Airway Protection and succs

[Lawsonc]

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I have a question for the EM guys.

One of the last intubations I performed during my paramedic internship was on a approx 50 year old female. She was found at home lethargic and unresponsive to family members. Some of the notable history mentioned were opiod usage for pain management, diabetic, and hx of dialysis approx 1 years prior. She was pale, dry and hot, had obvious signs of dehydration (tenting of skin) and adequate breathing at a rate of approx 18.

Upon doing my initial assessment for life threatening injuries, we obtained vitals- BP was unobtainable with no radial pulse and a weak central pulse, HR was approx 110, RR- 18. Large bore IV access was established, BGL checked- 18. Dextrose was administered with positive outcome, she was now more responsive but still remained altered with an updated BGL of 112. 0.8 of Narcan was given with no change in altered mental status. Another line was established, and a 500cc fluid bolus was given with no fluid in the lungs upon secondary assessment. Vital signs improved with a BP of 100/60, HR-90, RR-16, Sinus on the monitor with occasional PVC, 12 lead was sinus with no changes to ST segment or blocks noted. 02 sat is 97% with 15lpm.

At this time we are transporting with a 10 minute ETA to the community ER. The patient remains stable, more alert but still altered. At the ED the physician immediately goes for an RSI (no depolarizing agents used) prior to moving her to the CT, and lets me assist for my last tube.

My question is, had I intubated in the field, was using succs for its depolarizing factors a risk I should be worried about? I (field) ruled out DM with the Dextrose, ruled out OD with the Narcan, I was leaning more towards infection/sepsis, brain bleed, and or renal failure with electrolyte issues. Had I felt the need to intubate (which is a question in itself, was the airway compromised?) I was going down the road of using etomidate, benzo and then a non depolarizing agent. Is my concern legitimate? Or is the risk of sudden cardiac arrest and arrhythmia caused by the Succs not an issue.

 

[MSmentor018]

i've done both field and now hospital medicine. airway compromise issues is always a tough call in the field. the more drugs you add on board (to her already polypharmacy), more potential complications given the hx. you got the pt there safely with an intact ABC's and that's all that counts. with a dialysis hx i would err on caution and not use succ. bad thing is if you use roc and have complications that's a long sphincter tightening trip in the back of the bus. plus intubating in the field is always under subpar conditions so you're taking a risk. prehaps just etomidate or versed or whatever your county has on the trucks with that profile.

 

[Lawsonc]

At the time of the call I was of course planning in my mind, with that history I was thinking "succs is out" but it was only after the call that I thought about it in depth. Unfortunately the doc was busy and we had to clear, now a few months later I am reviewing the call to stay fresh and thought I would post my question up here.

If I had to tube her, I would have gone Etomidate and Versed and then follow up with vec.

I guess I am just looking to see if anyone has had issues with succs. Im glad you agree with the thought process, I was wondering if I was just being overly cautious.

 

[Apollyon]

"History of dialysis approx 1 years prior" - like, briefly, or she started 1yr ago and is ESRD and still on it?

If she's ESRD, sux is contraindicated, due to the risk of hyperkalemia. If she only had dialysis briefly, it is important to know why. If she is chronic kidney disease, the contraindication remains.

 

[Lawsonc]

That is where it gets complicated and hence my caution. I guess I could have explained that portion better. It is unknown if she she goes or not, family states she had been going the year prior. She still has access that one member says is for needing it in the future, but no one knows the exact time line and or if she is still going.

 

[southerndoc]

I rarely use succinylcholine anymore. 95% of my intubations are with rocuronium.

 

[Arch Guillotti]

If she's ESRD, sux is contraindicated, due to the risk of hyperkalemia. If she only had dialysis briefly, it is important to know why. If she is chronic kidney disease, the contraindication remains.

There is no contraindication to sux in ESRD unless the potassium is markedly elevated (or other routine contraindication).

 

[xaelia]

I use rocuronium at 1.2-1.6 mg/kg for the majority of my intubations. I consider sux mostly for people I need a neurologic examination on after intubation - blunt head trauma, status epilepticus, etc. Sux is fine for elective intubations.

 

[Lawsonc]

To kind of side track here, the whole "not using succs" brings up another question. How many of you use propofol for intubations? In this instance, propofol (commonly used in burn patients?) would have been a safer alternative? I know that cost was an issue at one point in time, but I believe that has changed?

