Wednesday, August 29, 2007

Rapid Sequence Immobilization

Aided with adrenaline and substances yet unknown to us, the man flexed his substantial muscles and screamed against his bounds. He let out anguished yells, cursing at all of us as we worked to hold him down. He was a big man, and we were all sweating.

My partner and I found him semi-conscious in the grass of a local park about a half hour before. He was lethargic when we walked up to him, his eyes distant and glazed over in some kind of dreamy confusion. He lay about 10 feet away from a twisted-up bicycle from which witnesses said he fell while riding through the park. They said that they knew him personally, that he is a "great guy who is always here with his family." Someone said that he had a history of seizures.

My partner glanced in my direction, and we agreed without words. I put both of my hands up towards my neck and he nodded, heading towards the ambulance for c-spine equipment and the stretcher. I did a quick assessment while I waited for the rest of the gear. No visible traumatic injuries, lung sounds clear, strong radial pulse at about 100, PEARRL. Blood sugar is 200. When my partner came back with the equipment we worked together with firefighters to roll the large man onto the board, securing his head, torso, and legs with snug straps. My partner and I bent our legs and then straightened, grunting as we lifted the massive package up to the stretcher.

In the ambulance the man began to come around. He was confused still, asking repetitive questions and often making statements that made no sense. I did my best to get a history and some background information, but the man was a poor historian at best. I got a full set of vitals, plugged in the EKG, started an IV, and told my partner we could go. The man remained confused the whole way, and despite my reassessments and double checking, I found very little that swayed me from a routine clinical impression of postictal-related altered mental status.

The man began to get a little more agitated as we rolled down the ED hallways towards the triage desk. He lifted his hands up towards the c-collar, but I was able to gently guide his hands away and talk him down. He listened to my words, agreeing momentarily but again reaching towards his restrictions a minute later. I told the triage nurse that it was probably only a matter of time before the patient lost control and ripped himself off of the board. He had that look that we have all seen before: chaos about to happen.

It did happen. About 5 minutes after getting him over the hospital bed, the patient began to lose control. Quiet requests turned into agitated demands, and then into senseless screaming. He pulled his head out of the blocks, the tape snapping and velcro ripping, all the while pulling at the backboard straps and rolling from side to side. The nurses and techs tried to calm him down, offer comforting advice through smooth tones, but the patient would hear none of it. He was on a one-way path, and would not come back. My partner and I jumped in to help, and even with our numbers, we struggled.

The doc strolled in casually, his white jacket crisp and clean, separate from the mess that was rapidly overtaking the small ED room. He asked for the story, and I told him while holding the patient down: a few brief details and a couple questions answered. He tried a round of Haldol and Ativan but it was without effect, and after another 10 minutes of fighting, the doctor casually waved his hand towards the intubation tray. The nurses, anticipating this decision, already had everything ready.

Rocuronium was sent through my IV, and within seconds, the patient was flaccid and docile. It was as if someone had found the patient's OFF button and finally decided to throw the switch, ending almost instantaneously the aggression we had been fighting for the past 20 minutes. Easy as pie, the doctor slid a miller blade into the open mouth, lifted, and passed the tube. It was good, of course. Everything was good.

I met up with the doctor later. The toxicology reports had come back, which indicated that the patient had extremely high levels of PCP in his system. It looked like the patient had smoked some of the drug before his bike ride through the park, and collapsed when the effects hit their peak. The potential trauma was still an issue, but the patient was not. He lay across the hall, silent except for the sound of the mechanical respirator performing it's windy functions.

The doctor and I discussed the drug a little bit when I made a remark about RSI. I admitted that I was glad the patient was calm with me, because I wouldn't have been able to restrain him in the ambulance if he had lost control then. The doctor was shocked to hear that we didn't have the capability to RSI patients. He stared at me, as if I were joking.

"So basically," he said, "either the patient is dead, or you are not going to get the tube?"

I admitted that this was probably the case for much of the time.

The doc sat back in his seat, thinking for a second.

"Jeez. You're right. Good thing he didn't come 'round till you got him here."


Patrick said...

Please tell me that there are services in your area that do RSI, and you're just not lucky enough to be one of them. Or that he was a new guy? Because if there is no RSI in your region and this ED doc doesn't know that, it speaks poorly for how the EMS coordinator / region and the ED physicians interact.

