1. Thousand appologies to all paramedics who do not think they are better
in airway management than anesthesiologists. I have high respect for all
of you and have many paramedic friends. Over here we work as a team and do
our best for our small constituencies.
2. RSI is usualy indicated when intubation would otherwise be very
difficult- the child is fighting,biting and so forth.With very rare
exceptions, these patients DO NOT NEED TO BE INTUBATED!
In severe shock, hypotension, coma or code situation RSI is probably not
needed. Some pharmacological help could be helpful, e.g.IV midazolam.
3.I am scared to death to think of the situation when a child is paralyzed
in the field, under very difficult environmental and physical conditions,
where there is no help available, and the airway can not be secured!
4.I totally agree with Dr.Terndrup ( and I am teaching it daily to our
paramedics) that in most situations, including codes, bag/mask ventilation
can be adequately performed for 30-45 minutes providing good oxygen supply
if correct technique is used (the only contraindication I can think of is
severe facial trauma).
5.I have seen infants with the tube placed in the esophagus in the
field with the logical consequences afterwards.
Our ENT Surgeon performes cca 8-12 tracheal reconstruction every year for
children who got severe stenosis following traumatic (and often
unnecessary)intubation in the field.
6.I do not want to say that children should not be intubated by paramedics.
I am aware that ET intubation is the best way to control the airway and
provide oxygen supply. I just do not think RSI should be used in the
prehospital setting and I do think that by better instruction of proper
bag/mask techniques (and yes, IO line placements) we could provide much
better care for our small patients.
Assistant Clinical Professor
Valley Children's Hospital
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