As far as sedation and pain management is concerned the county, I will be working as a reserve in (and ran this call as an intern), has Fentanyl, Morphine, Ativan, Valium, Versed, Etomidate, Succs, and Vec/Roc (depending on supply) on the rigs. (we carry Haldol and Nitrous Oxide for their specific indications)

I know propofol has been used on the birds, I am wondering if it is something we could see on the ground units, when compared to paralytics? From what I know so far it seems fairly safe.

 

[Lawsonc]

There is no contraindication to sux in ESRD unless the potassium is markedly elevated (or other routine contraindication).

I guess that is the issue/question I have. On an unresponsive patient with that history in the field and no labs, is the benefit to risk ratio in favor of using succs if needed?

As I mentioned there were no ST changes and no peaked T waves on the ECG or 12 lead if you want to even consider basing potassium levels on the monitor.

 

[Apollyon]

There is no contraindication to sux in ESRD unless the potassium is markedly elevated (or other routine contraindication).

Well, hell - that's what they taught me in residency (at "Big Name Teaching Hospital" - especially for anesthesia!). Seriously!

I even remember the situation - specifically - 8 years ago. It was a simulated case; not a real patient.

 

[pseudoknot]

I know propofol has been used on the birds, I am wondering if it is something we could see on the ground units, when compared to paralytics? From what I know so far it seems fairly safe.

I'm not sure what you mean by comparing propofol to paralytics. Propofol is an induction agent (like etomidate, versed [sort of], thiopental, etc.). If you are doing RSI you do need both an induction drug and a paralytic.

As for safety, I think propofol is "fairly safe" compared to shooting someone in the head. Compared to most other drugs we use it is extremely dangerous. I agree it can be used safely in the right hands, the right setting, and the right patients. With most prehospital intubation situations, hypotension is a big concern and propofol has a lot more hemodynamic suppression than the other induction drugs, so I would be pretty hesitant to use it in that setting.

 

[Lawsonc]

I completely get the Hypo-tension, and why we use etomidate instead. Just curious to what other issues people have had with the propofol. In the ED I have seen intubations performed without a paralytic but rather a heavy loading dosage of propofol. (this is what I was making reference to) so more along the lines of either, or?

The particular patient I had at the ER and prior to intubation, had declined in mental status and had little to no gag reflex. So etomidate, intubation, and then a follow up of a non depolarizing paralytic worked for her.

I would have had no issue intubating her in the field had she presented like such, but when we had her I still felt a paralytic would have been needed as she was making incomprehensible sounds and obviously still had her gag reflex intact.

I guess from what i've read so far the consensus is that this patient, would probably require a non depolarizing paralytic. This is of course if intubation was necessary in the home, and she still retained her gag reflex.

 

[WilcoWorld]

I find intubation without paralytics to be much more difficult and prone to complications & multiple attempts. The only time I'll do it is for an "awake" intubation. In such cases I'll use ketamine instead of something like propofol, because I want to preserve respiratory drive.

I understand the reticence to use paralytics, because I felt that way myself early on in my training - you want to "do no harm". Now the way I see it is that if you're taking over a patients ability to breathe, you shouldn't be afraid to use some drugs to get it done right.

 

[Tiger26]

Like Xaelia, I rarely use Succ anymore and pretty much exclusively use Rocc at 1.2 mg/kg or more unless I'm worried about getting a neuro exam for a head injury pt. I like the lack of contraindications and long half life in case I need to do multiple or different (i.e. surgical) techniques, since I'm not in the position to wake the patient up if the first attempt is unsuccessful.

 

[Groove]

CKD and/or ESRD isn't a definitive contraindication but a relative one, as is a hx of hyperkalemia... and if we're dealing with a CKD/ESRD pt, they have a higher risk of having already had a hyperkalemic episode at one point or another. In the field, and even in the ED, pt hx is limited. Pt with a GCS 6, I'm not going to stand there asking the family member their entire PMHx. If I even hear, suspect, smell, or even get that slightest "renal pt" vibe, I wouldn't use succ. For the OP, the reason, as already stated, is risk of hyperkalemia and the potential cardiac sequelae.

 

[Arch Guillotti]

CKD and/or ESRD isn't a definitive contraindication but a relative one

What are you basing this on?

 

[Arch Guillotti]

I use rocuronium at 1.2-1.6 mg/kg for the majority of my intubations. I consider sux mostly for people I need a neurologic examination on after intubation - blunt head trauma, status epilepticus, etc. Sux is fine for elective intubations.