Also, if you had felt compelled to intubate him, are you allowed any pharmacologic intervention?

fiznat said...

Patrick, there are a few services capable of RSI in the area, although to be honest I don't think that they bring patients to this hospital very often. Compound that with the rarity of RSI in itself, and I do doubt that this doctor has seen very many field RSI'ed patients come through his ED at all. He is not a new doc, but yes, perhaps a bit uninformed about our protocols.

We don't have a protocol to electively intubate patients for situations such as these, and I wouldn't expect it, but we do have a few medications that could have helped if the situation were different. We are allowed 5mg Haldol, 2mg Ativan IM for combative patients, and are given protocol for 5mg IV Versed POST intubation to keep patients from bucking tubes. Besides that, though, we have very little for sedation.

Ambulance Driver said...

I'm of mixed feelings about RSI.

I wrote the proposal that got RSI added to the paramedic scope of practice in Louisiana. I support it as a vital tool in the airway management toolbox.

I also realize that a large number of systems that practice RSI have no business doing so. Insufficient CQI and physician involvement, no use of waveform capnography, no backup supraglottic airways, no skills maintenance or refresher requirement, or just piss-poor BLS skills...all of them are integral components that need to be in place before an RSI program can be implemented.

Don't have all of those components in place, and you're asking for trouble.

Remember one thing above all else: A paralytic insures one thing and one thing only - that you will convert a patent or compromised airway into none at all.

Patrick said...

We do Drug Assisted Intubation with a choice of etomidate or midazolam as the initial agent, with V for post. It's dark ages compared to true RSI, but I mirror Ambulance Driver's sentiments about RSI, it's complications and problems.

Anonymous said...

I had a combative/confused patient on what sounded like a similar call to yours, bike and such. At that point in my field time for school my preceptor was mearly my backup, and I made the call to command for a trauma transport. Again, similar outcome with drugs on board and not an acutal head injury.

We only just got Etomidate in PA and in the once case I know it was used during my time was for a GSW to the head with the patient still partially alert if I recall right. We have strick rules on having two medics, medical command and such but for what its worth they got the tube.

RSI is a big issues to say the least.

Anonymous said...

as far as I'm concerned RSI stands for Really Stupid Idea. Why are paramedics making patients STOP breathing? There are very few cases I believe where this would be beneficial. If you can't get the tube just keep baggin em...

Blue Ridge Medic said...

I agree with AD on this one. There is a time and place for RSI, but only if it's your only viable option and your not doing it just to do it. My service does not have RSI at the moment, but we are looking into it yet again. I think that it is a good tool if the patient needs it and if not, it needs to stay in the box.


NYC EMS said...

That is why we work out in NYC EMS.I have used the short CPR board as a shield many times.I have had NYPD taser gun pt inside my ambulance.

PDXEMT said...

We have true RSI in my system and have had it for some time (etomidate and sux, with vec and versed as post-intubation options). We also have extensive use of end-tidal waveform CO2 (both awake on many pts, and on every intubated pt), Combitube and soon King LT airways as backup devices, and extensive QA/QI and refresher training. (Granted that I work in a fairly aggressive urban system with a high volume, etc -- I'm personally on track to get ten to twelve tubes this year, which is average.)

I think that RSI is an important part of the advanced airway toolkit, provided it is properly used. I see red every time someone calls it Really Stupid Idea -- you prefer to let that trauma or CVA patient aspirate blood or vomit on the way in, and die of aspiration pneumonia? I agree that it is critical to be able to bag a patient, because if you can't get the tube you need to be able to ventilate them. The only cases I've been on where our medics could not get the tube were ones where the ED doctor had extreme difficulty getting the tube as well.

I agree with the other folks in that you need to be careful as hell with RSI, and many times it's better to hold off. But there are patients who need an advanced airway now who have an intact gag, and ALS systems without RSI do that segment of the population a disservice.

Brendan said...

No RSI in my entire state, and I don't want it here. It's a long story, but it would be a freaking disaster. Pretty much every reason to NOT have RSI that ambulance_driver mentioned is in full effect here.

