What Are The Benefits Of Rapid Sequence Intubation
Benefits vs. the risks of rapid sequence intubation in the pre-hospital environment:
Rapid sequence intubation is a very risky procedure even in a stable environment, but when the unknown variables in the pre-hospital environment are considered, this procedure becomes more criticized every time it is used. When initiating the rapid sequence intubation protocol, the paramedic takes total control over the patient’s airway by sedating the patient with paralytic drugs and placing a breathing tube into the patient’s trachea. When evaluating the risks versus the benefits of an endotracheal tube insertion in the pre-hospital environment, paramedics must make split second decisions since the patient’s life depends on the paramedic’s knowledge and skills. If the paramedic’s attempt to intubate was unsuccessful, then he or she must be able to devise another plan of …show more content…
action, or the patient will ultimately die due to suffocation.
The authors attempt to prove the few advantages that goes along with the list of disadvantages concerning the use of rapid sequence intubation. Rapid sequence intubation is a widely controversial topic that has done more harm than good in most cases while contributing to the deaths of hundreds of patients every year. This type of airway management will be examined by weighing the risks versus the benefits of this critical procedure in the field.
In the pre-hospital environment, rapid sequence intubation can be useful as long as the procedure is accomplished in a timely and accurate manner. If the patient’s airway is becoming compromised, rapid sequence intubation is necessary to maintain a patent airway. When the patient’s airway becomes compromised, oxygen is not able to travel into the
lungs and suffocation occurs. According to Wang et al, “A study concluded that out of 496 severely ill trauma patients, every person was intubated and people who had a Glasgow coma scale of eight or higher had a higher post-hospital recovery rate than people who was not able to be intubated.” Rapid sequence intubation is indicated when there is reasonable suspicion that the patient’s airway will fail at any given moment due to injury or illness. Rapid sequence intubation is indicated in cases such as impending anaphylactic shock and trauma to the head or neck. Without this procedure, many lives would have been lost due to the patients’ airway to become obstructed by swelling or a foreign body. Per Wang et al, “With the use of sedative and paralytic drugs like etomidate and succinylcholine, the success rate for a rapid sequence intubation in the field stands at a remarkable 84% success rate.” Another benefit for a rapid sequence intubation over a King LT tube is that the endotracheal tube from the intubation kit is small enough to pass through the trachea. When the paramedic properly seats the tube inside of the trachea, the patient is getting 100% pure oxygen into their lungs. Russi et al states, “In the grand scheme of things, the rapid sequence intubation procedure is better at getting pure oxygen to the patient’s lungs than the King LT tube since the King LT tube can cause gastric distension.” When gastric distension occurs, the oxygen that is supposed to go into the lungs is going into the stomach, causing a bulging appearance of the abdomen.
Rapid sequence intubation is a risky procedure that has many negative connotations associated with it. There have been several agencies in North Carolina, including Stanly County EMS, whom have abandoned this risky procedure due to the liability and effectiveness in the pre-hospital environment. Primarily, the main reason for the heightened criticism of Rapid sequence intubations stems from inadequately pre-oxygenating the patient before intubation. According to Davis et al, “Studies have shown that if the patient’s oxygen saturation in their blood is not above 90%, then the patient’s oxygen levels will start to tank when the paramedic starts the intubation procedure.” On the other hand, even if the patient has been pre-oxygenated before the paramedic starts the intubation, the paramedic could have a hard time sticking the endotracheal tube into the patient’s trachea. Since the patient cannot breathe on his or her own since they were paralyzed with potent drugs, the paramedic has just caused the patient’s brain to become depleted of oxygen. This turn of events could prove fatal for the patient.
Another grave risk associated with rapid sequence intubations is that the patient’s blood pressure and heart rate could crash on the paramedic if the endoscope blade would happen to hit the vagus nerve in the back of the throat. In theory, if the patient is hypotensive, then the paramedic should avoid rapid sequence intubations, but if the paramedic had already started the procedure, he or she must continue with the intubation, or the patient will surely die. Davis et al states, “By increasing the duration of safe apnea times, providers have more time to achieve ET intubation and potentially manage the difficult airway.” In time critical situations, paramedics will likely place a King LT tube over a endotracheal tube for rapid sequence intubation because the King LT tube is much faster to place and it offers almost the same amount of oxygen into the lungs.
In a rapid sequence intubation, the paramedic will administer a sedative and a paralytic. Usually, etomidate is the sedative of choice, followed by succinylcholine as the paralytic. These narcotics will be used to make it easier for the paramedic to gain access of the patient’s respiratory drive. Other drugs can be used to substitute or in addition to etomidate and succinylcholine. Midazolam can be used in place of etomidate if it is not available. Likewise, rocuronium can be substituted for succinylcholine if it is not available. While performing a rapid sequence intubation, the paramedic must assure he or she has the right dosage for the drugs of choice in the intubation. Per Swanson et al, “In a six-year testing period, midazolam was shown to cause hypotension in patients because the drug was under dosed on many occasions.” Throughout many different studies, doctors chose etomidate over midazolam because etomidate was the most hemodynamically stable drug between the two sedatives. Per Swanson et al, “The study also concluded that etomidate could also decrease intracranial pressure within the skull.” Etomidate has been studied for many years resulting in an abundance of knowledge about that specific drug, but midazolam has not been through the testing that etomidate has. Even though there is not much scientific evidence supporting the usage of midazolam as a substitute for etomidate, midazolam is still considered the go-to drug when etomidate is not available.