Why 1.6 mg/kg? 1.2 is the "RSI" dose.

 

[Arch Guillotti]

I guess that is the issue/question I have. On an unresponsive patient with that history in the field and no labs, is the benefit to risk ratio in favor of using succs if needed?

I think the risk of pushing drugs and intubating in the field far outweighs the benefit, particularly in this scenario. IIRC this is being borne out in the prehospital literature.

I don't understand the rush to intubate a patient just because they are unresponsive so long as they are oxygenating and ventilating adequately. I realize they can't protect their airway but in my opinion I don't think this is a good enough reason to tube when you can just haul them to the hospital.

Disclaimer: I am biased because it isn't uncommon for me to see failed intubations in the field roll into the ED, some of which I have to become involved in.

 

[EctopicFetus]

While the last poster is right. I would argue that your ESRD patient is much more likely to have hyperkalemia so why risk it? Found down for how long? If prolonged may be in rhabdo and thats a def no no.

While ESRD is not in and of itself an issue I think we all worry about any ESRD on dialysis and their K.

 

[Lawsonc]

Why 1.6 mg/kg? 1.2 is the "RSI" dose.

Whats the worse that could happen? They get paralyzed? 😀

Sorry I had to.

 

[Lawsonc]

Thanks for the input so far guys, the answer I got was what I thought I might get, and confirmed my suspicions.

 

[docB]

A few points:

Just to get the nitpicking out of the way. To the OP you didn't actually "rule out" hypoglycemia and opiate OD as causes by giving glucose and Narcan. You treated them and appropriately moved on to other issues.

Should you have been worried about using sux in this patient prehospital. Absolutely yes. The patient had a history of being on dialysis, hence a propensity to go into renal failure. They now have an exacerbation of their underlying condition. A patient with a history of RF and new AMS and clinical findings suggestive of dehydration should make you VERY concerned about the possibility of ARF and hyperkalemia. I would not use sux in this patient.

It's important for everyone to make a distinction between treating this patient prehospital, where you don't know the K, and in the ED where you might know the K if you've had enough time.

I agree with Arch that the EMS lit is leaning toward trying to avoid prehospital intubation unless really indicated. The OP appropriately held off.

 

[Groove]

I think the risk of pushing drugs and intubating in the field far outweighs the benefit, particularly in this scenario. IIRC this is being borne out in the prehospital literature.

I don't understand the rush to intubate a patient just because they are unresponsive so long as they are oxygenating and ventilating adequately. I realize they can't protect their airway but in my opinion I don't think this is a good enough reason to tube when you can just haul them to the hospital.

Disclaimer: I am biased because it isn't uncommon for me to see failed intubations in the field roll into the ED, some of which I have to become involved in.

Arch, the problem is in situations such as aircare transport. They are perhaps overzealous in their intubations prior to loading the pt on the chopper, but try intubating someone in those tiny cramped conditions during air turbulence. They have the best shot at establishing and securing an airway in a relatively more calm and controlled environment. The same goes for paramedics trying to intubate a pt on a bumpy road at 70mph. Most times there is only one medic in the back of the truck and one driving. The one in the back is doing everything. If the pt codes, he does compressions, bags, ACLS, calls the MD, all by himself. After spending a few weeks with those guys out in the field and on the chopper, it gave me a new perspective.

As for RSI in the field. I still think it's too dangerous, but there is definitely a push for it at the moment in some states. Most of the pre-hospital intubation miss rates are around 6%. I think the Katz study was much higher but not consistent with the others.

 

[Groove]

What are you basing this on?

CKD and ESRD already predispose you to hyperkalemic states, and a history of hyperkalemia is a definitive contraindication, so why would you choose to use a depolarizing agent on someone that is already predisposed to hyperkalemia in the first place?

I mean, I wouldn't really care how low the risk, it's still a higher risk for cardiac arrhythmias, so why even do it? We already have plenty of literature to support that Roc is just as good in subsets of pt's where contraindications to succ exist.

 

[Lawsonc]

Arch, sorry to hear that.

I'm writing to you from the Pacific North West, where the numbers are there to prove intubation can be done safely in the field. From what I've gathered, this is not the case elsewhere. Folks have been doing it up here for the last 30 years with no issues, it is not something that I suspect will change any time soon.

 

[pseudoknot]

As for RSI in the field. I still think it's too dangerous, but there is definitely a push for it at the moment in some states. Most of the pre-hospital intubation miss rates are around 6%. I think the Katz study was much higher but not consistent with the others.

