mark tozer's blog: 07/01/2024

Tuesday, July 30, 2024

EMS Airway Management - RSI v DSI

EMS providers should understand the key differences between Delayed Sequence Intubation (DSI) and Rapid Sequence Intubation (RSI) to determine the most appropriate approach for managing a patient's airway in critical situations.

Here are some things to know:

1. PURPOSE AND INDICATIONS

Rapid Sequence Intubation (RSI):

Purpose:

RSI is designed to secure the airway quickly and efficiently by inducing unconsciousness and paralysis in a matter of seconds, allowing for immediate intubation.

Indications:

RSI is used in situations where a patient requires immediate airway control, such as in cases of severe respiratory failure, trauma, or cardiac arrest, and where the patient is unable or unlikely to tolerate laryngoscopy without pharmacologic assistance.

Delayed Sequence Intubation (DSI):

Purpose:

DSI is a modified version of RSI that allows for the controlled induction of unconsciousness in a patient who needs preoxygenation but is either combative, anxious, or unable to tolerate preoxygenation.
The key difference is that DSI provides a window for preoxygenation after sedation but before paralysis.

Indications:

DSI is particularly useful in patients with conditions like severe hypoxia, agitation, or anxiety, where cooperative preoxygenation is necessary but not possible without sedation.
It’s often employed in cases where hypoxemia needs to be optimized before intubation.

2. SEQUENCE OF STEPS

RSI Steps:

Preoxygenation: The patient is preoxygenated, typically with a non-rebreather mask or BVM.
Induction and Paralysis: Sedative and paralytic agents are administered almost simultaneously to rapidly induce unconsciousness and paralysis.
Intubation: The patient is immediately intubated once paralysis sets in, typically within seconds to a minute of drug administration.

DSI Steps:

Sedation: The patient is sedated first, usually with a dissociative agent like ketamine, allowing them to tolerate preoxygenation without agitation.
Preoxygenation: After sedation, the patient is preoxygenated in a more controlled manner, improving oxygen reserves before proceeding to intubation.
Paralysis and Intubation: Once adequate preoxygenation is achieved, a paralytic is administered, and the patient is then intubated as in RSI.

3. KEY DIFFERENCES IN APPROACH

Sedation Timing:

RSI: Sedation and paralysis occur almost simultaneously, leaving little time for any further patient preparation or intervention.
DSI: Sedation is performed first, allowing the patient to be more effectively preoxygenated while still breathing spontaneously.

Oxygenation Focus:

RSI: The priority is rapid intubation, often under the assumption that the patient has been adequately preoxygenated beforehand.
DSI: The focus is on improving oxygenation in patients who are at risk of severe hypoxia before intubation, using the sedation phase to achieve better preoxygenation.

Patient Condition:

RSI: Best suited for patients who can be adequately preoxygenated before the induction of anesthesia and paralysis.
DSI: Ideal for patients who are agitated, hypoxic, or otherwise unable to cooperate with preoxygenation due to altered mental status, respiratory distress, or other factors.

4. ADVANTAGES AND DISADVANTAGES

Rapid Sequence Intubation:

Advantages:

Quick and efficient airway control.
Reduces the risk of aspiration and airway trauma.

Disadvantages:

In patients who are not adequately preoxygenated, the risk of hypoxia during the apneic period is higher.
May be challenging in patients who are difficult to preoxygenate or who have an unstable airway.

Delayed Sequence Intubation :

Advantages:

Allows for better preoxygenation in high-risk patients.
Reduces the risk of hypoxia during intubation by optimizing oxygen levels before paralysis.

Disadvantages:

Takes longer than RSI, which may not be suitable in situations requiring immediate airway control.
Requires careful monitoring to ensure that the patient remains adequately sedated without losing airway reflexes prematurely.

5. CLINICAL CONSIDERATIONS

Patient Selection:

RSI: Preferred in situations where time is of the essence, and the patient is at immediate risk of airway compromise.
DSI: Considered in cases where there is enough time to optimize the patient’s oxygenation before paralysis, especially in patients who are at high risk for desaturation or in those who are uncooperative.

Skill and Experience:

Both RSI and DSI require advanced airway management skills. EMS providers must be adept at assessing the patient’s condition and deciding which approach is most appropriate.

