Hi Rowley, and thanks for the explanations.

I just can't go with the no sux thing, it goes against the 
whole ethos of RSI in my view, and in such a precarious 
arena. I have researched the sux efficacy previously and 
will have to bow to your 25 degrees limit - I haven't seen 
that, but using two vials (200mg) will obviously get over 
that. Sux also gives the best intubating conditions. If 
you look at the evidence surrounding failed emergency 
airways, one of the few recurring themes is inadequate sux 
doses.
Funnily enough I only use panc prehospital - I use vec at 
work (as it really is a clean drug unlike atracuruim) and 
find the CV effects of panc take over from ketamine, after 
all, ketamine will only last 10-15 mins at most and to me 
its a bonus rather than a hindrence.
I must say im gobsmacked at your preoxgenation comment. 
Just last week I intubated a 23 yr old in ITU who I 
preoxygenated for a good 3 minutes, who then desaturated 
within 40 secs - and was a grade 3 intubation. I can just 
imagine what would have happened if I just given him just 
a few breaths had it been on the road.
As for intubation, I see the paramedics coming back time 
and time again failing to intubate probably 25% of the 
punters in theatre. I used to let them intubate on the 
road, but got sick of seeing sats drop and having to take 
over, or the sux wearing off. I do appreciate your 
seniority, but i'll stick to my way of doing things!