On the one hand, I think this is probably rarely indicated, and has the potential to delay definitive care. On the other hand, the literature on prehospital RSI is, for the most part, completely worthless, because it mostly predates the advent of waveform capnography (and video laryngoscopy). I think the game is different now than it was 20 years ago.

 

[deleted109597]

Folks have been doing it up here for the last 30 years with no issues, it is not something that I suspect will change any time soon.

Negative.

The vast abundance of pre-hospital literature across all specialties (trauma, cardiac, ED) shows that more time spent dicking around at the scene decreases survival for almost all conditions. Easy things that can be done while transporting, and a few things such as early defibrillation do show a benefit. Intubation is not one of those things.

Also, to say with "no issues" is not entirely true either. I daresay that there is not a 100% success rate with intubations in the pacific northwest.

 

[xaelia]

Why 1.6 mg/kg? 1.2 is the "RSI" dose.

I base that range off looking at the studies included in the most recent Cochrane Review - there were a couple at 1.2mg/kg and a few more at 1.4-1.6mg/kg. I'm not doing math in the bay - I pick a round number that's somewhere between 1.2-1.6mg/kg by gross estimation. Usually it's 100mg unless there's some extremes of size.

The Review favored sux, btw, for optimal intubating conditions - because of all the inadequate conditions experienced for roc at the 0.6 - 0.7mg/kg doses in a large sample of studies.

Someone else also mentioned the long half-life - this is both an advantage and a disadvantage. Yes, in a can't-intubate-can't-ventilate patient you have theoretically have the option for them to wake up - but I would argue you never have that option in emergent intubations in the ED and you should always be prepared to cut at the beginning of every intubation. The long half-life also works best for when the PGY-1 gets to take a couple looks before the PGY-3 or I get involved. I don't want to have to start yelling for more paralytic in the middle of a difficult (or a crash) airway.

I've actually become more aware that my induction agent is wearing off before the paralytic and I've gone to ketamine because it has both a long half-life and because it has analgesic properties - I don't think we appreciate enough the physiologic pain stress associated with intubation.

I don't think we have sugammadex yet.

 

[Groove]

On the one hand, I think this is probably rarely indicated, and has the potential to delay definitive care. On the other hand, the literature on prehospital RSI is, for the most part, completely worthless, because it mostly predates the advent of waveform capnography (and video laryngoscopy). I think the game is different now than it was 20 years ago.

Absolutely agree with the delayed care, along with increased risk of complications but why is it worthless? Good luck getting capno and glidescope type devices along with proper training for prehospital medical personell widely adopted anytime in the next 10-15 years. Capnography maybe...as some medics already routinely use this (not the majority though...) and should be trained for it, but definitely not VAL.

I also read a few more prehospital intubation articles and meta-analysis from the past 10 years and it seems that the miss rate is, in general, higher than 6% as I stated earlier. More like 10-16%. That's non RSI.

 

[docB]

Arch, sorry to hear that.

I'm writing to you from the Pacific North West, where the numbers are there to prove intubation can be done safely in the field. From what I've gathered, this is not the case elsewhere. Folks have been doing it up here for the last 30 years with no issues, it is not something that I suspect will change any time soon.

The debate any more isn't whether or not it can be done in the field. It can although the complication rate is comparatively high. The question now is whether it provides any benefit. The outcome data is showing that patients intubated in the field do worse than those with similar pathologies who were not intubated prehospital. It's not about safety or skills. It's now about if the treatment modality is helpful or harmful.

As for RSI in the field. I still think it's too dangerous, but there is definitely a push for it at the moment in some states. Most of the pre-hospital intubation miss rates are around 6%. I think the Katz study was much higher but not consistent with the others.

The lit is pretty clear that RSI greatly reduces the complications in intubation and improves first pass success. While, as mentioned above, we are going to have to decide if prehospital intubation should continue or not if we are doing it it should be done with RSI as this is clearly superior to brutane.

 

[Lawsonc]

Absolutely agree with the delayed care, along with increased risk of complications but why is it worthless? Good luck getting capno and glidescope type devices along with proper training for prehospital medical personell widely adopted anytime in the next 10-15 years. Capnography maybe...as some medics already routinely use this (not the majority though...) and should be trained for it, but definitely not VAL.

