Posted at 10.08.2018
Airway management is the first main concern for management of any patient it is therefore very critical to learn how to manage the patient in virtually any emergency concerning the airway. Some emergencies can be maintained with just handbag valve face mask (BVM) ventilations done appropriately to maintain saturations above 94% and some need more invasive procedures to keep and protect the airway.
Rapid sequence intubation (RSI) is an extremely critical skill. It needs a pre-hospital professional (paramedic) to have a more impressive range of learning and competence. The paramedic needs to be very experienced and also need to make a good judgement. Decision making is essential on whether to RSI or not. This needs to be done quickly and efficiently to be able to help the individual as best as you possibly can. The challenge surrounding the Pre-Hospital setting is whether it's good or bad for the individual.
There are a lot of facts surrounding this problem as it is not only the skill that make a difference the outcomes but other factors as well. In a prehospital setting paramedics need to be properly trained. Working out focuses and puts focus on skills and decision making. Most bad decisions have poor intubation rates. A number of the studies show it as a good skill with good results plus some disagree.
In the following assignment I say that pre clinic RSI is effective if done effectively on an individual that it is indicated for and which the benefits outweigh the risks.
It is the supervision of a strong sedative (sedation) and a neuromuscular blocking (NMB) agent (paralysis) for the purpose of intubating patients who have a gag reflex or who would be difficult to intubate and the benefits outweigh the potential risks. Neuromuscular blockade permits easier intubation and ventilation. A muscle relaxant is given in speedy sequence with a sedative before intubation is attempted. RSI utilizes a sedative, a short term paralytic they are administered to the patient to permit the passing of an endotracheal tube (ETtube) to be placed in the patient's trachea to allow useful ventilation to the individual. For bradycardic patients, especially children, atropine is used. Lidocaine for patients with an increase of intracranial pressure (ICP).
Routine: to create anaesthesia and neuromuscular blockade in preparation for intubation. (Usually done in private hospitals by medical doctors, anaesthetists or specialists in a handled environment)
Emergency: to produce neuromuscular blockade to accomplish placement of an endotracheal pipe in those patients where the airway cannot be otherwise monitored.
Indications for RSI
Trauma patients with a GCS of 9 or less with a gag reflex
Trauma patients with significant cosmetic trauma and poor airway management
Seizures resulting in position epilepticus unresponsive to benzodiazepines.
Hypoxic and combative, struggling to intubate by regular means,
Trauma with seizures or trismus
Closed head personal injury or major stroke with unconsciousness.
Burnt patients with airway burns up and a compromised airway
Respiratory exhaustion such as severe asthma, cardiovascular system inability (CHF) or persistent obstructive pulmonary disease (COPD) with hypoxia.
Overdoses with altered mental position where there's a loss of airway.
It helps it be simpler to intubate, reduces intracranial pressure (ICP) associated with intubation and it is short acting. Improves oxygenation.
I will be looking at different articles compiled by differing people to see whether prehospital RSI is beneficial or not. If not, how can it be improved.
In the article, Spaite et al, immediate series intubation of patients with severe brain injuries in the out-of-hospital setting. The application of saving oximeters was used to evaluate the air saturation and pulse rate. 57% of these trauma victims proven desaturation during out of hospital rapid series intubation. Among those who experienced desaturation, 84% possessed initial air saturations in the normal range with the utilization of basic airway skills only. In addition, practically 1 in 5 patients experienced bradycardia during desaturation. It is also observed that, in 84% of patients who experienced desaturation, the paramedics who had been doing the RSI explained the performance as easy.
In this informative article, Spaite et al, pre medical center RSI is not supported as it is stated to have a high motarlity rate and a reduction in good outcomes. In addition, it says that significantly less is well known about the security and performance of out-of-hospital speedy sequence intubation. Among the most frequent things of a lot of the previous reports of out-of-hospital swift collection intubation is the shortage or minimal reporting of significant difficulties. Spaite also says that EMS has less studies assessing the implementation of new treatments and strategies that survey extremely low complication rates. The lack of complications mentioned may be caused by practitioners not documenting the complications in order to protect themselves or from having less capturing all the patient information that's needed is.
According to the article, Lockey D et al, there is absolutely no good proof that pre hospital RSI improves end result in injury patients, the huge benefits aren't excluded either. It goes on to say that the signs in medical center and pre-hospital RSI will be the same. This won't mean that every patient who is indicated should have an RSI. That's where good medical decision making skills enter into place taking different issues into consideration specifically: patient, the skill service provider and resources. In addition, it emphasized on more training and practice for the skill providers.
In another article, Lah K et al, it is stated the RSI is conducted by pre medical center physicians pays to, effective, safe, successful and part of standard care. Nonetheless it also says that in a paramedics established system RSI can be a harmful method especially in difficult airway conditions because of limited knowledge of medication kinetics and pharmacodynamics. I beg to are different on this declaration because it is up to person to learn the drugs in their scope of practice or drugs that they are going to utilize.
In looking at medical and stress patients intubated in the field it was uncovered that these two groups fluctuate in many guidelines. The patients in the medical group were in a negative condition initially, had a worse prognosis and a higher rate hypotension and bradycardia during RSI. Among the injury patients it was discovered that there were more second efforts of RSI and problems with visualization which could be from trauma to the airway, injury to the C-spine that will require the individual to be located inline immobilization of the cervical column, it can also be from the bloodstream or vomitus in the mouth. This shows that every patient has a particular need which needs to be acknowledged and considered when making the decision to RSI.