That said, by protocol we have the option of requesting MC clearance for a dose of Versed to facilitate intubation, and if the provider is smart they'll ask for Morphine as well.

Beyond that, there are very, very few places outside of the range of an ER where BLSing the airway isn't sufficient.

Anonymous said...

I am quite fond of the PCP patients I run. Quite a few of them. At least one person a week is high on PCP.

They present very unique management issues that I have not found with other intoxicants. Principal to this is the propensity towards extreme unpredictability and agitation. This makes them very interesting patients that almost always generate a really good story to share with coworkers. Plus, there is the overwhelming enjoyment of walking into an otherwise calm and quiet ER with a complete wrecking ball of a patient -- trays crashing around, staff panicked, security holding tasers and handcuffs, syringes of Geodon, etc..

Had a female patient who decided, for reasons unknown, to break into a business and remove all the light bulbs from lamps, and urinate on the floor. She was alert, oriented, but entirely inappropriate. GCS of 15. Patient stated she was in town on business. Worked for an airline company as a hired assassin to combat middle eastern terrorists. Had spent the night looking for a rental car.

Had a patient who was buying something at a convenience story. He stood starting at the chips for 40 minutes. Did not do anything except stare at the chips for 40 minutes. Patient was alert, but not oriented. Stated that the time was 8 pm, he'd been in the story for 5 minutes looking for beer. Time was actually 1 am. Patient could not remember his name, or describe events of the evening. Patient was coaxed into the ambulance and transport begun no sooner than the back doors clicked shut. Transport to the absolute closest hospital with me thinking, "Can I get out of this without getting punched?"

All PCP patients eventually go buck nuts crazy. It is not if, it is when. I have watched otherwise docile people fly into an insane rage. Talking to them has no effect. If anything, increasing any stimulation, noise, verbal, visual, seems to provoke intense reactions.

Restraints are frequently necessary. Unfortunately, there is often little warning for the outburst meaning that physical restraint is often the most expeditious option.

Until moving to a large city, I had no concept that someone would willingly ingest an animal anesthetic that was removed from the market specifically due to the horrible reactions it causes on both people and animals.

Back to the subject of airway management: Do you have the option for awake nasal intubation? This patient would not be a suitable candidate, since anyone who is alert but not cooperative cannot be easily intubated.

Not many services use nasal tubes any more, but those that do have strong adherents to nasal intubation.

Anonymous said...

One other comment I forgot to add. This comment thread has had some interesting comments regarding RSI. Several commenters have mentioned the utility of BLS airways in the prehospital setting.

What is forgotten, by me frequently, and many medics, is that dual purpose that intubation (regardless of how it is done): ventilation, and airway patency.

There are many patients who are perfectly capable of ventilating on their own. However, a patient who is profoundly intoxicated cannot protect their own airway, regardless of their ability to ventilate themselves.

Sometimes its easy: cardiac arrest patients. GCS 3 trauma patients. These patients need both airway protection and a patent airway to ensure adequate ventilation.

Where it gets tricky, and where RSI has a purpose if executed correctly, is to allow patients in that GCS 4-14 range to be intubated without causing a horrible physiological reaction or airway trauma that can result from a patient actively fighting oral or nasal intubation attempts.

The decision to intubate is probably one of the hardest decisions to make as a paramedic. It carries with it a number of consequences. Does the benefit to the patient outweigh the risk? Is it worth intubating this patient knowing that to do so will mean an extended ICU stay while pulmonary specialists fight to wean the patient of the vent?

But knowing that aspiration pneumonia resulting from a failure to protect an airway carries with it a mortality rate in the hospital of between 10 and 70% should also be a consideration. To have a patient survive several surgeries, multisystem trauma, or a failed suicide attempt, only to later die due to aspiration of gastric contents is not a good thing.

BLS airways have their role. Indeed all good care begins with BLS. However, even when done correctly, it is near impossible to avoid gastric distention due to use of a BVM. Bag mask ventilation is something exceedingly difficult since it is often just taken for granted how to do it. Very few people are truly proficient at it. I watch people use a BVM and have yet to see anyone other than an RT, or CRNA do it properly. This includes all manner of prehospital providers and first responders.

Extended use of BLS airways (other than the combitube) can contribute to the vomit fountain that often accompanies patients with an altered mental status.