I also read a few more prehospital intubation articles and meta-analysis from the past 10 years and it seems that the miss rate is, in general, higher than 6% as I stated earlier. More like 10-16%. That's non RSI.

Capnography is old news, can't speak for everyone, but its been on the rigs for years up here (with the lifepack 15 monitors I don't know if you can order one without capnography and most 12s at least have the option to be added) I'm also a big fan of the nasal cannula version, not just the ETT-tube cuff piece. I find it interesting you mention wave form capnography, as at least in this region its been in the field for years, and has yet to hit the ER.

I enjoy any of the video based scopes, I have had the opportunity to do multiples intubations in the OR with various brands and product. Just remember in the field we carry an abundance of alternative airways. If you can't tube them with the ETT, you have a BVM-OPA/NPA, LMA, Combitube, King tube, Surgical airways, etc. There should be no excuse for not getting and securing an airway of some sort. In Europe I know they have video based scopes in the field. I am going to disagree with you on that comment, because I think if that is what its going to take, many large departments will go that route in the next 10-15 years.

In regards to training, as it is always brought up. What training do you need to intubate? Its not unreachable or unobtainable for field personnel to get to a high level of competency. If anything training in terms of the actual physical skill set should be the last reason used. It takes practice and experience helps, but I bet my plumber who never finished high school with a half days class could do the actual physical process of intubation better then me.

There is a real negative vibe in EMS right now when it comes to advanced airways. I just hope the right thing happens, and they go for more education, more training and a more detailed definition of when it is appropriate to use such adjuncts. Maybe the priority does need to change, not denying that. Taking skill sets away though? Don't know if that is the answer either, because there is a time and place for everything.

 

[Lawsonc]

The debate any more isn't whether or not it can be done in the field. It can although the complication rate is comparatively high. The question now is whether it provides any benefit. The outcome data is showing that patients intubated in the field do worse than those with similar pathologies who were not intubated prehospital. It's not about safety or skills. It's now about if the treatment modality is helpful or harmful.



The lit is pretty clear that RSI greatly reduces the complications in intubation and improves first pass success. While, as mentioned above, we are going to have to decide if prehospital intubation should continue or not if we are doing it it should be done with RSI as this is clearly superior to brutane.

That all makes perfect sense, but as you probably know that is not how many of these articles, studies, and soon to be implemented policies, are presenting it. The big thing has been on success rates, which is a poor reason. If its about treatment and patient outcome, that is undeniable and I would not argue that.

 

[pseudoknot]

I'm also a big fan of the nasal cannula version, not just the ETT-tube cuff piece. I find it interesting you mention wave form capnography, as at least in this region its been in the field for years, and has yet to hit the ER.

The cannulae are great, during the 30% of the time when they work. Most of my sedated folks are mouth breathers. And yes, I find it sad that I have capnography on my ambulance but not in the ED.

In regards to training, as it is always brought up. What training do you need to intubate? Its not unreachable or unobtainable for field personnel to get to a high level of competency. If anything training in terms of the actual physical skill set should be the last reason used. It takes practice and experience helps, but I bet my plumber who never finished high school with a half days class could do the actual physical process of intubation better then me.

I think the anesthesia literature shows that you need 100-200 intubations to get a basic level of competence. I find it very telling that paramedics tend to think of intubation as an easy skill, but anesthesiologists say it's something you can never take for granted. Doing 10-20 easy intubations can give you a strong and false sense of confidence.

 

[Lawsonc]

The cannulae are great, during the 30% of the time when they work. Most of my sedated folks are mouth breathers. And yes, I find it sad that I have capnography on my ambulance but not in the ED.


I think the anesthesia literature shows that you need 100-200 intubations to get a basic level of competence. I find it very telling that paramedics tend to think of intubation as an easy skill, but anesthesiologists say it's something you can never take for granted. Doing 10-20 easy intubations can give you a strong and false sense of confidence.

I like the Cannula for your COPDers, asthmatics, etc. Its a great way of watching the wave form for changes in their condition due to treatment. As far as mouth breathing is concerned they have that piece that falls bellow and if you play with one it should pick up mouth breathing as well. I have also heard of putting one of those on underneath a non-rebreather (of course with 02 running through the NRB mask) just for the capnography, don't know how accurate that is though.

I don't think intubation is easy at all, I have the utmost respect for the anesthesia folk. I do however, think there is no reason why a paramedic can't be competent. The actual motor skill is not difficult, its the experience that comes with knowing how to manipulate and navigate different anatomy.

