say that the indications in hospital and pre-hospital RSI are the same. This doesn’t mean that every patient who is indicated should have an RSI. This is where good clinical decision making skills come into place taking different issues into account namely: patient, the skill provider and resources. It also emphasized on more training and practice for the skill providers.
In the next article, Lah K et al, it is said the RSI is performed by pre hospital physicians is useful, effective, safe, successful and part of standard care. However it also says that in a paramedics based system RSI can be a harmful procedure especially in difficult airway cases because of limited knowledge of drug kinetics and pharmacodynamics. I beg to differ on this statement because it is up to a person to learn the drugs in their scope of practice or drugs that they are going to use.
In comparing medical and trauma patients intubated in the field it was discovered that these two groups differ in many parameters. The patients in the medical group were in a bad condition initially, had a worse prognosis and a higher rate hypotension and bradycardia during RSI. Among the trauma patients it was found that there were more second attempts of RSI and problems with visualization which could be from trauma to the airway, trauma to the C-spine which will require the patient to be positioned inline immobilization of the cervical column, it can also be from the blood or vomitus in the oral cavity. This shows that every patient has a special need which needs to be acknowledged and considered when making the decision to RSI.
In the article, Mackay CA et al, it was found that adequately trained pre hospital practitioners can safely use sedative and muscle relaxant drugs in prehospital trauma patients. With a lot of training and practice it is possible to increase the good outcomes concerning RSI.
In this article, Ochs et al, has limitations regarding the outcome data. It says that the benefits of early intubation may be disrupted by the prolonged on scene time or the potential complications that will be caused by the procedure itself, this also comes back to good clinical judgement. A decision will have to be made on whether to give ventilations via BVM while transporting to the nearest appropriate facility or to continue trying to intubate the patient. This is where the risks and benefits will have to be weighed.
It concludes by stating that from all the practitioners who did the procedure with 84% successful ET tubes insertion and 15% combitube insertion and a failure rate of less than 1%. This is a very good result, it shows that with proper training and practice, pre hospital RSI can be done with a good outcome of a high success rate.
3.3 Other issues
There is no good current evidence that pre hospital RSI improves patient outcomes in trauma patients except in traumatic brain injury patients. RSI in TBI patients decreases (ICP). This however does not imply that there are no benefits to pre hospital RSI. Before each RSI there should be a risk versus benefits analysis, taking the patient, resources and other issues into account.
The patient will have to fit the indications criteria to be able to be considered for RSI (as mentioned above).
Personnel: you will need another ALS (has to be able to intubate) to help you
Equipment: Suction unit, oxygen, airway (laryngoscope, ET tubes, stylet, BVM with reservoir), all the relevant drugs (mix and draw up and label), monitoring equipment (ECG, saturation monitor, End Tidal CO2 monitor, Esophageal detector device).
Inability to intubate the patient
In this article, Cobas et al, there are certain explanations as to why the patient could not be intubated. It may be associated with the increased time spent at the scene which consumes valuable transport time. Also states that several attempts could be dangerous by creating haemodynamic disturbances while increasing hypoxia.
Incorrect drug dose administration. RSI on a patient that it is not indicated for. Failed intubation is a risk as it will require the practitioner to perform rescue airway to re-oxygenate the patient.
3.4 Important aspects
Adequate training is a priority with (RSI).
With a lot of training and practicing it makes the skill easier to perform and makes the practitioner more comfortable to perform the skill. It also reduces the time in which the skill has to be preformed which in turn reduces the time spent on scene.
Knowledge of the pharmacology
When you know your drugs it makes it very easy to decide on what drug to use to suit the patient’s condition. Also makes the practitioner more comfortable as they know what to do in case of side effects or other drug related challenges. It also makes it easier to decide on a certain drug to suit a certain patient’s needs best.
Know your equipment
It is also crucial to know all your equipment from the tools to the monitoring equipment. You have to know the tools so that you can know how to use them correctly. The monitoring equipment helps you to know more about the patient’s condition if the patient is responding well, stable or deteriorating.
This is a very important and vital step. The patient must be connected to monitors: ECG, Pulse Oximetry, blood pressure, End Tidal capnometry, IV line put up, all equipment to be prepared and tested (suction, laryngoscopes, endotracheal tubes, backup blades and tubes), preoxygenation, all drugs that will be used to be calculated and drawn up in syringes.
God preparation reduces complications, reduces time it will take to do the procedure and also reduce the anxiety for the practitioner.
RSI is a critical skill that has to be done correctly to improve the patient outcomes. It is therefore essential to have all the required elements to do the procedure. The following are recommended as the minimum elements required to have to perform the skill adequately.
The minimum requirements:
Training and continual education (with hands on experience with drugs and airway management of patients who have been pharmacologically paralysed in the hospital)
Equipment for patient monitoring, drug storage and correct usage, monitoring of tube placement
Standing and standardized RSI protocols including the use of selected pretreatment , sedative and neuromuscular blocking (NMB) agents
Back up airway equipment or methods in case of a failed RSI (BVM ventilations, combitube, Laryngeal mask airway (LMA), surgical cricothyroidotomy, needle cricothyroidotomy)
Continued quality assurance, quality control and performance review
Another advanced life support paramedic (able to intubate)
Good judgement to make a good clinical decision for the patient’s best interests
Every practitioner should have these things in their response car or ambulance, it should be part of their everyday equipment to make sure that they are prepared for RSI and to perform the skill as efficiently as possible.
It would work better if it could be made official. There should be documentation stating that every practitioner who is qualified to perform this skill should have all these requirements before even attempting to do the skill and failure thereof should be treated as an act of negligence and charged accordingly.
In conclusion, RSI is a critical life saving skill that is beneficial to some patients, especially the TBI patients. It is also risky if it is not done correctly. I still agree that it is beneficial and therefore should be done as best as possible.
What can be done to reduce the risk, it is to train practitioners adequately, have the practitioners do hands on practicals at the hospital with professionals who can monitor, and critique to help them do the skill as best as possible. Learn all the drugs and be able to perform other airway procedures in case of failed RSI.
There should also be quality assurance and yearly reviews or retraining to reduce skill degradation.
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