Case summary:

An ALS crew responded to a 70s woman who was unresponsive.  The crew arrived on scene and found the patient slouched in a chair and not responding to any stimulus (GCS 4).  The crew placed a nonrebreather on her .  She had dried vomit on her lips and face and had the following vitals:

Initial vitals: BP 188/134,  HR 113,  RR 8,  Sat 84% on 15L,  glucose 175

The crew noted failure to protect her airway and persistent hypoxia despite O2 supplementation, so they requested back up and planned for rapid sequence intubation (RSI).  While back up was on the way, they quickly extricated to the rig, continued to resuscitate the patient and prepared equipment for RSI.  The crew also mixed push dose epinephrine so that it could be given quickly if the patient became hypotensive. 

Vitals right before pushing RSI meds: BP 204/102,  HR 140,  RR 8,  Sat 99% on 15L, ETCO2 20 mmHg, GCS 4

Once the patient was optimized as much as possible and all equipment was ready based on our RSI checklist, the crew administered ketamine as the induction agent and rocuronium as the paralytic as a part of our RSI protocol.  The crew successfully placed the endotracheal tube on the first attempt and confirmed placement with waveform capnography.  The crew then proceeded to transport to the receiving facility.  At ~20 minutes after the induction dose of ketamine was administered, the crew gave another dose of ketamine to ensure that the patient remained sedated and never experienced paralysis without sedation.  The patient was handed off to the receiving hospital in stable condition. 

Highlights of the case:

Call for back up early

Critically ill patients often require more resources than are initially dispatched to the patient.  Once you realize that a patient might benefit from additional support, request this support as soon as possible.  If after initial care, it is determined that those additional resources are not needed, they can always be disregarded.  However, if those resources were never called for and things worsen, you cannot go back in time and call for back up earlier.  When in doubt, it is best to error on calling for back up early.  This crew found a critically ill patient that they felt would benefit from RSI.  They called for backup right away so as not to delay the care that she needed.

Preparation for intubation

Intubation is a dangerous time for the patient since tons of things can go wrong and we have very little time to address them if they do go wrong.  For this reason, we want to prepare as much as possible in advance.  This includes anticipating everything that can go wrong and preparing for these things.  Our RSI drug boxes have a laminated copy of our RSI check-list that lists all the things we need to have ready before we perform RSI.  This is also listed in our protocol, and we want to utilize this every time we intubate so that our intubation attempts go as smoothly as possible.  Part of preparation is resuscitating the patient as much as possible before we intubate as well as preparing for post intubation hypotension.  This crew had everything planned out and prepared in advance which made the intubation go as smoothly as possible.  In addition, the prepared push dose epinephrine prior to it being needed so that they could quickly administer it if the patient became significantly hypotensive.  While this patient did not need the push dose epi, the crew was ready for this high-risk patient.

Always remember to re-sedate patients when using longer acting paralytics

Paralysis without proper sedation is something we can never allow since it has been described of as torture by patients who have experienced it.  Some paralytics last longer than the sedative used as the induction agent.  That is the case for our system where ketamine is used as the induction agent and rocuronium is used as the sedative.  We selected rocuronium as our paralytic since it does not have the same contraindications that succinylcholine has.  Given that we often have little to no history on the patients that we RSI in the field which complicates determining if the contraindications to succinylcholine are present, our system felt that rocuronium was the safer paralytic to use.  The negative to rocuronium is that it lasts longer than the induction agent which can expose our patients to the real risk of paralysis without sedation.  Given that patients will be paralyzed for up to an hour after getting rocuronium, we cannot rely on movement or the usual signs for undersedation to determine if more sedative is needed.  Often, the only thing we will see is a sudden spike in HR or BP to indicate undersedation (or no sedation at all).  In order to prevent this, we should administer post intubation at the proper interval no matter what else is going on.  If the patient is hypotensive, we should treat the BP but we still need to administer the sedative.  Our system uses ketamine as the post-intubation sedation agent and we recommend redosing roughly every 20 minutes.  It is important to note that there might be a delay for the receiving facility to get their own sedation medications ready once the patient is handed off to them.  If it is getting close to when the patient needs to be re sedated and you are about to hand off the patient, we should consider giving another dose early to decrease the chance of not having active sedation right after transfer of care.  This crew remembered to re-dose ketamine every 20 minutes as well as made sure a dose was given just before transfer of care.