This is just my opinion, but if you were to ask me what my greatest skill set is, its not intubation and never will be. I learned fairly quickly that even after my measly 50 tubes, (OR and field) I would never be near what the experts who do it everyday are. Its the ability to know when to stop, and go for alternative airways, and go through difficult airway algorithms that makes me what I believe a competent airway provider.

 

[Groove]

I find it interesting you mention wave form capnography, as at least in this region its been in the field for years, and has yet to hit the ER.

Region...maybe, can't speak for yours. Nationwide routine usage? Negative.

In Europe I know they have video based scopes in the field. I am going to disagree with you on that comment, because I think if that is what its going to take, many large departments will go that route in the next 10-15 years.

Ok, let's take the policy, training, politics, distribution logistical nightmare out of the equation. Glidescope Cobalt is what you need. Cost? $11,000 How many ambulances in the U.S.? 48,000. 48K x 11K = 528 million bucks. Who exactly do you think is going to pay for all of that? That's rough approximation....10.5 million per state simply to equip you. If VAL devices are expensive enough that we're having a hard time even getting them in most EDs in the country, you can bet you won't be finding one on your truck ANYTIME soon.

What training do you need to intubate?

Did you really just say that? That statement alone speaks volumes.

You seem very defensive with this whole topic. You should recognize and respect your limitations and not ever be blinded by overconfidence in the field. You're not an airway expert, nor are you expected to be, but you are trained to have a certain degree of competency because sometimes it just has to be done. Every procedure, intervention that you do has associated risks to the pt you're transporting. If you can safely avoid taking these risks, then that's always the best option.

 

[deleted109597]

In regards to training, as it is always brought up. What training do you need to intubate? Its not unreachable or unobtainable for field personnel to get to a high level of competency. If anything training in terms of the actual physical skill set should be the last reason used. It takes practice and experience helps, but I bet my plumber who never finished high school with a half days class could do the actual physical process of intubation better then me.

It may not be unreachable or unobtainable, but it's still pretty damn hard. I've seen upper level ED residents struggle with airways, and they should do them pretty often. A statistic I got in Jacksonville Fl was that their EMT-Ps did an average of <2 intubations per year. That is not enough to keep a skill set up.

None of us is saying you shouldn't do it because you (as pre hospital personnel) aren't good enough though. We're saying you shouldn't do it because it doesn't help, and is likely harmful based on data.

 

[Lawsonc]

Region...maybe, can't speak for yours. Nationwide routine usage? Negative.

Ok, let's take the policy, training, politics, distribution logistical nightmare out of the equation. Glidescope Cobalt is what you need. Cost? $11,000 How many ambulances in the U.S.? 48,000. 48K x 11K = 528 million bucks. Who exactly do you think is going to pay for all of that? That's rough approximation....10.5 million per state simply to equip you. If VAL devices are expensive enough that we're having a hard time even getting them in most EDs in the country, you can bet you won't be finding one on your truck ANYTIME soon.

Did you really just say that? That statement alone speaks volumes.

You seem very defensive with this whole topic. You should recognize and respect your limitations and not ever be blinded by overconfidence in the field. You're not an airway expert, nor are you expected to be, but you are trained to have a certain degree of competency because sometimes it just has to be done. Every procedure, intervention that you do has associated risks to the pt you're transporting. If you can safely avoid taking these risks, then that's always the best option.

20 years ago they were experimenting with 12 leads in the field, now all ALS units carry lifepacks (or equivalent Zoll, Phillips, etc) that can cost 20-40,000 USD. A 10,000 dollar piece of equipment is not out of the equation 10 years down the road. (given the time frame you mentioned)

As I mentioned I am not an airway expert, nor will I ever probably be, but there is a level of competency. I am sorry for sounding defensive, I just wanted to bring up some other points.

As far as the comment about intubation and training, you took it out of context, if you read the whole post, that was not all that was said. It was a question, because I still can't understand what differs in the training, other then experience, and practice. Of which should be no excuse for local EMS agencies, that should fight for those opportunities. That however is an internal battle, that I know EMS accreditation agencies are looking into as we speak, and county EMS offices need to address.

 

[Lawsonc]

It may not be unreachable or unobtainable, but it's still pretty damn hard. I've seen upper level ED residents struggle with airways, and they should do them pretty often. A statistic I got in Jacksonville Fl was that their EMT-Ps did an average of <2 intubations per year. That is not enough to keep a skill set up.