Over the years, many doctors have questioned the success rate of rapid sequence intubation. One question the doctors ask themselves, “Is this procedure benefitting the general population, or is this risky procedure just a waste of our time?” Over the past ten years, rapid sequence intubation has been a hot topic in the field of Emergency Medical Services. Per Wang et al, “The improvement of rapid sequence intubation success rates has depended on pharmacologically assisted endotracheal intubation. In a study completed by San Diego EMS, the success rate of children from eleven month to fifteen years was an astounding 97.6% over the course of a five-year period.” In adults, the success rate is drastically reduced due to difficulties accessing the airway, and different disease which changes the landscape of the pharynx. Wang et al states, “In a different study in Delaware, the adult success rate of a rapid sequence intubation with etomidate was 62.5%.” This drastic decline in the success rate has provoked many EMS services to rethink their stance on rapid sequence intubation, and determining if it is a liability that the EMS service can withstand.
In the pre-hospital environment, rapid sequence intubation has many risks associated with a little reward in an unstable environment. With that being said, is rapid sequence intubation needed in a field with a copious number of unknown variables? Stanly County EMS has abandoned the rapid sequence intubation procedure as of November, 2016 due to a miscalculation of a drug resulting in the death of a patient. When doctors and other medical staff has reviewed the long-term results, the safest bet would be to leave the intubation part to the doctors in the hospital where they can perform the procedure in a stable environment. “The factors that impede prehospital endotracheal intubation are not fully understood, and it is currently difficult to assess whether prehospital rapid sequence intubation would address these shortcomings” (Wang et al). In general, rapid sequence intubation can prove to be a good tool in the mental toolbox, but if something goes wrong, the paramedic better come up with a good explanation and an even better lawyer.
In some cases, rapid sequence intubation has been beneficial for patients, but most patients have not been so lucky. Due to human error or natural conditions, many lives have been lost when trying to accomplish this tricky procedure. Throughout the research and statistics, the numbers show that rapid sequence intubation should be left to the doctors in the hospital. Since only less than two-thirds of individuals surviving an endotracheal intubation in the pre-hospital environment, the doctors are pushing for a change in the protocols throughout the country. Even something as simple as a King LT airway could have saved precious seconds when dealing with the limbo between life and death.
Rapid sequence intubation is a very risky procedure even in a stable environment, but when the unknown variables in the pre-hospital environment are considered, this procedure becomes more criticized every time it is used. When initiating the rapid sequence intubation protocol, the paramedic takes total control over the patient’s airway by sedating the patient with paralytic drugs and placing a breathing tube into the patient’s trachea. When evaluating the risks versus the benefits of an endotracheal tube insertion in the pre-hospital environment, paramedics must make split second decisions since the patient’s life depends on the paramedic’s knowledge and skills. If the paramedic’s attempt to intubate was unsuccessful, then he or she must be able to devise another plan of …show more content…
action, or the patient will ultimately die due to suffocation.
The authors attempt to prove the few advantages that goes along with the list of disadvantages concerning the use of rapid sequence intubation. Rapid sequence intubation is a widely controversial topic that has done more harm than good in most cases while contributing to the deaths of hundreds of patients every year. This type of airway management will be examined by weighing the risks versus the benefits of this critical procedure in the field.
In the pre-hospital environment, rapid sequence intubation can be useful as long as the procedure is accomplished in a timely and accurate manner. If the patient’s airway is becoming compromised, rapid sequence intubation is necessary to maintain a patent airway. When the patient’s airway becomes compromised, oxygen is not able to travel into the
lungs and suffocation occurs. According to Wang et al, “A study concluded that out of 496 severely ill trauma patients, every person was intubated and people who had a Glasgow coma scale of eight or higher had a higher post-hospital recovery rate than people who was not able to be intubated.” Rapid sequence intubation is indicated when there is reasonable suspicion that the patient’s airway will fail at any given moment due to injury or illness. Rapid sequence intubation is indicated in cases such as impending anaphylactic shock and trauma to the head or neck. Without this procedure, many lives would have been lost due to the patients’ airway to become obstructed by swelling or a foreign body. Per Wang et al, “With the use of sedative and paralytic drugs like etomidate and succinylcholine, the success rate for a rapid sequence intubation in the field stands at a remarkable 84% success rate.” Another benefit for a rapid sequence intubation over a King LT tube is that the endotracheal tube from the intubation kit is small enough to pass through the trachea. When the paramedic properly seats the tube inside of the trachea, the patient is getting 100% pure oxygen into their lungs. Russi et al states, “In the grand scheme of things, the rapid sequence intubation procedure is better at getting pure oxygen to the patient’s lungs than the King LT tube since the King LT tube can cause gastric distension.” When gastric distension occurs, the oxygen that is supposed to go into the lungs is going into the stomach, causing a bulging appearance of the abdomen.