CONCLUSION

Understanding the differences between DSI and RSI allows EMS providers to tailor their approach to the specific needs of the patient. While RSI is the standard for rapid airway control, DSI provides an important alternative for patients who need improved oxygenation before intubation.

The choice between the two depends on the patient's condition, the urgency of the situation, and the provider's assessment of the most effective strategy for ensuring a successful intubation.

Sunday, July 28, 2024

EMS In The News - Man Allegedly Shoots at Ambulance

"Falck medics who responded “to a call for a structure fire literally dodged a bullet,” Aurora Fire Rescue said in a statement."

In Aurora, Colorado, paramedics narrowly avoided injury when a man allegedly shot at their ambulance during a house fire response.

The incident occurred near South Chambers Road and East Quincy Avenue. The suspect ran from the burning house with a gun and fired at the arriving ambulance, hitting the windshield. Fortunately, none of the three paramedics were hurt.

Police apprehended the 34-year-old suspect using non-lethal rounds, and he faces charges of arson and attempted murder after his hospital release.

For further information, access the article link here.

Lauren Penington - The Denver Post

Friday, July 26, 2024

EMS Medication Administration - RSI Endotracheal Intubation

EMS Providers should have a comprehensive understanding of rapid sequence endotracheal intubation (RSI) medication administration to ensure successful and safe management of patients requiring advanced airway interventions.

Here are some points they should know:

1. Indications and Goals

Indications:

To facilitate endotracheal intubation (ETI) in patients who require definitive airway management.
Medications administered during intubation typically include induction agents (sedatives) and neuromuscular blocking agents (paralytics) and analgesics (pain relievers).

Goals:

Achieve rapid sedation and paralysis to facilitate smooth intubation without causing harm or distress to the patient.
Ensure patient comfort and safety throughout the procedure.

2. Medications Used

Analgesic Agents:

Fentanyl: EMS Providers should consider opioid administration to intubated patients, as NMBAs and sedatives do not relieve the pain associated with intubation and positive pressure ventilation (Fatolitis, 2022).

Induction Agents:

Etomidate: Rapid onset sedative with minimal cardiovascular effects.
Propofol: Potent sedative with rapid onset and short duration of action.
Ketamine: Dissociative agent providing sedation, analgesia, and amnesia.
Midazolam: Benzodiazepine used for sedation, less commonly for induction due to slower onset.

Neuromuscular Blocking Agents (NMBAs):

Succinylcholine: Depolarizing agent for rapid paralysis.
Rocuronium / Vecuronium: Non-depolarizing agent with longer duration of action and less side effects compared to succinylcholine.

3. Preparation and Technique

Medication Preparation:

Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
Calculate and prepare appropriate doses based on patient weight and condition.

Procedure Preparation:

Ensure all equipment for intubation is ready and functional (e.g., laryngoscope, endotracheal tube, suction).
Confirm patient positioning, secure environment, and adequate personnel for assistance.

4. Administration Techniques

Induction Agent Administration:

Administer induction agents rapidly to achieve sedation and facilitate intubation.
Ensure titration of medications to achieve desired sedation level without compromising hemodynamics.

Neuromuscular Blocking Agent Administration:

Administer NMBAs after confirming adequate sedation to prevent patient awareness and facilitate intubation.
Monitor for onset of paralysis and ensure proper ventilation during apnea phase.

5. Monitoring and Management

Monitoring:

Continuously monitor vital signs including heart rate, blood pressure, oxygen saturation, and ECG if possible.
Monitor level of sedation and depth of paralysis to adjust as necessary.

Management:

Be prepared to manage potential complications such as hypotension, respiratory depression, or adverse reactions to medications.
Have reversal agents available if needed (e.g., naloxone for opioid-induced respiratory depression).

6. Post-Intubation Care

Securing the Airway:

Confirm proper placement of the endotracheal tube (ETT) using clinical and adjunctive methods (e.g., end-tidal CO2 monitoring).
Secure the ETT and confirm effective ventilation.

Continued Monitoring:

Maintain continuous monitoring of vital signs and oxygenation.
Prepare for transport to appropriate medical facility, ensuring ongoing airway management and support.

7. Special Considerations

Pediatric and Geriatric Patients:

Adjust medication doses and techniques based on age, weight, and physiological differences.

Difficult Airway Management:

Be prepared for difficult intubations and have backup plans in place (e.g., alternative airway devices, surgical airway equipment).

Patient Condition:

Consider comorbidities and potential contraindications to specific medications based on patient history.