None of us is saying you shouldn't do it because you (as pre hospital personnel) aren't good enough though. We're saying you shouldn't do it because it doesn't help, and is likely harmful based on data.

As mentioned in my response to Groove, that is a flaw in a local EMS agencies, the counties around me require first year medics to perform 16 intubation in the first year, 24 by the second year for re certification (some slightly different in time frame, but most require at least 16 tubes). I still feel this number is low.

I agree, its a skill that unfortunately is used very little, the competency level is probably low on a national level, and 99% of the time the conditions are not ideal. That being said there are two ways to go about it, you either train, educate, and work with the providers, or you take it away and leave it at that.

 

[Lawsonc]

I got what I needed out of this thread, my question was answered by you guys, and for that I am appreciative. My question, my thought, and the ultimate answer all lined up, and that is why I knew you guys would be a great bunch to ask. Yes on a patient with poly pharmacy, HX of renal failure, and being found down for 3 days, succs probably isn't the best idea. Having other options such as a long acting non depolarizing agent, and a hypnotic would be best. Just to clarify, I am not an advocate for tubing anything that moves. As is evident in my first post and this call in particular, I held off intubation until the ER. The MD made the decision, and I was able to perform the intubation, for which I was grateful.

I am not an expert in all things airway, but have a general level of competence and hope to one day among my peers of field personnel be considered an expert. Obviously field intubation is an open book, that is still being written, and varies in opinion from region to region and among different providers.

I will always follow the science, and do what is in the best interest of my patient, because of this I feel training and education and clinical experiences need to be improved for field personnel as a progression of the career.

I hope to be competent and have a vast level of skills and tools at my disposal, but obviously do what is appropriate and weigh the risk/benefit balance on my own experience, and the hard facts.

 

[BF2BC EMT]

As mentioned in my response to Groove, that is a flaw in a local EMS agencies, the counties around me require first year medics to perform 16 intubation in the first year, 24 by the second year for re certification (some slightly different in time frame, but most require at least 16 tubes). I still feel this number is low.

I agree, its a skill that unfortunately is used very little, the competency level is probably low on a national level, and 99% of the time the conditions are not ideal. That being said there are two ways to go about it, you either train, educate, and work with the providers, or you take it away and leave it at that.

As I was leaving to start school my last system county cut it completely. P students weren't allowed in OR's anymore because of dicking around. So no practice there. I saw someone said their P's were getting 2 or less a year, we were about the same.

The things I noticed the most were medics trying to stay(to long) and play to drop one someone who may not have needed it.
Getting it in place on scene and not having it secured properly during the move and not noticing if it became displaced.

Also were I lived all EMS was ran through fire and 90% did not care about learning or continuing education when it came to anything medical. Yes the skill can be taught but I know the medic that went through the university of new Mexico program has a lot more skill/knowledge then the medic who graduated a 10 week class

 

[Lawsonc]

As I was leaving to start school my last system county cut it completely. P students weren't allowed in OR's anymore because of dicking around. So no practice there. I saw someone said their P's were getting 2 or less a year, we were about the same.

The things I noticed the most were medics trying to stay(to long) and play to drop one someone who may not have needed it.
Getting it in place on scene and not having it secured properly during the move and not noticing if it became displaced.

Also were I lived all EMS was ran through fire and 90% did not care about learning or continuing education when it came to anything medical. Yes the skill can be taught but I know the medic that went through the university of new Mexico program has a lot more skill/knowledge then the medic who graduated a 10 week class

Schools with no access to OR time should not be allowed, neither should 10 week programs. We had to do minimum of 2 shifts a month in the OR for 6 months, and I still have much more to learn.

In terms of the Fire based EMS, I saw that down in California ALOT! Not "always" the case where I am now a little way up north. Most firefighters do their 5 years (seems to be the average before your department puts you through medic school) so they can go to medic school

 

[Arch Guillotti]

Hmm. I give roc all the time and have not heard of any dose higher than 1.2 mg/kg. I would be interested to see any published data about the speed to onset of higher doses. Maybe it's out there but I haven't seen it (not that I have been really looking😎).

1.2 mg/kg roc gives a rapid onset but nothing beats sux.

I think that if you really are concerned about having to cut the neck then roc is not a great option. I understand you can't really wake patients up in the ED and (in my biased anesthesiologist opinion) I think that there are many alternative approaches that can be used before the neck is resorted to (yes I know that sometimes there are other considerations at play). With that being said the ED where I am "usually" does a good job managing airways.

