Rapid Sequence Intubation

smcc360 · Aug 14, 2012

Hi, all. I'm looking for any knowledge anybody has about rapid sequence intubation by a paramedic/emergency room doctor.

In the scene I'm writing, a cold water drowning victim suffered laryngospasm until full cardiac arrest, and now well-equipped first responders are trying to save his life.

Would the laryngospasm persist after the heart stopped, or would the airway open back up? And would adrenaline be administered via trach tube, or IV?

Any general insight about the process would be much appreciated, too. Thanks.

taichiquan.panda · Aug 14, 2012

RSI

smcc360 said:
Hi, all. I'm looking for any knowledge anybody has about rapid sequence intubation by a paramedic/emergency room doctor.

In the scene I'm writing, a cold water drowning victim suffered laryngospasm until full cardiac arrest, and now well-equipped first responders are trying to save his life.

Would the laryngospasm persist after the heart stopped, or would the airway open back up? And would adrenaline be administered via trach tube, or IV?

Any general insight about the process would be much appreciated, too. Thanks.

As an ER nurse, I've participated in many RSI's. I've seen laryngospasm in cardiac arrest as well as profuse swelling from repeat intubation attempts, and have administered paralytics prior to further attempts. If intubation by normal methods can't be done, then a tracheatomy is performed. Haven't seen many of these, though, as paralytics are immediate acting and highly successful. So to answer your first question, depending on the amount of tracheal swelling involved from larygospasm and intubation attempts, I think it would be unlikely the airway would spontaneously re-open.

As for adrenaline (aka Epinephrine), that's a medication that is administered after intubation and alongside CPR, though it is used subcutaneously for anaphylaxis and as a nebulized breathing treatment for stridor in children. ACLS (Advanced Cardiac Life Support) guidelines allow for certain medications to be administered via trach, but dispersal and absorption of these meds are spotty at best. IV access needs to be obtained ASAP, usually large bore...if you can't get an IV, IO (intraosseous) access is advised.

Code situations...CPR, intubation, meds, etc, consist of specific algorithms set forth by the American Heart Association. Although each step in the algorithm is followed, these steps are also occurring simutaneously...hence the need for more than one responder. And any medication given without adequate CPR simply won't work...it has to circulate to be effective.

Didn't mean the post to be so lengthy, but I hope it helped. I've participated in numerous codes, some successful, others not so much. Incidentally, cold-water drowning victims have a higher success rate in code situations than warm-water drowning victims. The cold water decreases the cardiac workload. And new therapies include hypothermia treatment for some post-arrest victims.

Cheers!

smcc360 · Aug 14, 2012

That's perfect! Thank you very much. And I didn't find your post too lengthy--in fact, I'm about to pester you with more stupid questions!

For the paralytic, I have them administering succinylcholine. Is that accurate/up to date? And would that be via syringe, IV, or some other way?

And would CPR be done on a gurney? I can have them stick a backboard under him, if that's more realistic.

Thanks again. Your post is a huge help!

taichiquan.panda · Aug 14, 2012

Hey, no problem. I did ED/Trauma for 15 years, so write what you know, eh?

Yeah, Succ is up to date. We used Vecuromium, too. Typically, paralytics are given with a sedative like Etomidate or Propofol to keep someone under long enough to intubate then hook up the ventilator. Propofol or Versed drips are common, too. And meds are given IV or IO...gotta get it in the system quick. If a field IV isn't large enough, or, God forbid we get a code with no access, we find one ASAP. If the field paramedic can't obtain an IV, IO is their next step.

Also, when you push an IV med like Epi, Succ, etc, you have to immediately flush with 10-20mL normal saline for circulation.

Can do CPR on a gurney if a backboard is in place. No backboard? The floor or any other hard surface will do. Key point is hard surface, otherwise you're wasting the compressions.

Feel free to ask whatever. If I don't know the exact answer, I am friends with a few ED docs.

smcc360 · Aug 14, 2012

Again, many thanks. Hearing it from someone who's done it is a huge help.

taichiquan.panda · Aug 15, 2012

More than happy to help! Hit me up if you have any other questions.

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