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we use sufficient midazolam to sedate, cricoid pressure, lidocaine (icp/head
injury), atropine (bradycardia), sux, then if necessary Vecuronium bromide
for longer paralysis (with additional sedation); so far no adverse effects;
if unable to intubate, then LMA is placed.  I have the article also, and
find many flaws with their procedure and process for investigation.

john

John Atwell Rasmussen, Ph.D., REMTP
Lieutenant, Education and Training
Greenville County EMS
(864) 467-7389
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-----Original Message-----
From: MARK FORREST [mailto:atacc.doc@virgin.net]
Sent: Monday, April 14, 2003 6:18 PM
To: trauma-list@trauma.org
Subject: Pre-hospital RSI

Dear Colleagues,
I approached the paper on 'paramedic RSI in severe traumatic brain
injuries', J Trauma, vol 54, March 2003 with great interest. 
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' 

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...' 
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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<DIV><SPAN class=749412612-15042003><FONT face="Microsoft Sans Serif" size=4>we 
use sufficient midazolam to sedate, cricoid pressure, lidocaine (icp/head 
injury), atropine (bradycardia), sux, then if necessary Vecuronium bromide for 
longer paralysis (with additional sedation); so far no adverse effects; if 
unable to intubate, then LMA is placed.&nbsp; I have the article also, and find 
many flaws with their procedure and process for 
investigation.</FONT></SPAN></DIV>
<DIV><SPAN class=749412612-15042003><FONT face="Microsoft Sans Serif" 
size=4></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=749412612-15042003><FONT face="Microsoft Sans Serif" 
size=4>john</FONT></SPAN></DIV>
<DIV>&nbsp;</DIV>
<DIV align=center><FONT face=Arial color=#000000 size=2>John Atwell Rasmussen, 
Ph.D., REMTP</FONT></DIV>
<DIV align=center><FONT face=Arial color=#000000 size=2>Lieutenant, Education 
and Training</FONT></DIV>
<DIV align=center><FONT face=Arial color=#000000 size=2>Greenville County 
EMS</FONT></DIV>
<DIV align=center><FONT face=Arial color=#000000 size=2>(864) 
467-7389</FONT></DIV>
<DIV align=center><FONT face=Arial color=#000000 size=2>The information 
transmitted is intended only for the person or entity to which it is addressed 
and may contain confidential and/or privileged material. If you are not the 
intended recipient of this message you are hereby notified that any use, review, 
retransmission, dissemination, distribution, reproduction, or any action taken 
in reliance upon this message is prohibited. If you received this in error, 
please contact the sender and delete the material from any computer. Any views 
expressed in this message are those of the individual sender and may not 
necessarily reflect the views of the company.</FONT></DIV><FONT size=2></FONT>
<BLOCKQUOTE dir=ltr style="MARGIN-RIGHT: 0px">
  <DIV class=OutlookMessageHeader dir=ltr align=left><FONT face=Tahoma 
  size=2>-----Original Message-----<BR><B>From:</B> MARK FORREST 
  [mailto:atacc.doc@virgin.net]<BR><B>Sent:</B> Monday, April 14, 2003 6:18 
  PM<BR><B>To:</B> trauma-list@trauma.org<BR><B>Subject:</B> Pre-hospital 
  RSI<BR><BR></FONT></DIV>
  <DIV><FONT face=Arial size=2>Dear Colleagues,</FONT></DIV>
  <DIV><FONT face=Arial size=2>I approached the paper on 'paramedic RSI in 
  severe&nbsp;traumatic brain&nbsp;injuries', <STRONG>J Trauma, vol 54, March 
  2003 </STRONG>with great interest. </FONT></DIV>
  <DIV><FONT face=Arial size=2>The conclusions are <EM>'Paramedic RSI improves 
  intubation success rates but is associated with increase in mortalityand 
  decrease in "good outcomes" when compared to hand-matched controls' 
  </EM></FONT></DIV>
  <DIV><EM><FONT face=Arial size=2></FONT></EM>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Various reasons are given for this, but after 
  reading the methods I am frankly not surprised.</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>I was horrified to read that the RSI is performed 
  with sux and midazolam, but sedation is only given if systolic BP is 
  &gt;120mmHg and even when given, the maximum dose was 3mg (for the &gt;100Kg 
  group)!</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>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'!</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Is this a standard 'RSI' practice&nbsp;in other 
  parts of the world?</FONT></DIV>
  <DIV>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Another area of concern in the methods involves 
  the period of de-nitrogenation&nbsp;before starting.<EM> 'a minimum of 60 
  seconds using a non-rebreather mask. If oxygen saturation&nbsp;remained below 
  95%, then bag and mask ventilation were instituted before 
  medication...'</EM></FONT><EM>&nbsp;</EM></DIV>
  <DIV><FONT face=Arial size=2>When I was taught RSI all manual ventilation was 
  avoided to prevent increased risk of gastric inflation and increased risk of 
  aspiration!</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Considering these two issues and a number of 
  others including the hyperventilation to ETCO2&nbsp; 30-35mmHg and hypoxia 
  <EM>'sufficient to produce bradycardia'</EM> in many of the cases, I am in no 
  way surprised by the poor outcome figures.</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Any comments, especially by paramedics/docs who 
  competently perform RSI on a regular basis?</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Regards</FONT></DIV>
  <DIV><FONT face=Arial size=2>Mark F</FONT></DIV>
  <DIV><FONT face=Arial size=2>UK</FONT></DIV>
  <DIV><EM><FONT face=Arial 
size=2></FONT></EM>&nbsp;</DIV></BLOCKQUOTE></BODY></HTML>

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