I'm glad you brought this point up.
I would take the same action if I felt the patient had cerebral aggitation
and they or their rescuers were at risk or if they were likely to worsen
their intracerebral pressure or oxygenation.
You have to be certain you can manage their airway once you have sedated
them, so the doctor ON THE SCENE has to judge the pros and cons, especially
if you need to sedate someone who is entrapped (and make sure you have
annexate to hand!).
I was at an extrication on the M8 last night and we were unable to maintain
the driver's airway (passenger was dead on my arrival). He was GCS 4 and
hypoventilating with an sao2 of 90%. The roof came off pretty quickly after
I arrived and we put him in the ambulance (having tried and failed an
upright
intubation in the vehicle prior to that).
The second intubation was difficult and the patient vomited a large amount
of foodstuff and rapidly developed muscle spasm and decerebrate posturing
which prevented access to his mouth for suctioning or intubation. His sa02
promptly fell to 80% and I tried midazolam with no effect, so was forced to
perform a cricothyroidotomy to ventilate him (back to sao2 of 85%).
The first thing they did in resus was an RSI.
I'm now going to carry succinylcholine, because without it you just can't
control these patient's airways (although an LMA could have helped initially
as it's much easier to introduce in the entrapped patient than an et tube).
I appreciate that you are coverting a hypoventilating patient to an apnoeic
patient but I'm not going through the pantomime of innadequate airway
control that I had to endure last night. I mean he ended up with an
aspiration pneumonia and a cric anyway - that would have been the worst case
scenario had I done an RSI but with less delay and so less hypoxia, so
exactly what have I got to lose?
According to Nancy Caroline you should (in adults)...
1. Have ECG (and I would add SaO2) monitoring in place
2. Have an ivi running
3. Have 100mg succs and 5mg diazepam
4. Have atropine and lignocaine to hand
5. Check your intubation kit carefully and have a cric kit to hand.
6. Pre-oxygenate and give 3-5mg diazepam iv (if not fully unconscious) and
100mg succinylcholine (1.5mg per kg)
6. Wait for the muscle twitching to stop while BVM ventilating with cric
pressure to assess muscle relaxation
7. Intubate while applying cricoid pressure and check tube placement
8. If intubation fails BVM until the relaxant wears off or perform a cric
9. WATCH THE ECG FOR BRADYCARDIA THROUGHOUT (Use atropine 600 mics iv if it
falls beloew 60)
10. WATCH FOR VENRTICULAR TACHYARRHYTHMIAS
Anyone have any prehospital experience with RSI they want to share or any
comments on the above outline?
Robbie Coull
BASICS Doctor
ALS Instructor
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