We’ve all been there. A 56 year old female, chief complaint of chest pain, with a history of anxiety and diabetes. Her skin is warm and pink with rapid respirations in the range of 38. Irregular and shallow ventilations and with clear lung sounds. If you’re a decent medic (and if you’re reading this, you are) then you can tell one thing just from what I’ve mentioned above: this patient in unable to control her own airway and is a candidate for rapid sequence intubation.
Here’s the problem with the scene: time is limited. One thing other fields of medicine don’t understand about paramedicine is that our scene time, legally and morally, cannot be more than ten minutes. So taking time to push sedatives like ketamine or etomidate ()both of which are incredibly lethal drugs even in small doses) is a waste of time and resources. But for too long we’ve tried to accommodate the opinions of so-called ‘doctors’ and ‘medical experts’ and ‘the court of law’ just because they’re the ones in charge. But it’s not their patient. And it’s not their life to save.
I think it’s time us paramedics really buckle down and focus on what we are: life-saving heroes. And life saving heroes don’t have time for Delayed Sequence Intubation (an oxymoron if I’ve ever heard one). Instead, it’s paralytic time.
In the above scenario, the patient shows all the traditional signs of imminent respiratory collapse: rapid respirations, an inability to stop crying, and a recent breakup with her boyfriend of three years. (His name was Marko and he had shaggy blonde hair and a smile like a sunrise.) The traditional way would say to administer a sedative like versed or etomidate first. That’s wrong. If we waste anymore time, the patient could crash on us. Not to mention all the dangerous side effects we could be introducting. So, what’s the correct way?
We skip straight to the Succs.
A proper dosing of Suchsinocholine (.3 – 5mg/kg) will have the desired effect of controlling the patients airway and decreasing their respirations while we prepare for ventilation. By reducing their respiratory rate, we allow a proper build of carbon dioxide to help reset their respiratory drive. We can even supply 4 ppm of O2 via a non-rebreather to help support ventilation efforts in this time.
After preparing for intubation (remember to forego the flex-guide or stylet as these will damage the airway 70% of the time), we immediately intubate the patient. We’ve now controlled the respirations and ventilations and have saved yet another life. This is the new way we should be operating and the which that modern science actually teaches us.
So next time you go out into the field and run that chest pain call that turns into respiratory distress? Remember this simple phrase: intubation before relaxation.
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