midaz in RSI

[Hamhock]

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I am still in mid-residency, but close enough to the end that I listen carefully about working in "the community" and even some academic spots that have very different cultures and access to drugs. I have recently been hearing more frequently about EDs not having access to Propofol or etomidate.

So, I have been thinking about how I would RSI without either of these --> thinking about ketamine and midaz. Most texts and "published" sources list the RSI dose of midaz as 0.1 mg/kg, but a lot of attendings I talk to (haven't seen any do it yet) say that really midaz should be more like 0.2 or 0.3 for RSI.

Anyone with lots of experience with midaz in RSI? Any other thoughts?
Thanks, HH
Edit: I am talking about using midaz with roc or sux

 

[southerndoc]

Surely a place that allows you to RSI with paralytics will allow you to administer etomidate.

 

[xaelia]

We have a special kind of mouth rape that occurs on our general medicine floors in the hospital during respiratory failure in which the "RSI" medications allowed for residents at night are Versed and Fentanyl. Only pulmonary/critical care fellows and anesthesia can sedate and paralyze to intubate.

 

[Stitch]

Some of us in peds use versed/fentanyl , but it's mainly in infants (at least here). The doses used are as you describe: closer to 0.3 mg/kg of versed and we follow it with roc. The neonatologists I worked with in residency used this combination a lot, but I can't say how common that is, and of course it's a very different population.

We've gotten away from etomidate where I am, but still have it readily available if necessary.

 

[kungfufishing]

We have a special kind of mouth rape that occurs on our general medicine floors in the hospital during respiratory failure in which the "RSI" medications allowed for residents at night are Versed and Fentanyl. Only pulmonary/critical care fellows and anesthesia can sedate and paralyze to intubate.

Describing this as "mouth rape" is unfortunately true, accurate, funny, and the best descriptor I have heard of the airway 'management' I witnessed in the dead of the night during my medicine intern year.

 

[njac]

describing this as "mouth rape" is unfortunately true, accurate, funny, and the best descriptor i have heard of the airway 'management' i witnessed in the dead of the night during my medicine intern year.

+1

 

[bulgethetwine]

I am still in mid-residency, but close enough to the end that I listen carefully about working in "the community" and even some academic spots that have very different cultures and access to drugs. I have recently been hearing more frequently about EDs not having access to Propofol or etomidate.

So, I have been thinking about how I would RSI without either of these --> thinking about ketamine and midaz. Most texts and "published" sources list the RSI dose of midaz as 0.1 mg/kg, but a lot of attendings I talk to (haven't seen any do it yet) say that really midaz should be more like 0.2 or 0.3 for RSI.

Anyone with lots of experience with midaz in RSI? Any other thoughts?
Thanks, HH
Edit: I am talking about using midaz with roc or sux

Actually, with versed, it's more like SSI (Slow sequence induction).

Seriously though, if you can't use etomidate, try ketafol or even just ketamine (2mg/kg).

 

[Paseo Del Norte]

I am still in mid-residency, but close enough to the end that I listen carefully about working in "the community" and even some academic spots that have very different cultures and access to drugs. I have recently been hearing more frequently about EDs not having access to Propofol or etomidate.

So, I have been thinking about how I would RSI without either of these --> thinking about ketamine and midaz. Most texts and "published" sources list the RSI dose of midaz as 0.1 mg/kg, but a lot of attendings I talk to (haven't seen any do it yet) say that really midaz should be more like 0.2 or 0.3 for RSI.

Anyone with lots of experience with midaz in RSI? Any other thoughts?
Thanks, HH
Edit: I am talking about using midaz with roc or sux

I will offer my thoughts; however, I want to be clear that I am not a physician. Not even close, not even a "doctor" nurse. So, take it for what you think its worth.

I am exposed to a fair amount of RSI as part of a flight team with RSI protocols. However, I am happy to say our RSI numbers are lower than years past. Clearly, I have reservations about the utility and efficacy of pre-hospital RSI, but that is a different story.

You are correct in that I find many people really under-dose midazolam in the setting of RSI. In my area of the country, I fly patients out of ER's who have received as little as 2 mg of midazolam for RSI. The average is around 5 mg. Still not adequate for even an "average" sized adult. The problem being, how many people have the balls to bomb a compromised patient with 10 or more mg of midazolam?

IMHO, midazolam is not an ideal agent for RSI for the following reasons:

-It has a rather slow onset of action
-Hemodynamic changes are not uncommon with smaller doses let alone induction doses
-It is often under-dosed with 0.1 mg/kg being a general minimal induction dose
-Better agents exist

We actually cannot utilise midazolam as an induction agent at my service. Our current agent of choice is etomidate with some heavy discussion about allowing ketamine. I think both agents are probably better suited for the emergent RSI patient. I have the most experience with etomidate and enjoy its short onset (essentially one arm to brain cycle) and hemodynamic stability.

If you want some good reading check out Dr. Ron Walls. His book "The Manual of Emergency Airway Management" is an excellent source. In addition, he has a nice Q&A session following each chapter with literature to support the answers. I think the third edition is the newest.

http://www.amazon.com/gp/product/07..._m=ATVPDKIKX0DER&pf_rd_r=1SQ42FV9B6TM78WX90PH

 

[Coastie]

I'd never use midaz for an RSI. You need rapid sequence, not slow sequence.

I am still in mid-residency, but close enough to the end that I listen carefully about working in "the community" and even some academic spots that have very different cultures and access to drugs. I have recently been hearing more frequently about EDs not having access to Propofol or etomidate.