Cheers

Rob



On Mon, 17 Sep 2007 20:17:33 +0100
  Rowley Cottingham <[log in to unmask]> wrote:
> Thanks for your input, Rob. I did try to explain why I 
>made each comment,
> but perhaps didn't do it very well.
> 
> I know the tale about sux. However, the rules only hold 
>true up to around 25
> deg C. It is quite easy for a car interior to exceed 
>50deg C just in the UK;
> I have burnt myself on touching a car's steering wheel 
>when in Australia. So
> it's just too d*mn variable a feast for something one 
>relies on. 
> 
> Preoxygenation is a bit of an antiquated ritual. It used 
>to be three minutes
> by the clock - for no terribly obvious reason save to 
>upset surgeons as far
> as I could see. It's now a few breaths and I'm 
>comfortable with that.
> Holding your own breath while intubating is better!
> 
> I know a lot of people still use pancuronium, but I have 
>to admit I can't
> see the attraction. It has a dismal rate of onset and, 
>as you rightly point
> out, a quite unnecessary persistent tachycardia. As you 
>say, that and
> ketamine creates an unholy mix and I dumped it years 
>ago; initially in
> favour in my in hospital practice for atracurium 
>(another fridge-dweller)
> but in prehospital use for its much cleaner, faster 
>acting and smarter son
> Vecuronium. OK it has to be made up, but it can live in 
>the tropics of a car
> boot. If we are being honest, the sympathomimetic action 
>of ketamine is a
> pain too, but there is no safe alternative to that at 
>present. 
> 
> Let's get back to intubation. Now, which part of RSI can 
>you guarantee that
> the paramedic has learned? Yes, the single skill of 
>putting in the tube. So
> why make him do all the bits he ISN'T trained in - 
>especially cricoid
> pressure and drug administration? I have now tried this 
>both ways (ooer) and
> far prefer the paramedic intubating. Think of it as 
>though you were
> mentoring a new F2 in RSI. Can I persuade you to give it 
>a try?
> 
> Rowley.
> 
> -----Original Message-----
>From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Robert 
>Dawes
> Sent: 16 September 2007 09:35
> To: [log in to unmask]
> Subject: Re: RSI in the pre-hospital setting
> 
> 
> I agree with the majority of what Rowley says. There are 
> some points that I don't however.
> 
> Its not widely known that sux retains up to 90% of its 
> efficacy for 3 months outside the fridge, so just change 
> it every three months, but the chances are that you will 
> use it anyway. Always use 1.5 - 2.0 mg/kg - I just use 
>two 
> vials. Get hold of a few disposible "Water" circuits, 
>you 
> can add PEEP to buy you more preoxygenation time which 
>in 
> my view is the most important step in RSI behind making 
> the decision in the first place.
> I wouldn't use vec as an paralytic for an RSI 
>prehospital 
> - if it went wrong you would have a very hard time 
>getting 
> out of that one. As for post RSI, pancuronium is my 
>choice 
> because of its longevity and it positve cardiovascular 
> effects. I use ketamine the same as Rowley except for 
> medical RSI's. I never let the paramedic intubate an 
>RSI. 
> They perform at best 2-3 intubations a year on dead 
>people 
> and I am the more skilled intubator and the tube needs 
>to 
> be in ASAP, I am also more upto date with rescue 
> techniques such as a surgical airway. I always preload a 
> bougie, and use a bougie with a hollow core which is 
> attached to high flow O2. I use GlideRite ET tubes which 
> don't get caught up on the arytenoids 
> (http://www.verathon.com/gs_gliderite.htm) . These may 
>be 
> little points, but they all conpsire to give the best 
> chance.
> 
> Rob
> 
> 
> 
> On Sun, 16 Sep 2007 09:13:00 +0100
>  Rowley Cottingham <[log in to unmask]> wrote:
>> There are several interesting points about prehospital
>>rapid sequence
>> induction.
>> 
>> The first is that this is probably one of the three most
>>challenging
>> patient groups in which to perform RSI along with the 
>>term-pregnant woman
>> and the bariatric patient. 
>> 
>> The second is that the environment can also present
>>severe hazards and
>> challenges.
>> 
>> The third is that the support is often not from people
>>who normally
>> assist intubation. 
>> 
>> With a strong background in anaesthesia you would expect
>>me to have few
>> qualms about intubating people at the roadside - indeed 
>>I do RSI when
>> required, and it makes subsequent management, especially 
>>of the combative
>> head injury, much easier and probably improves outcome. 
>>However I still
>> find that I have to steel myself to do it, and it is 
>>related to the three
>> points above. 
>> 
>> The greatest nightmare is failing to intubate and then
>>losing the airway.
>> You therefore need to have equipment and skill 
>>immediately available
>> firstly to undertake a failed RSI go-around and secondly 
>>to transfer to a
>> surgical airway. I still like suxamethonium although for 
>>the last few
>> prehospital intubations I haven't had it to hand - so 
>>have gone for
>> Vecuronium. That really makes the hairs on the back of 
>>the neck tingle as
>> you have now paralysed someone for 20 minutes - so there 
>>is no recovery
>> in 3 as there is with sux. 
>> 
>> Sux is just too troublesome. Keep it in the car? Has it
>>gone off? Will it
>> work? Take some from the fridge at work? I'm usually 
>>called out from home.
>> Keep some in the fridge at home? That's a bit weird, 
>>frankly. I wish
>> powdered suxamethonium bromide was still available.
>> 
>> So I have had a few thoughts about prehospital RSI that
>>I have tried and
>> work well. Firstly, assemble all the kit. Yes, you. 
>>Despite what I said
>> before about potential difficult intubations (and this 
>>echoes Vic's story)
>> mostly the intubation itself isn't the hard bit - so let 
>>the paramedic do
>> it. They have actually learned on paralysed patients in 
>>theatre so it
>> will feel familiar. You are then in control of the 
>>drugs, the neck, the
>> oesophagus, the patient status generally and you can 
>>pass kit properly
>> checked and prepared with syringe in place etc to them. 
>>You are well
>> placed if something goes wrong with the airway as you 
>>let them do the BVM
>> of the failed intubation drill while you make sure you 
>>know where the
>> cric kit is. You can then satisfy yourself about breath 
>>sounds, CO2
>> monitoring etc.
>> 
>> This shares the workload safely and effectively. It's
>>great for the less
>> keen intubator as can still do this by using the 
>>psychomotor skill of the
>> paramedic and then can bale out with cric kit if need 
>>be. 
>> 
>> Oh, one other thing; try and get everything shut off
>>while you do this.
>> The din, smell, vibration and sudden clunks of 
>>extrication are incredibly
>> off-putting and mostly can be stopped for 2 minutes. 
>>It's one of the few
>> times you really need to hear breath sounds as you 
>>worsen a tension
>> surprisingly rapidly. Don't forget that you then have a 
>>paralysed patient
>> who won't breathe after 3 minutes but may wake up, so a 
>>big slug of
>> midazolam and morphine or ketamine (I haven't talked 
>>about induction
>> agents, but it's ketamine or ketamine) will do the job, 
>>remembering that
>> midazolam WILL knock the blood pressure.
>> 
>> /Rowley./
>> 
>> 
>> 
> 
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