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Pre-hospital RSI
Errington Thompson trauma-list@trauma.orgWed, 16 Apr 2003 22:51:10 -0500
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This is a multi-part message in MIME format. ------=_NextPart_000_008E_01C3046A.ACCDAA70 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable What flaws have you found? E Errington C. Thompson, MD, FACS Trauma Surgeon Trinity Mother Frances Tyler, Tx. ecthompson@tyler.net Don't think you are Know you are =20 - Morpheus (The Matrix) ----- Original Message -----=20 From: Rasmussen, John=20 To: 'trauma-list@trauma.org'=20 Sent: Tuesday, April 15, 2003 7:29 AM Subject: RE: Pre-hospital RSI 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 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. -----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.=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 ------=_NextPart_000_008E_01C3046A.ACCDAA70 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> <HTML><HEAD> <META http-equiv=3DContent-Type = content=3Dtext/html;charset=3Diso-8859-1> <META content=3D"MSHTML 6.00.2800.1106" name=3DGENERATOR> <STYLE></STYLE> </HEAD> <BODY id=3DMailContainerBody=20 style=3D"FONT-WEIGHT: normal; FONT-SIZE: 12pt; COLOR: #000000; = BORDER-TOP-STYLE: none; FONT-STYLE: normal; FONT-FAMILY: Times New = Roman; BORDER-RIGHT-STYLE: none; BORDER-LEFT-STYLE: none; = TEXT-DECORATION: none; BORDER-BOTTOM-STYLE: none"=20 bgColor=3D#ffffff leftMargin=3D0 topMargin=3D0 acc_role=3D"text" = CanvasTabStop=3D"true"=20 name=3D"Compose message area"><?xml:namespace prefix=3D"v" = /><?xml:namespace prefix=3D"o" /> <DIV>What flaws have you found?</DIV> <DIV> </DIV> <DIV>E</DIV> <DIV> </DIV> <DIV>Errington C. Thompson, MD, FACS<BR>Trauma Surgeon<BR>Trinity Mother = Frances<BR>Tyler, Tx.<BR><A=20 href=3D"mailto:ecthompson@tyler.net">ecthompson@tyler.net</A></DIV> <DIV> </DIV> <DIV>Don't think you are<BR>Know you=20 are<BR> <BR> &n= bsp; &nb= sp; =20 - Morpheus (The Matrix)<BR></DIV> <BLOCKQUOTE dir=3Dltr=20 style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; = BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px"> <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV> <DIV style=3D"FONT: 10pt arial"><B>From:</B> <A=20 title=3DJRasmussen@greenvillecounty.org=20 href=3D"mailto:JRasmussen@greenvillecounty.org">Rasmussen, John</A> = </DIV> <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A = title=3Dtrauma-list@trauma.org=20 href=3D"mailto:'trauma-list@trauma.org'">'trauma-list@trauma.org'</A> = </DIV> <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Tuesday, April 15, 2003 = 7:29=20 AM</DIV> <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> RE: Pre-hospital = RSI</DIV> <DIV><BR></DIV> <DIV> <DIV><SPAN class=3D749412612-15042003><FONT face=3D"Microsoft Sans = Serif"=20 size=3D4>we use sufficient midazolam to sedate, cricoid pressure, = lidocaine=20 (icp/head injury), atropine (bradycardia), sux, then if necessary = Vecuronium=20 bromide for longer paralysis (with additional sedation); so far no = adverse=20 effects; if unable to intubate, then LMA is placed. I have the = article=20 also, and find many flaws with their procedure and process for=20 investigation.