In the article, Mackay CA et al, it was found that properly trained pre medical center practitioners can properly use sedative and muscle relaxant drugs in prehospital injury patients. Using a great deal of training and practice it is possible to raise the good outcomes relating to RSI.
In this article, Ochs et al, has limitations regarding the outcome data. It says that the benefits associated with early on intubation may be disrupted by the extended on landscape time or the potential complications which will be caused by the procedure itself, this also comes home to good clinical judgement. A choice should be made on whether to give ventilations via BVM while carrying to the nearest appropriate service or even to continue trying to intubate the patient. That's where the potential risks and benefits should be weighed.
It concludes by stating that from all the experts who did the procedure with 84% successful ET tubes insertion and 15% combitube insertion and failing rate of less than 1%. This is a very good result, it demonstrates with proper training and practice, pre clinic RSI can be carried out with a good end result of a high success rate.
There is not a good current research that pre hospital RSI increases patient benefits in stress patients except in distressing brain personal injury patients. RSI in TBI patients decreases (ICP). This however will not imply there are no advantages to pre hospital RSI. Before every RSI there should be a risk versus benefits examination, taking the patient, resources and other issues into account.
The patient will have to fit the indications criteria to be able to be considered for RSI (as mentioned above).
Personnel: you'll need another ALS (has to be able to intubate) to help you
Equipment: Suction product, oxygen, airway (laryngoscope, ET tubes, stylet, BVM with tank), all the relevant drugs (combination and draft and label), monitoring equipment (ECG, saturation monitor, End Tidal CO2 screen, Esophageal detector device).
Inability to intubate the patient
In this article, Cobas et al, there are certain explanations as to the reasons the patient cannot be intubated. It might be from the increased time spent at the landscape which consumes valuable carry time. Also areas that several attempts could be dangerous by creating haemodynamic disruptions while increasing hypoxia.
Incorrect drug dose administration. RSI on an individual that it is not indicated for. Failed intubation is a risk as it will require the practitioner to perform save airway to re-oxygenate the patient.
Adequate training is important with (RSI).
With a lot of training and training it creates the skill easier to perform and makes the specialist more comfortable to execute the skill. It also reduces the time in which the skill has to be preformed which in turn reduces the time spent on picture.
Knowledge of the pharmacology
When you understand your drugs it creates it super easy to decide on what drug to utilize to suit the patient's condition. Also makes the practitioner convenient as they know very well what to do in case of side results or other drug related challenges. It also makes it much easier to decide on a certain medication to suit a certain patient's needs best.
Know your equipment
It is also essential to know your entire equipment from the various tools to the monitoring equipment. You have to know the tools so as to know how to use them appropriately. The monitoring equipment helps you to know more about the patient's condition if the individual is responding well, steady or deteriorating.
This is an essential and vital step. The individual must be connected to displays: ECG, Pulse Oximetry, blood pressure, End Tidal capnometry, IV line put up, all equipment to prepare yourself and examined (suction, laryngoscopes, endotracheal tubes, backup cutting blades and pipes), preoxygenation, all drugs that'll be used to be computed and used in syringes.
God preparation reduces issues, reduces time it will require to do the task and also decrease the stress and anxiety for the specialist.
RSI is a crucial skill that needs to be done appropriately to enhance the patient outcomes. Hence, it is essential to have all the mandatory elements to do the procedure. Listed below are suggested as the bare minimum elements required to have to execute the skill properly.
The least requirements:
Training and continual education (with hands on experience with drugs and airway management of patients who've been pharmacologically paralysed in the hospital)
Equipment for patient monitoring, drug storage and correct consumption, monitoring of tube placement
Standing and standardized RSI protocols like the use of particular pretreatment, sedative and neuromuscular blocking (NMB) agents
Back up airway equipment or methods in case of a failed RSI (BVM ventilations, combitube, Laryngeal cover up airway (LMA), surgical cricothyroidotomy, needle cricothyroidotomy)
Continued quality confidence, quality control and performance review
Another advanced life support paramedic (able to intubate)
Good judgement to make a good professional medical decision for the patient's best interests
Every practitioner must have these exact things in their response car or ambulance, it should be part with their everyday equipment to ensure that they are well prepared for RSI and perform the skill as successfully as is feasible.
It would work better if it could be made official. There should be documentation stating that each practitioner who is qualified to perform this skill should have each one of these requirements before even attempting to do the skill and failing thereof should be treated as an work of negligence and charged appropriately.
In bottom line, RSI is a crucial life keeping skill that is beneficial for some patients, especially the TBI patients. It is also risky if it is not done properly. I still agree that it is beneficial and therefore should be achieved as best as is feasible.
What can be done to reduce the risk, it is to train practitioners adequately, have the practitioners do practical practicals at a healthcare facility with professionals who can monitor, and critique to help them do the skill as best as you possibly can. Learn all the drugs and be able to perform other airway procedures in case of failed RSI.
There also needs to be quality confidence and every year reviews or retraining to lessen skill degradation.