8. Training and Proficiency

Simulation Training:

Regular practice in simulated scenarios to maintain proficiency in intubation medication administration and airway management techniques.

Continuing Education:

Stay updated on current guidelines, best practices, and new medications relevant to intubation and airway management.

9. Legal and Ethical Considerations

Scope of Practice:

Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent:

Obtain informed consent from the patient or guardian whenever possible, considering the urgency and necessity of the procedure.

Documentation:

Accurate documentation of medication administration, intubation process, airway assessment, and ongoing patient monitoring.

Conclusion

Medication administration for RSI is a critical skill for EMS Providers performing advanced airway management. It requires proficiency in medication administration, airway assessment, and management of potential complications.

Continuous training, adherence to protocols, and effective teamwork are essential for ensuring successful patient outcomes in emergency situations.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Fatolitis, N. (2022) Keys To Success For Airway Management. EMS Airway. https://emsairway.com/.../keys-to-success-for-airway.../... Accessed July 26, 2024

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Nickson, C. (2024) Rapid Sequence Intubation (RSI). Life In The Fast Lane. https://litfl.com/rapid-sequence-intubation-rsi/ Accessed July 26, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Wednesday, July 24, 2024

EMS Medication Administration - Rectal Route

EMS Providers should have a thorough understanding of rectal medication administration to ensure safe and effective treatment.

Here are some key points they should know:

1. Indications and Contraindications

Indications:

Need for rapid absorption and onset of action when other routes are not feasible or practical.
Common medications administered rectally include anticonvulsants (e.g., diazepam for seizures), antiemetics, and certain sedatives or analgesics.
Patients who are unable to take medications orally or intravenously.

Contraindications:

Rectal bleeding, inflammation, or injury.
Recent rectal surgery.
Allergy to the medication.
Conditions where rectal administration may not be safe or effective, as determined by local protocols or medical direction.

2. Mechanism of Action

Absorption:

Medications administered rectally are absorbed through the rectal mucosa into the systemic circulation, bypassing the gastrointestinal tract and first-pass metabolism in the liver.

3. Preparation and Technique

Medication Preparation:

Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
Ensure the medication is appropriate for rectal administration and prepare it according to protocol (e.g., suppository form).

Patient Preparation:

Position the patient on their left side (Sims Position) or in a knee-chest position to facilitate administration and retention of the medication.
Wear gloves and ensure privacy and dignity of the patient during the procedure.

4. Administration Techniques

Insertion:

Lubricate the suppository or applicator tip with water-soluble lubricant.
Gently insert the suppository or applicator into the rectum past the internal sphincter (approximately 1-2 inches in adults, less in children).
Instruct the patient to remain in position for a specified time to ensure retention and absorption of the medication.

5. Patient Communication and Education

Explain the Procedure:

Inform the patient (if conscious) about the purpose of the medication administration, how it will help, and what to expect during and after the procedure.

Instructions:

Provide clear instructions on maintaining the position to allow the medication to be absorbed properly.

6. Monitoring and Follow-Up

Observation:

Monitor the patient for signs of medication absorption, such as reduced seizure activity or relief of nausea.

Reassessment:

Regularly reassess the patient’s condition to determine the effectiveness of the medication and any need for additional intervention.

7. Complications and Management

Retention:

Ensure the suppository or medication remains in place for adequate absorption.

Adverse Reactions:

Be prepared to manage potential adverse reactions, such as local irritation or allergic reactions.

Discomfort:

Address any discomfort or concerns the patient may have during or after the procedure.

8. Special Considerations

Pediatric and Geriatric Patients:

Adjust dosage and technique based on age and physical condition; consider using smaller suppository sizes for children.

Environmental Factors:

Ensure privacy and maintain patient dignity during the procedure.

Patient Condition:

Be aware of any conditions that might affect rectal medication administration, such as rectal prolapse or recent rectal trauma.

9. Training and Proficiency

Simulation Training:

Regular practice using simulation models to maintain proficiency in rectal medication administration techniques.

Continuing Education:

Stay updated on best practices, new medications, and techniques for rectal administration.

10. Legal and Ethical Considerations

Scope of Practice:

Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent:

Obtain informed consent from the patient or guardian whenever possible.

Documentation:

Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective rectal medication administration requires EMS providers to combine theoretical knowledge with practical skills.

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.