RSI meds - page 2

out of curiosity... what meds do your docs like to use for RSI. anybody using ketamine, read that it can be useful in hypotensive pt.s and especially with status asthmaticus.... Read More

  1. by   Medic2RN
    We give Lido prior to intubating anytime there is suspected head trauma or possible bleed.

  2. by   RNCENCCRNNREMTP
    Quote from traumakimmy
    any of your docs giving lido when intubating? we have one that insists on it. just wondering if there were more out there.

    kim
    There is conflicting evidence that shows IV lidocaine, when given at least 3 minutes before the intubation, helps to blunt the sharp rises in intracranial pressure in a patient with a traumatic brain injury. Problem is, people rarely wait the requisite 3 minutes and so the lidocaine is probably moot. If you are going to do RSI you need to do it right otherwise it is just old fashioned "brutane" at work.

    Andrew B
  3. by   PA-C in Texas
    I started ordering Versed but switched almost entirely to etomidate followed by fentanyl after the tube. You really can't beat it's hemodynamic profile. And always sux for paralysis- have never had a problem with it. Even with burns, as long as the burn is less than 8 hours old, it shouldn't be a problem.
  4. by   jewelcutt
    Just curious you guys, are you actually talking about a true rapid sequence induction or regular intubating? I'm assuming since they're ER patients all should be considered an aspiration risk and thus necessitate a RSI. I'm also curious what percentage of your intubations are true RSI's with cricoid pressure before induction agent and continued till verification of tube in trachea and cuff inflated? Etomidate is a great drug for preservation of cardiac stability, propofol and pentothal are less forgiving. Ketamine will actually cause an increase in BP, ICP and preserves airway reflexes. If it is a true RSI the fastest acting muscle relaxant should be used, i.e succs, roc can be used if there are concerns with using succs. I don't suggest vec or pan because they take a little while to work all the while increasing the patient's aspiration risk. Do you paralyze all of your intubations? How many are done awake (or some form of it?). You shouldn't give doses of paralytic while on a vent unless some sort of sedation is given also though, how terrifying would that be.
  5. by   11:11
    Quote from paraloco
    We use Etomidate and sux also. If we need to re-sedate prior to arrival, we give em another 20 of sux.
    Ummm....

    sux isnt for sedation....
  6. by   mommatrauma
    The best patient is paralyzed and intubated....

    head injuries we use Lido...1mg Vec as defasiculating dose, then Etomidate and Succs and vec and versed to keep them down....

    your basic RSI we do Etomidate, Succs, Vec to keep them paralyzed and Versed to keep them sedated....

    We use Roc instead of Succs for our potential hyperkalemics...Vec is bad induction agent not only cause of its prolonged onset, but also because of its prolonged duration of approx 60 minutes and in a can't intubate, can't ventilate situation...that can get ugly....

    As for Ketamine...wonderful drug...I think everyone in the waiting room should get a dose on arrival...We used to use it alot in children for conscious sedation...with a little atropine for secretion control....the benifits are that its not a resp depressant and that you don't have to have IV access to give it...and it is fairly short acting with a 20 sec onset...The downside is that you can have horrible emersion nightmares in children with it causing more problems than they are worth...because of that, we don't use it as often...our hospital did do a study on adult usage and found it to be very useful with less nightmare problems...

    And just as a side note...please keep your paralyzed patients sedated...just cause they are paralyzed doesn't mean they aren't aware of what is going on...I know if I couldn't move but was awake to know it I'd be freaking on the inside...so if i end up in your ER...please sedate me...thanks
  7. by   kmchugh
    Anytime you are doing a rapid sequence induction (RSI), your primary concerns are airway and aspiration. Therefore, what you give should not promote emesis (etomidate is well known for this) and should not leave a patient paralyzed and aepnic for a prolonged period. Non-depolarlizers are a bad choice of paralytic, because of how long they take to wear off. (Do any of your docs know the drugs that can be used to reverse non-depolarizers? If so, are they available?) Pavulon (pancuronium) is about the worst choice for a paralytic for rapid sequence induction. It has a LOOOONG time to onset, and even LOOOOOOOONGER time to wear off. What if you induce, the patient's airway collapses, and the doc cannot visualize the airway with the scope? You can't fix dead.

    Anytime I do an emergency intubation outside of the OR (and I treat every emergecy intubation as a rapid sequence intubation), I will use versed, because it does not depress respiration, and will provide for amnesia. My paralytic of choice (provided the K+ is WNL) is succinylcholine. If the K+ is high, I use more versed, and don't paralyze. Yes, a non-paralyzed patient can be safely intubated.

