Some notes on RSI

What I am about to discuss should be taken with caution. Never deviate from your protocols and standing orders. You should always follow protocol and medical direction. This is also by no means a complete discussion on RSI or the medications that can be used for it. Any questions, feel free to ask, any suggestions would be greatly appreciated. Experiences you’ve gone through first hand would also be great, I would like to post a follow up to this post with at least 5 real world uses of RSI explored in detail. While some aspects of patients have been changed to protect the identity, I have tried to stay as close as possible to the emergency so as to provide as clear a picture as possible into the use of these treatments. This is also by no means a complete guide, just a few thoughts I’ve put together based off of personal experience, recent education and the experiences of knowledgeable and dedicated providers around me.

RSI can stand for rapid sequence intubation or rapid sequence induction. Either way it is a very extreme treatment regiment and should be done with extreme caution. What we are doing is paralyzing someone and taking over their respirations. Completely taking over a patient’s body. If we don’t breath for them they can no longer breath for themselves once we have paralyzed them. In very few other situations is the term, the patient’s life is in your hands, more applicable.

Some notes on some of the more common medications used in RSI.

Fentanyl/Sublimaze should be used for analgesic properties. Fentanyl also has very little to no effect on blood pressures so you can use it and trust that pain management will be as safe as possible. One of the things I like in my drugs is for them to have as little side effects as possible, if a drug is an analgesic I don’t want it to also drop my patient’s blood pressure. 
Dosage is usually 1 to 2 mcg/kg for adults and 2 to 3 mcg/kg for pediatrics. 
Notes on Fentanyl: it can cause muscle rigidity which in extreme cases can cause respiratory complications. I have heard uneducated doctors (I know, a misnomer) state this is the reason we shouldn’t be using fentanyl in the field. If used properly, given at a correct rate and correct rate of infusion this is rarely seen. Respiratory depression can also be seen. It is an opiate so it can be reversed with Narcan. For our use it would not be a problem since we are paralyzing and controlling the airway.

Anectine/Succinylcholine: ultra short-acting depolarizing-type, skeletal muscle relaxantThis will be important later. Some precautions: do not use in patients with rhabdomyolysis. Do not use in patients with diagnosed or suspected hyperkalemia, in patients with personal or familial history of malignant hyperthermia, skeletal muscle myopathies. This is important because we have to remember that if a person is hyperthermic or has diagnosed hyperkalemia we should skip anectine and go to your longer acting paralytic such as Vecuronium or Rocuronium. Care should also be used with people suffering from ocular injury, since Anectine can cause increased ocular pressure.
Dose: 1mg/kg not to exceed 150mg. Onset will usually be seen in under a minute so long as the IV line is patent and running well.

Typically we would sedate and give pain management prior to paralyzing. The nature of EMS is one that we cannot always predict what situations we will run into. There are guidelines we can follow, best practices we can learn, but there can always be a new complication. Take this story for example:

EMS crew is responding to the scene of a patient experiencing a seizure. As per family prior to the seizure the patient was showing sings and symptoms of a CVA. The patient has a past medical history of CVA as well as Hypertension. No history of seizures. When the EMS unit arrives the patient is still seizing. Grand Mal seizure lasting over 25 minutes, as per family. Treatment is begun, IV established, oxygen, Ativan is administered @ 4mg via IV. The patient shows no signs of improvement. In fact the patient begins to have emesis seep from his clenched teeth, suctioning is started but the medics are unable to open the jaw. oxygen saturations are dropping. The decision is made to RSI the patient. The first drug administered for RSI is Anectine @ 1mg/kg. Within 20 seconds the patient has stopped seizing and jaw has relaxed. Airway is open and suctioned, patient is intubated. Initial inline CO2 is marked at 70, oxygen saturation is instantly better going to 100% within a couple of minutes. It can be said that no analgesic was administered prior to RSI. That would be true, but the patient’s condition, at least in the medic’s perspective, warranted immediate intervention. If you were to begin ventilations without opening and clearing the airway aspiration could be a major issue, if Versed or another benzodiazepine was used respiratory depression could occur and without a patent airway the patient could be in worse shape. As soon as the airway is cleared and controlled the patient is administered fentanyl, versed and then given Vecuronium. The patient was transported and received at the ER. Within 30 minutes they had done everything they needed and had the patient inside the operating room receiving treatment for a massive stroke.