</FONT></SPAN></DIV> <DIV><SPAN class=3D749412612-15042003><FONT face=3D"Microsoft Sans = Serif"=20 size=3D4></FONT></SPAN> </DIV> <DIV><SPAN class=3D749412612-15042003><FONT face=3D"Microsoft Sans = Serif"=20 size=3D4>john</FONT></SPAN></DIV> <DIV> </DIV> <DIV align=3Dcenter><FONT face=3DArial color=3D#000000 size=3D2>John = Atwell Rasmussen,=20 Ph.D., REMTP</FONT></DIV> <DIV align=3Dcenter><FONT face=3DArial color=3D#000000 = size=3D2>Lieutenant, Education=20 and Training</FONT></DIV> <DIV align=3Dcenter><FONT face=3DArial color=3D#000000 = size=3D2>Greenville County=20 EMS</FONT></DIV> <DIV align=3Dcenter><FONT face=3DArial color=3D#000000 size=3D2>(864)=20 467-7389</FONT></DIV> <DIV align=3Dcenter><FONT face=3DArial color=3D#000000 size=3D2>The = information=20 transmitted is intended only for the person or entity to which it is = addressed=20 and may contain confidential and/or privileged material. If you are = not the=20 intended recipient of this message you are hereby notified that any = use,=20 review, retransmission, dissemination, distribution, reproduction, or = any=20 action taken in reliance upon this message is prohibited. If you = received this=20 in error, please contact the sender and delete the material from any = computer.=20 Any views expressed in this message are those of the individual sender = and may=20 not necessarily reflect the views of the company.</FONT></DIV><FONT=20 size=3D2></FONT> <BLOCKQUOTE dir=3Dltr style=3D"MARGIN-RIGHT: 0px"> <DIV class=3DOutlookMessageHeader dir=3Dltr align=3Dleft><FONT = face=3DTahoma=20 size=3D2>-----Original Message-----<BR><B>From:</B> MARK FORREST=20 [mailto:atacc.doc@virgin.net]<BR><B>Sent:</B> Monday, April 14, 2003 = 6:18=20 PM<BR><B>To:</B> trauma-list@trauma.org<BR><B>Subject:</B> = Pre-hospital=20 RSI<BR><BR></FONT></DIV> <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 traumatic brain injuries', <STRONG>J Trauma, vol = 54, March=20 2003 </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=20 decrease in "good outcomes" when compared to hand-matched controls'=20 </EM></FONT></DIV> <DIV><EM><FONT face=3DArial size=3D2></FONT></EM> </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> </DIV> <DIV><FONT face=3DArial size=3D2>I was horrified to read that the = RSI is=20 performed with sux and midazolam, but sedation is only given if = systolic BP=20 is >120mmHg and even when given, the maximum dose was 3mg (for = the=20 >100Kg group)!</FONT></DIV> <DIV><FONT face=3DArial size=3D2></FONT> </DIV> <DIV><FONT face=3DArial size=3D2>This does NOT constitute = 'anaesthesia' and=20 these patients were paralysed and not 'asleep'. No record is made of = post-intubation systolic blood pressures, which were probably very = high.=20 Similarly, no account was made of the effects on ICP during such=20 'awake-intubation'!</FONT></DIV> <DIV><FONT face=3DArial size=3D2></FONT> </DIV> <DIV><FONT face=3DArial size=3D2>Is this a standard 'RSI' = practice in other=20 parts of the world?</FONT></DIV> <DIV> </DIV> <DIV><FONT face=3DArial size=3D2>Another area of concern in the = methods involves=20 the period of de-nitrogenation before starting.<EM> 'a minimum = of 60=20 seconds using a non-rebreather mask. If oxygen = saturation remained=20 below 95%, then bag and mask ventilation were instituted before=20 medication...'</EM></FONT><EM> </EM></DIV> <DIV><FONT face=3DArial size=3D2>When I was taught RSI all manual = ventilation=20 was avoided to prevent increased risk of gastric inflation and = increased=20 risk of aspiration!</FONT></DIV> <DIV><FONT face=3DArial size=3D2></FONT> </DIV> <DIV><FONT face=3DArial size=3D2>Considering these two issues and a = number of=20 others including the hyperventilation to ETCO2 30-35mmHg and = hypoxia=20 <EM>'sufficient to produce bradycardia'</EM> in many of the cases, I = am in=20 no way surprised by the poor outcome figures.</FONT></DIV> <DIV><FONT face=3DArial size=3D2></FONT> </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> </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=20 size=3D2></FONT></EM> </DIV></BLOCKQUOTE></DIV></BLOCKQUOTE></BODY><= /HTML> ------=_NextPart_000_008E_01C3046A.ACCDAA70--
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