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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