Opinions needed on RSI

Trauma Columnist · Nov 9, 2004

I've been in that situation too. What about an EJ? In Illinois - RNs can place them. What would have happened if you had insisted that a central line be placed?

tridil2000, MSN, RN · Nov 9, 2004

I've been in that situation too. What about an EJ? In Illinois - RNs can place them. What would have happened if you had insisted that a central line be placed?

when the resident was in, i asked about a jugular line. he said to keep trying. imo, he wimped out of it.

when the charge nurse was looking i said to her.. i think they should just go for a jugular or a femerol and i FELT... she thought i was panicking. then she got the line.

panic is one thing, but i just thought we were choosing the 'scenic' route - and spoke up.

if i had been more persistant, then they would have surely said i was panicking.

well, this place is like a level 4 hospital... so that may say it all!

justcurious · Nov 9, 2004

could it be that the resident just did not feel secure placing a jugular line? some folks are like that, they won't admit a weakness... to save their face, they'd make someone else do it

or maybe he is just plain dumb

jaimealmostRN · Nov 12, 2004

I am still in school, but have expirence as a tech in the ED. Common sense tells us/me that the resident/attending should have put in a line....the charge nurse got lucky IMO...had the pt died and this went to court, that dr(s) could have gotten in a lot of trouble b/c of their hesitence (sp?). JMO.

rnmls · Dec 16, 2004

i was very annoyed last night at our er resident AND attending. i had a pt come in in severe resp distress.
hx
smoker and copd
rr 40
retracting every muscle
couldn't speak
orthopic
very tight
i got 3 albuterol txs rolling and called for pcxr and put him on the monitor. st @110 bp 200/90
he told me he had been intubated before and needed central lines bc he was a hard stick.
so, i tried twice in both acs.
about now the resident comes in and tells me to keep trying!!!!
now, i felt that with this guys history and 'pending doom' for lack of a better term, he should have dropped a jugular line in him or a femerol line. imo, we didn't have time to fart around getting a little 22 in a thumb for a possible upcoming resp arrest.
the charge nurse comes in after him and looks.... meantime, his bp is now 210/110 and hr st 128 or so bc of all the treatments. he's working his butt off to breathe and now his heart's getting stressed. the charge nurse looks and looks and after about 10 minutes, she gets a 22 in the outer back of the wrist.... that little vein bythe boney prominence. honestly, i thought we wasted a lot of time on such an iffy line. well, low and behold, it worked.... and yes, as long as it worked we were temporarily fine for rsi.
as i started the nss it got sluggish bc it was a bit positional. i held the catheter straight andit resumed. as i pushed the etomidate and succs, i had to hold it and go gently.... out he went and he was tubed.
end of story.... he was tubed successfully. then as expected, his bp falls to 104/50. now, i stand there with the saline wide open through this bitty positional 22.
he levels off. and really things are fine. so, yes, the little 22 in the tiniest vein did the job... but i really felt uneasy about the delay we caused the situation, for that line. in my previous experiences, a jugular (18) would have been placed or a cordis would have been popped into the femerol vein in 5 minutes and we would have went from there with certainty and with the assurance of having a secure line for rsi.
i am trying to look at the bright side, we were lucky, we got a line and in the end it worked. but still, if you were in that kind of distress, would you want people spending over 20 minutes getting a 22 in the back of your wrist?
i'd love to hear from some of you who work at level 1s. would you guys do it this way???
thanks for your input
trish

sounds to me like the resident caused a delay in this patients treatment and an incident report should be generated and your charge nurse dosent sound like she worth her salt your crititcally ill patient deserved better than a 22 next time stand up and advocate louder

qanik · Dec 16, 2004

Sounds like a tough situation for you to be in. I agree with you he should have had a central line put in quickly. Also note trauma's post about EJ's they are good quick lines That nurses can usually place. IF you read any good RSI literature they will advocate 2 Good lines. Now that being said you can also find yourself in a situation where the A may not wait for the C. I have been on flights where patients where huge (tough IV periph or central) and their respiratory situation was deteriorating quickly (burns), where I have made the decision to RSI them By giving IM succs and then intubating, following that with IM MSO4 and Versed as well as a Non depolarizing agent like Vec. Now you have accomplished A and can progress to C. I think its important to remember A before C. As you noted you may get into a situation where you need the IV for the BP ( although in this case, etomidate and succs should have minimal hemodynamic effects). Most likely when he went down you took the "fight" out of him and that was the loss of BP. In this case it sounds like your resident was afraid of the procedure or unskilled in it. I think your right on to be upset as it is another case of delaying A for ever while you fiddle for C.

Brent