>Chris Cheeseman wrote:
>> There has been some suggestion on the list recently that muscle paralysis
as a sole agent for
>> intubation might be a good idea.
I don't remember anyone advocating it as a particularly "good" idea as a
sole agent but I am prepared to be reminded???
Andrew Hobart wrote:
>The other point is that of course in head injury paralysis alone does
nothing to abolish the ICP
>raising reflexes induced by passing a tube.
>A general anaesthetic induction agent of some sort is vital.A big slug of
opiate helps to abolish
>the laryngeal reflexes.
It is my understanding that in order to get an "anaesthetic" effect solely
from opiates then you have to use a hell of a lot. There was some recent
correspondance in the BMJ (or was it JAEM) recently about this- I'll find
out. Many people will use a small dose of short acting opiate (eg 25mg
fentanyl or 250mcg alfentanyl) as part of a rapid sequence though this is
not widely recommended. Even those anaesthetists I know that use fentanyl
during RSI in elective cases (eg when doing an RSI for a patients with
reflux) shy away from using it an a truly emergent situation.
The other thing about RSI is that if it goes pear shaped you really want
your patient to at least get back to where you started as soon as possible.
In particular one could argue that you want them to breath again as soon as
possible if you cannot gain control of the airway after the sux. If an
opiate is used (particulary if a large dose is given) this may not happen.
Chris Cheesman's recollection of an awake intubation under sux sounds awful,
I'm sure we would all agree that this should be avoided. I believe that the
latest incarnation of ATLS suggests midazolam/sux as the drugs of choice for
RSI in the ED. Again I believe that this may result in a mix of
amnesic+relaxant rather than anaesthetic+relaxant.
Simon Carley
SpR in Emergency Medicine
Hope Hospital
Salford
England
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