    Kevin McHugh, CRNA

    Edited to add: Yes, ketamine is a good drug, but it is a misconception that it cannot cause respiratory depression. It can do so, and at clinically useful doses. I've seen it do so. It is also a powerful hallucinogen, and can lead to a far more combative patient. Etomidate is great, because it has about the least cardiodepressive effect, but it depresses respiration. Studies have also shown that etomidate actually causes more emesis, hence it's nickname among anesthesia providers "vomidate." Propofol is a great drug, short acting and fairly benign. Unless of course your patient has a heart problem. It will drop a blood pressure to zero in the blink of an eye. And pentothal can do it all. I know anesthesia providers who would not use anything but pentothal for induction and intubation of a head injured patient. But at the same time it can cause significant problems, and is not the drug of choice for an RSI by any means.
    Last edit by kmchugh on Mar 6, '05
  8. by   mommatrauma
    Quote from kmchugh
    Anytime you are doing a rapid sequence induction (RSI), your primary concerns are airway and aspiration. Therefore, what you give should not promote emesis (etomidate is well known for this) and should not leave a patient paralyzed and aepnic for a prolonged period. Non-depolarlizers are a bad choice of paralytic, because of how long they take to wear off. (Do any of your docs know the drugs that can be used to reverse non-depolarizers? If so, are they available?) Pavulon (pancuronium) is about the worst choice for a paralytic for rapid sequence induction. It has a LOOOONG time to onset, and even LOOOOOOOONGER time to wear off. What if you induce, the patient's airway collapses, and the doc cannot visualize the airway with the scope? You can't fix dead.

    Anytime I do an emergency intubation outside of the OR (and I treat every emergecy intubation as a rapid sequence intubation), I will use versed, because it does not depress respiration, and will provide for amnesia. My paralytic of choice (provided the K+ is WNL) is succinylcholine. If the K+ is high, I use more versed, and don't paralyze. Yes, a non-paralyzed patient can be safely intubated.

    Kevin McHugh, CRNA

    Edited to add: Yes, ketamine is a good drug, but it is a misconception that it cannot cause respiratory depression. It can do so, and at clinically useful doses. I've seen it do so. It is also a powerful hallucinogen, and can lead to a far more combative patient. Etomidate is great, because it has about the least cardiodepressive effect, but it depresses respiration. Studies have also shown that etomidate actually causes more emesis, hence it's nickname among anesthesia providers "vomidate." Propofol is a great drug, short acting and fairly benign. Unless of course your patient has a heart problem. It will drop a blood pressure to zero in the blink of an eye. And pentothal can do it all. I know anesthesia providers who would not use anything but pentothal for induction and intubation of a head injured patient. But at the same time it can cause significant problems, and is not the drug of choice for an RSI by any means.
    I absolutely disagree with your statement that Versed does not decrease respiration...I feel it absolutely does...I have not once given Versed to a pt that I haven't had to put O2 on...I have had many problems with patients having breathing issues and have had to give Romazicon to reverse it more times than I can count on one hand, and I'm not even talking about the patients we give both Versed and Fentynal to. I'm talking Versed alone...Also, it also alot less hemodynamically forgiving in shocky patients w/unstable vitals than Etomidate...and as vomiting goes...when doing RSI, the whole premise behind it, is that you are assuming your pt has a full stomach when you start...RSI decreases their aspiration risk...you are paralyzing them...temporarily taking away their gag reflex...if you can't stimulate their gag...there is no vomiting, however if they do vomit as you are putting them down...suction, that's what it is there for...after they are intubated you are dropping an NGT/OG tube to keep the stomach decompressed and prevent the aspiration...
  9. by   tridil2000
    . Yes, a non-paralyzed patient can be safely intubated.

    Kevin McHugh, CRNA


    of course they can bc that's how we did them prior to rsi ~circa 1995.

    lido is given first for head issues, always. then we use etomidate, vec and/or succs. we use ketamine on asthmatics. we rarely use versed anymore.

    for conscious sedation our fav is diprovan.
  10. by   jayne109
    we use etomidate and sux on just about everybody as well. Once intubated, we give norcuron, versed and occasionally (for trauma pts especially)fentanyl.

    just my 2cents
  11. by   taidan
    in the EMS service i work with we have a choice of either versed/fentynal or etomidate then succs. We use lido for ^ICP and atropine to blunt brady in peds.
  12. by   11:11
    Fentanyl is a wonderful drug
  13. by   taidan
    Quote from 11:11
    Fentanyl is a wonderful drug
    Yup. esp. for us Medics , Before My service got Fentynal I would give morphine then the docs would complain that they cant do a motor sens. exam. Now with fentynal the anelgesia is more potent and shorter acting. Also has less adverse hemodynamic effects.

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