I have followed the discussion of RSI with interest and would offer my opinion on two aspects. In the situation of anesthesia "frowning" on the use of SCH, I see it differently. When I intubate a patient, I want them "down and back" as soon as possible with a minimal effect on ICP. As ED patients, these chilren usually have evolving disease or injury processe which I want to be able to monitor and intervene for, whether the patient is in the CT scanner, having a procedure done or simply waiting to go to the PICU. If anesthesia is present and taking the patient directly to the OR, that's a different story. In that situation, use of a longer-acting NMB is entirely appropriate The paralyzed child cannot struggle if he/she becomes hypoxic or develoos an ET tube complication (not an uncommon situation in the ED patient who may need to be moved several times, has multiple care providers, and may have blood, secretions or debtis in their airway!). With paralysis, you are !
totally reliant on the pulse ox to monitor oxygenation but if the patient has had atropine, neither the pulse ox nor the pupil exam (for ICP) are reliable for 30 minutes .I am particularly uncomfortable paralyzing for long periods the child with seizures or the potential for seizures. I would rather see them sedated with a benzodiazepine and add Dilantin as needed. I also take the same view when preparing an intubated patient for transport .
For many ED intubations actual, or potential for increased ICP is a consideration and it is my understanding that this is the benefit of using a free-radical scavenger which also lower neuronal metabolic demand (like thiopental or etomidate). I feel comfortable with etomidate or thiopental for seation in this situation and the anesthesiologists in our institution prefer to use etomidate when they come to the ER to assist with an intubation. However I also teach pediatric residents RSI. When I talk to them, I tell them they may not do an RSI on full-stomach, non-neonate for five years but when ther do, potentially in a small, local hospital with an inexperienced staff, they will be exoected to have the same outcome as an anesthesiologist in a large, well-prepated OR. Hence, unless they'll be doing a lot of intubations in controlled settings, they should become familiar with the use of sedatives and paraltics that are widely available and familiar like SCh and thiopental.
>From: Jeffrey Mann <[log in to unmask]>
>To: Multiple recipients of list PED-EM-L <[log in to unmask]>
>Subject: Re: Etomidate-only RSI.
>Reply-To: Jeffrey Mann <[log in to unmask]>
>Date: Friday, March 05, 1999 2:46 PM
>Harvey and Jay - Thanks for your responses. I agree that the optimum
>conditions for RSI are created by the combination of general anesthetic
>(eg, thiopental or propofol or etomidate) + NM paralysing agent.
>I brought up the issue of 'etomidate-only' intubation because I came
>across a letter in the American Journal of Medicine (January 1998) on
>this subject, where the proponents of its use suggested that it was
>useful in the situation where the patient had a situation of antecedent
>hypoxia and/or cardiovascularly instability + ? abnormal upper airway
>anatomy with a "possible" difficult airway situation. The author
>suggested that etomidate-alone created sufficient muscle relaxation and
>depression of conciousness to create a good intubating-situation without
>having to paralyse the patient. I have personally never used etomidate
>so I did not know whether this recommendation was valid. I have read
>that etomidate causes myoclonus and I wondered whether it also
>occasionally caused bruxism => thereby actually increasing the
>difficulty with intubation.
>Jay - do you think that using rocuronium in the ED setting, where it is
>difficult to 100% anticipate a "difficult" airway and a "CVCI" (cannot
>ventilate-cannot intubate) situation, carries too great a risk - becuase
>it causes such a prolonged state of neuromuscular paralysis?
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