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Mon, 14 Apr 2003 23:18:10 +0100

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Dear Colleagues,
I approached the paper on 'paramedic RSI in severe traumatic brain =
injuries', J Trauma, vol 54, March 2003 with great interest.=20
The conclusions are 'Paramedic RSI improves intubation success rates but =
is associated with increase in mortalityand decrease in "good outcomes" =
when compared to hand-matched controls'=20

Various reasons are given for this, but after reading the methods I am =
frankly not surprised.

I was horrified to read that the RSI is performed with sux and =
midazolam, but sedation is only given if systolic BP is >120mmHg and =
even when given, the maximum dose was 3mg (for the >100Kg group)!

This does NOT constitute 'anaesthesia' and these patients were paralysed =
and not 'asleep'. No record is made of post-intubation systolic blood =
pressures, which were probably very high. Similarly, no account was made =
of the effects on ICP during such 'awake-intubation'!

Is this a standard 'RSI' practice in other parts of the world?

Another area of concern in the methods involves the period of =
de-nitrogenation before starting. 'a minimum of 60 seconds using a =
non-rebreather mask. If oxygen saturation remained below 95%, then bag =
and mask ventilation were instituted before medication...'=20
When I was taught RSI all manual ventilation was avoided to prevent =
increased risk of gastric inflation and increased risk of aspiration!

Considering these two issues and a number of others including the =
hyperventilation to ETCO2  30-35mmHg and hypoxia 'sufficient to produce =
bradycardia' in many of the cases, I am in no way surprised by the poor =
outcome figures.

Any comments, especially by paramedics/docs who competently perform RSI =
on a regular basis?

Regards
Mark F
UK

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<META http-equiv=3DContent-Type content=3D"text/html; =
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<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DArial size=3D2>Dear Colleagues,</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>I approached the paper on 'paramedic =
RSI in=20
severe&nbsp;traumatic brain&nbsp;injuries', <STRONG>J Trauma, vol 54, =
March 2003=20
</STRONG>with great interest. </FONT></DIV>
<DIV><FONT face=3DArial size=3D2>The conclusions are <EM>'Paramedic RSI =
improves=20
intubation success rates but is associated with increase in mortalityand =

decrease in "good outcomes" when compared to hand-matched controls'=20
</EM></FONT></DIV>
<DIV><EM><FONT face=3DArial size=3D2></FONT></EM>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Various reasons are given for this, but =
after=20
reading the methods I am frankly not surprised.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>I was horrified to read that the RSI is =
performed=20
with sux and midazolam, but sedation is only given if systolic BP is =
&gt;120mmHg=20
and even when given, the maximum dose was 3mg (for the &gt;100Kg=20
group)!</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>This does NOT constitute 'anaesthesia' =
and these=20
patients were paralysed and not 'asleep'. No record is made of =
post-intubation=20
systolic blood pressures, which were probably very high. Similarly, no =
account=20
was made of the effects on ICP during such =
'awake-intubation'!</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Is this a standard 'RSI' =
practice&nbsp;in other=20
parts of the world?</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Another area of concern in the methods =
involves the=20
period of de-nitrogenation&nbsp;before starting.<EM> 'a minimum of 60 =
seconds=20
using a non-rebreather mask. If oxygen saturation&nbsp;remained below =
95%, then=20
bag and mask ventilation were instituted before=20
medication...'</EM></FONT><EM>&nbsp;</EM></DIV>
<DIV><FONT face=3DArial size=3D2>When I was taught RSI all manual =
ventilation was=20
avoided to prevent increased risk of gastric inflation and increased =
risk of=20
aspiration!</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Considering these two issues and a =
number of others=20
including the hyperventilation to ETCO2&nbsp; 30-35mmHg and hypoxia=20
<EM>'sufficient to produce bradycardia'</EM> in many of the cases, I am =
in no=20
way surprised by the poor outcome figures.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Any comments, especially by =
paramedics/docs who=20
competently perform RSI on a regular basis?</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Regards</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Mark F</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>UK</FONT></DIV>
<DIV><EM><FONT face=3DArial =
size=3D2></FONT></EM>&nbsp;</DIV></BODY></HTML>

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