I have done many RSI's and I can only recall having the paralytic wear off a couple of times. You can always redose the sux (but may need to give atropine also).

I base that range off looking at the studies included in the most recent Cochrane Review - there were a couple at 1.2mg/kg and a few more at 1.4-1.6mg/kg. I'm not doing math in the bay - I pick a round number that's somewhere between 1.2-1.6mg/kg by gross estimation. Usually it's 100mg unless there's some extremes of size.

The Review favored sux, btw, for optimal intubating conditions - because of all the inadequate conditions experienced for roc at the 0.6 - 0.7mg/kg doses in a large sample of studies.

Someone else also mentioned the long half-life - this is both an advantage and a disadvantage. Yes, in a can't-intubate-can't-ventilate patient you have theoretically have the option for them to wake up - but I would argue you never have that option in emergent intubations in the ED and you should always be prepared to cut at the beginning of every intubation. The long half-life also works best for when the PGY-1 gets to take a couple looks before the PGY-3 or I get involved. I don't want to have to start yelling for more paralytic in the middle of a difficult (or a crash) airway.

I've actually become more aware that my induction agent is wearing off before the paralytic and I've gone to ketamine because it has both a long half-life and because it has analgesic properties - I don't think we appreciate enough the physiologic pain stress associated with intubation.

I don't think we have sugammadex yet.

 

[Arch Guillotti]

In regards to training, as it is always brought up. What training do you need to intubate? I

lol

 

[Arch Guillotti]

Agree. Published literature that i have seen supports this, despite the irrational paragod syndrome that seems to persist.

Negative.

The vast abundance of pre-hospital literature across all specialties (trauma, cardiac, ED) shows that more time spent dicking around at the scene decreases survival for almost all conditions. Easy things that can be done while transporting, and a few things such as early defibrillation do show a benefit. Intubation is not one of those things.

Also, to say with "no issues" is not entirely true either. I daresay that there is not a 100% success rate with intubations in the pacific northwest.

 

[Arch Guillotti]

CKD and/or ESRD isn't a definitive contraindication but a relative one, as is a hx of hyperkalemia... and if we're dealing with a CKD/ESRD pt, they have a higher risk of having already had a hyperkalemic episode at one point or another.

In the absence of hyperkalemia, neither ESRD or CKD is a contraindication to sux.

I do not consider a past history pf hyperkalemia a contraindication either. All I care about is their K prior to sux administration.

 

[Lawsonc]

lol

Context, if your going to comment, quote the whole paragraph.

 

[Groove]

In the absence of hyperkalemia, neither ESRD or CKD is a contraindication to sux.

I do not consider a past history pf hyperkalemia a contraindication either. All I care about is their K prior to sux administration.

I hear ya, Arch... the problem is that most times, I have no idea what their K is prior to intubation and might have very limited history from the EMT (i.e. new pt in trauma bay, little old lady found down, GCS 6, sats 70%, hx of renal something but no family around at the scene, etc). Our current institutional policy is typically no sux on these types of pt's due to the pre-disposed risk to hyperkalemia 2/2 their renal pathology (many times the extent of which is unknown), and again...why take the risk if I don't know their K? I honestly don't know if there's much, if any literature to back up that policy but it has always made sense to me.

 

[BF2BC EMT]

In the absence of hyperkalemia, neither ESRD or CKD is a contraindication to sux.

I do not consider a past history pf hyperkalemia a contraindication either. All I care about is their K prior to sux administration.

But outside of the hospital setting a pt with ESRD-CDK-Hyperk would mean sux would be contraindicated due to lack of diagnostic equipment and often the lack of known pmh?

Dumb question- the sux if it were to be pushed would release more K and some arrhythmia would follow? And onset would be rapid?

Please no laughing😎

 

[pseudoknot]

Dumb question- the sux if it were to be pushed would release more K and some arrhythmia would follow? And onset would be rapid?

Succinylcholine typically raises K by about 0.5 mEq/L. The concern with the renal patients is that if it's high already that could push them over the edge. My impression is that the renal issue is a bit overhyped. The population you clearly do have to worry about are those with extrajunctional acetylcholine receptors, where you can see very large increases in K after succinylcholine administration (leading to cardiac arrest). Patients at risk for this include muscular dystrophy, burns after 2-3 days (NOT acutely!), rhabdo with lengthy down time, critical illness myopathy.