Prehospital RSI and ETI

[Guest guest]

I think the jury is still out on all this. I have read all of the research

and come to some conclusions--some of which I cannot explain.

1. Pediatric patients do just as well, if not better, when managed by BVM.

Why is this? Are paramedics poor at pediatric intubation? Probaby. Would RSI

improve the outcome? Maybe. Is skills decay and rust-out too much iof an

issue to continue to keep paramedic pediatric intubation a part of the

skills complement? Maybe.

2. Head-injured patients who receive prehospital intubation AND prehospital

RSI have higher mortality. First, is this a Southern California problem? I

think that is alot of it. Too many paramedics, low-level of skills, and

limited oversight. The study is being reproduced in Seattle asd we write.

Hypoxia and hyperventilation tend to occur when paramedics do not use

wave-form capnography (not sure why). Perhaps paramedics don't spend enough

time pre-oxygenating te patient before ETI or RSI. And, perhaps adrenalin

drives them to hyperventilate the patient. When capnography is used, the

mortality drops.

3. Should all paramedics intubate? Maybe not. Skills decay is quite a

problem and should not be attempted unless mastery is continued.

4. Pharmacologically-assisted intubation is horse crap. Either do RSI or

don't. Giving an induction agent does not prevent the sympathetic

stimulation that accompanies intubation, which increases ICP, chances of

aspiration.

5. We are learning that some skills (such as IO infusions) are less needed

than once thought. Some time we must make a decision as to which skills a

paramedic will remain competent in and which will not. I probably did 60

neonatal circumcisions as a resident and have done none in 15 years. Should

I try on your baby or one of my family members? Probably not. I might do it

OK or I might forget a step. Same thing for prehospital skills.

The McSwain study I referenced about BVM usage versus ETI in New Orleans.

There is no evidence that the group who received ETI and the group that only

received BVM were well-matched. The ETI group may have been sicker (I would

suspect).

Research, research, research. Lee, don't shoot the messenger, Look at the

message. One paper, no big deal. Two papers with the same result? Huh. Three

papers with the same result? We really have to look into this.

E. Bledsoe, DO, FACEP

Midlothian, TX