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Home > List Archives

Pre-hospital RSI

Errington Thompson trauma-list@trauma.org
Wed, 16 Apr 2003 22:51:10 -0500


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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

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<DIV>What flaws have you found?</DIV>
<DIV>&nbsp;</DIV>
<DIV>E</DIV>
<DIV>&nbsp;</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>&nbsp;</DIV>
<DIV>Don't think you are<BR>Know you=20
are<BR>&nbsp;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&n=
bsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb=
sp;&nbsp;&nbsp;&nbsp;&nbsp;=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.&nbsp; 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>&nbsp;</DIV>
  <DIV><SPAN class=3D749412612-15042003><FONT face=3D"Microsoft Sans =
Serif"=20
  size=3D4>john</FONT></SPAN></DIV>
  <DIV>&nbsp;</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&nbsp;traumatic brain&nbsp;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>&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=20
    performed with sux and midazolam, but sedation is only given if =
systolic BP=20
    is &gt;120mmHg and even when given, the maximum dose was 3mg (for =
the=20
    &gt;100Kg group)!</FONT></DIV>
    <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</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>&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=20
    the period of de-nitrogenation&nbsp;before starting.<EM> 'a minimum =
of 60=20
    seconds using a non-rebreather mask. If oxygen =
saturation&nbsp;remained=20
    below 95%, then 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=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>&nbsp;</DIV>
    <DIV><FONT face=3DArial size=3D2>Considering these two issues and a =
number of=20
    others 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=20
    no 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=20
size=3D2></FONT></EM>&nbsp;</DIV></BLOCKQUOTE></DIV></BLOCKQUOTE></BODY><=
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