Norcuron/vecuronium: a non-depolorizing neuromuscular blocker. Remember I stated earlier that Anectine is a depolarizing agent. If a patient has a condition that may be exacerbated by Anectine it could still be safe to use vecuronium if the patient requires RSI. Dose is usually 0.1mg/kg. Onset is a little longer than Anectine but if you have the opportunity to premedicate with a sedative and an analgesic you should be on track with RSI. Of most RSI’s that I have seen only a couple have required vecuronium as the initial agent. Usually where I have seen Anectine work in 30 to 45 seconds on average, vecuronium has taken about a minute and a half to two minutes. The big difference is how long they will keep a patient under. 
Here is an example I love: 

Medics are called out to an emergency room for an emergency transfer. The hospital has been dealing with a trauma patient who has been diagnosed with rhabdomyolosis. The patient’s condition is deteriorating and his airway is now being compromised. The medics are told to prepare to transport an intubated and ventilated patient. The ER doctor is about to RSI the patient. As the medics prepare their equipment for transport they see that the patient is still very much moving and fighting the intubation process which is making the doctor not establish an airway. The patient is being sedated only, fentanyl, versed and some morphine is being used in increasing doses with little to no effect. 
For anyone who has used analgesics it is known that they are great for certain things and completely ineffective for others. An isolated fracture, some chronic back pain, maybe even some open fractures from trauma and fentanyl can help, versed can sedate. Try realigning a  dislocation with only fentanyl and you will quickly learn it is not as effective.  The same goes for someone sticking a tube down your trachea. The medics step in and begin to ask why the doctor is attempting an RSI without a paralytic also telling them that if the patient is successfully intubated and transport is initiated they will not take the patient without paralyzing him, it would be too dangerous in the unit to do so. The doctor, in the way only doctors can, scolds the medic and says a paralytic can’t be used because a depolarizing agent can exacerbate rhabdomyalosis. The response, which was delivered in the way only a medic can, said, “if your scared of exacerbating rhabdomyalosis because of a depolarizing paralytic maybe you should use a non-depolorizing agent like vecuronium.”
Let me explain something here, this was not my call, this was not me answering the doctor, but I was so proud watching it unfold. Everyone is quiet, except for the squirming patient, and for a split second I think the medics might be thrown out of the ER. Then the doctor calmly turns to the nurse and asks if they could draw up some vecuronium. Did the paramedic know everything there was to know on rhabdomyalosis? No, I asked him, but he did know enough about his medications that he was able to work the problem and had enough experience to find a suitable solution. The rest is history.

In any emergency there is pressure, in a critical call where you are getting ready to paralyze someone the pressure can cause you to forget one name or the other of medications or conditions. Some names you just have to learn and it’s a good thing to learn more than one name for each drug. Someone might not learn the same one you do. For example:

Anectine is Succinylcholine and most people just call it Sux. I don’t, I call it Anectine just because it is easy to say for me. I have trouble saying succinylcholine. 

Ativan is lorazepam.
Midazolam is versed.
One way I remember this is A is closer to L so Ativan is lorazepam. M is closer to V so Midazolam is Versed.

A good versed dose is typically 0.1mg/kg. This is a large dose and while you should still use a paralytic you should be ready to assist ventilations as soon as you’re administering versed in the off chance that it knocks out the patient’s respirations.

We don’t carry Valium in my service so I don’t have to worry about it. Valium is Diazepam. 

Final note on RSI for now: I typically am very pro education and believe even new medics have to learn how their meds work. I tell all my precepts that the books can’t show you everything. Only after you use a medication on a patient, over and over, different age ranges and for different symptoms are you really going to know what that medication does. Epinephrine, albuterol, brethine, benadryl, and many more. With an RSI you don’t just have to be proficient in intubation, different medication administration, and probably most importantly, a level head for when you get questioned about your call at the ER, you have to be experienced. This is one procedure I do not advocate for new paramedics. It isn’t that they are not knowledgeable enough, it is that experience is very important. If a medication causes a reaction you weren’t expecting you have to be able to react and correct the situation. Pride should not be a reason you are continuing to try to intubate a patient you have attempted to RSI and found extremely difficult. When done correctly it can be an absolutely life saving procedure, if done incorrectly it can be disastrous. 

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