So, I have been thinking about how I would RSI without either of these --> thinking about ketamine and midaz. Most texts and "published" sources list the RSI dose of midaz as 0.1 mg/kg, but a lot of attendings I talk to (haven't seen any do it yet) say that really midaz should be more like 0.2 or 0.3 for RSI.

Anyone with lots of experience with midaz in RSI? Any other thoughts?
Thanks, HH
Edit: I am talking about using midaz with roc or sux

 

[Peds2ER]

We have a special kind of mouth rape that occurs on our general medicine floors in the hospital during respiratory failure in which the "RSI" medications allowed for residents at night are Versed and Fentanyl. Only pulmonary/critical care fellows and anesthesia can sedate and paralyze to intubate.

So the logic is that since there are no critical care or pulmonary folks in house to bail you out of a tough spot, best to set you up for failure? Unbelievably stupid policy...

 

[Coastie]

We have a special kind of mouth rape that occurs on our general medicine floors in the hospital during respiratory failure in which the "RSI" medications allowed for residents at night are Versed and Fentanyl. Only pulmonary/critical care fellows and anesthesia can sedate and paralyze to intubate.

How many intubations do ER residents do throughout a residency? This policy doesn't make too much sense.

 

[deleted109597]

How many intubations do ER residents do throughout a residency? This policy doesn't make too much sense.

35 required. Most have that before end of 2nd year (whether it is documented is another story). And the policy doesn't apply to the ED. Also, if someone is obtunded, you don't need to RSI them, you can just intubate them, which is what usually happens.

So the logic is that since there are no critical care or pulmonary folks in house to bail you out of a tough spot, best to set you up for failure? Unbelievably stupid policy...

Obviously this doesn't apply in the ED.
There is critical care in house for the SICU, which is covered on trauma. However, MICU and the rest of the hospital, no paralytics without anesthesia, critical care, or pulm. Most if not all hospitals have the same policy.

 

[Coastie]

35 required. Most have that before end of 2nd year (whether it is documented is another story). And the policy doesn't apply to the ED. Also, if someone is obtunded, you don't need to RSI them, you can just intubate them, which is what usually happens.

Obviously this doesn't apply in the ED.
There is critical care in house for the SICU, which is covered on trauma. However, MICU and the rest of the hospital, no paralytics without anesthesia, critical care, or pulm. Most if not all hospitals have the same policy.

Gotcha. I was about to say, if the policy applied in the ED, then it's asking for trouble..I would have thought it was more than 35 intubations.

Intubating on regular floors/icu's can be tricky. I can see why the policy is there..You burn that bridge with sux (or heaven forbid, roc) and you're up a creek, FAST.

For the "mouth rape", xaelia, do you guys have access to lidocaine jelly/spray/nebulized? It can go a long way in helping out the poor gomers begging for intubation at night.

 

[Jeff698]

In an effort to make the "mouth rape" (great term, BTW) on the floors slightly less damaging, perhaps we need to take another look at the myth that these patients need emergent intubation at all.

I think we should give up trying to teach physicians to intubate who aren't going to actually intubate. Putting an ET tube into a trachea isn't the only way to manage an airway, just one of the most difficult.

Instead of using a poor excuse for RSI, let them just put in a King LT or an LMA. By the time you actually need an ET in place, you'll be able to get someone there who is skilled at doing it.

Take care,
Jeff

 

[Coastie]

In an effort to make the "mouth rape" (great term, BTW) on the floors slightly less damaging, perhaps we need to take another look at the myth that these patients need emergent intubation at all.

I think we should give up trying to teach physicians to intubate who aren't going to actually intubate. Putting an ET tube into a trachea isn't the only way to manage an airway, just one of the most difficult.

Instead of using a poor excuse for RSI, let them just put in a King LT or an LMA. By the time you actually need an ET in place, you'll be able to get someone there who is skilled at doing it.

Take care,
Jeff

I think bag masking is the most important skill that is overlooked in medical training today.

Physicians should also be trained in various forms of ventilation, but I'd say LMAs are pretty dangerous, and require quite a bit of skill. It's not a secure airway, and when they go into laryngospasm/bronchospasm, that guy is in trouble.

 

[Zanegray]

We used phenobarbital for intubation the other day. It was in an etoh detox patient - was quite effective.

Anyone else use phenobarb for intubation?

 

[Coastie]

We used phenobarbital for intubation the other day. It was in an etoh detox patient - was quite effective.

Anyone else use phenobarb for intubation?

I don't believe any "standard" induction agent is superior over another for an etoh detox patient. Have any data?

Thiopental is a barbituate. Never used phenobarb. What dose?

 

[Jeff698]

I think bag masking is the most important skill that is overlooked in medical training today.

Physicians should also be trained in various forms of ventilation, but I'd say LMAs are pretty dangerous, and require quite a bit of skill. It's not a secure airway, and when they go into laryngospasm/bronchospasm, that guy is in trouble.

Every MD should be an airway expert, confident and capable with a wide range of adjunct devices.

Nice thought, but it isn't reality and, for the vast majority of physicians, it isn't necessary because of the low likelihood of them needing the skill. I think we need to get away from the idea that because intubation is a definitive airway then every doc should be competent in performing it. Over-teaching has its own risks. Intubation is not an easy skill and it most certainly deteriorates without use, especially when the skill wasn't truly mastered to begin with.

Blind insertion devices require less up front experience to master and the skill degenerates less. It is an appropriate TEMPORARY airway in the vast majority of patients likely to be initially managed by a physician not skilled in airway management.

Take care,
Jeff