The state of Georgia has begun to consider Rapid Sequence Intubation for field level Paramedics. RSI has long been a tough topic to approach for many different reasons. Medical Directors are ultimately responsible for the well being of the patient. If a Paramedic gives inappropriate care to a patient, the Medical Director is left with all the liability. If the outcome of the care causes death, there is a possibility that he or she could loose their medical license.
Rapid Sequence Intubation requires everyone to be very cognitive of their skill level and mind set. When the Paramedic delivers the paralytic agents, the patient looses his or her respiratory drive and as a result they stop breathing. At this point, it is the Paramedics responsibility to to control the patient’s airway and to provide rescue ventilation via a Bag Valve Mask. The RSI medication allows the muscles in the oral pharynx to relax so that the medic can pass a breathing tube into the trachea.
This step listed above is the most critical element of the procedure. Should the medic cause damage to the mucosa membrane in the mouth the amount of bleeding could be tremendous. Blood in the mouth is a bad thing and not to mention that the fluid obstructs the airway. There should be a Medical EMS Protocol available that would allow the paramedic to perform Advanced Cardiac Life Support if the need should arise. The American Heart Association is the leading credentialing agency for ACLS.
Upon passing the endotracheal tube pass the vocal chords, the pilot balloon must be inflated to 10cc of air via a syringe. The additional staff on scene must listen for adequate breath sounds and listen for epigastric sounds as well. The end tidal co2 should be used as a diagnostic tool for successful intubation for confirmation. Capnography is new technology that detects the presence of exhaled co2 which indicates that the endotracheal tube has been placed properly.
Securing the tube in the correct position may be very challenging due to the anatomy of the patient’s oral pharynx. A commercial tube holder is available from most med supply vendors. While the tube is being secured, everyone must monitor the cardiac monitor to watch for ventricular fibrillation. Should the patient proceed into cardiac arrest, it is of the utmost importance the paramedic be trained in Pediatric Advanced Life Support in order to resuscitate the patient. As you can see as you read this article, RSI requires many elements to work correctly for a positive patient outcome. The risk versus benefit must be in favor of the RSI protocol prior to initiating the protocol.
The American Heart Association provides excellent information for medical staff to study. Although, the Medical Directors are still reluctant to release Paramedics to begin the RSI protocol. Should we see a change in the future, I believe Baltimore Maryland will be the first city to implement measures. For more information on this topic please visit your local EMS service in your community.