Rapid sequence intubation is a risky procedure that has many negative connotations associated with it. There have been several agencies in North Carolina, including Stanly County EMS, whom have abandoned this risky procedure due to the liability and effectiveness in the pre-hospital environment. Primarily, the main reason for the heightened criticism of Rapid sequence intubations stems from inadequately pre-oxygenating the patient before intubation. According to Davis et al, “Studies have shown that if the patient’s oxygen saturation in their blood is not above 90%, then the patient’s oxygen levels will start to tank when the paramedic starts the intubation procedure.” On the other hand, even if the patient has been pre-oxygenated before the paramedic starts the intubation, the paramedic could have a hard time sticking the endotracheal tube into the patient’s trachea. Since the patient cannot breathe on his or her own since they were paralyzed with potent drugs, the paramedic has just caused the patient’s brain to become depleted of oxygen. This turn of events could prove fatal for the patient.
Another grave risk associated with rapid sequence intubations is that the patient’s blood pressure and heart rate could crash on the paramedic if the endoscope blade would happen to hit the vagus nerve in the back of the throat. In theory, if the patient is hypotensive, then the paramedic should avoid rapid sequence intubations, but if the paramedic had already started the procedure, he or she must continue with the intubation, or the patient will surely die. Davis et al states, “By increasing the duration of safe apnea times, providers have more time to achieve ET intubation and potentially manage the difficult airway.” In time critical situations, paramedics will likely place a King LT tube over a endotracheal tube for rapid sequence intubation because the King LT tube is much faster to place and it offers almost the same amount of oxygen into the lungs.
In a rapid sequence intubation, the paramedic will administer a sedative and a paralytic. Usually, etomidate is the sedative of choice, followed by succinylcholine as the paralytic. These narcotics will be used to make it easier for the paramedic to gain access of the patient’s respiratory drive. Other drugs can be used to substitute or in addition to etomidate and succinylcholine. Midazolam can be used in place of etomidate if it is not available. Likewise, rocuronium can be substituted for succinylcholine if it is not available. While performing a rapid sequence intubation, the paramedic must assure he or she has the right dosage for the drugs of choice in the intubation. Per Swanson et al, “In a six-year testing period, midazolam was shown to cause hypotension in patients because the drug was under dosed on many occasions.” Throughout many different studies, doctors chose etomidate over midazolam because etomidate was the most hemodynamically stable drug between the two sedatives. Per Swanson et al, “The study also concluded that etomidate could also decrease intracranial pressure within the skull.” Etomidate has been studied for many years resulting in an abundance of knowledge about that specific drug, but midazolam has not been through the testing that etomidate has. Even though there is not much scientific evidence supporting the usage of midazolam as a substitute for etomidate, midazolam is still considered the go-to drug when etomidate is not available.
Over the years, many doctors have questioned the success rate of rapid sequence intubation. One question the doctors ask themselves, “Is this procedure benefitting the general population, or is this risky procedure just a waste of our time?” Over the past ten years, rapid sequence intubation has been a hot topic in the field of Emergency Medical Services. Per Wang et al, “The improvement of rapid sequence intubation success rates has depended on pharmacologically assisted endotracheal intubation. In a study completed by San Diego EMS, the success rate of children from eleven month to fifteen years was an astounding 97.6% over the course of a five-year period.” In adults, the success rate is drastically reduced due to difficulties accessing the airway, and different disease which changes the landscape of the pharynx. Wang et al states, “In a different study in Delaware, the adult success rate of a rapid sequence intubation with etomidate was 62.5%.” This drastic decline in the success rate has provoked many EMS services to rethink their stance on rapid sequence intubation, and determining if it is a liability that the EMS service can withstand.
In the pre-hospital environment, rapid sequence intubation has many risks associated with a little reward in an unstable environment. With that being said, is rapid sequence intubation needed in a field with a copious number of unknown variables? Stanly County EMS has abandoned the rapid sequence intubation procedure as of November, 2016 due to a miscalculation of a drug resulting in the death of a patient. When doctors and other medical staff has reviewed the long-term results, the safest bet would be to leave the intubation part to the doctors in the hospital where they can perform the procedure in a stable environment. “The factors that impede prehospital endotracheal intubation are not fully understood, and it is currently difficult to assess whether prehospital rapid sequence intubation would address these shortcomings” (Wang et al). In general, rapid sequence intubation can prove to be a good tool in the mental toolbox, but if something goes wrong, the paramedic better come up with a good explanation and an even better lawyer.
In some cases, rapid sequence intubation has been beneficial for patients, but most patients have not been so lucky. Due to human error or natural conditions, many lives have been lost when trying to accomplish this tricky procedure. Throughout the research and statistics, the numbers show that rapid sequence intubation should be left to the doctors in the hospital. Since only less than two-thirds of individuals surviving an endotracheal intubation in the pre-hospital environment, the doctors are pushing for a change in the protocols throughout the country. Even something as simple as a King LT airway could have saved precious seconds when dealing with the limbo between life and death.