Overview of EMS Facilitated Intubation Without Paralytics
Facilitated intubation is a medical procedure where a tube is inserted into the body using some form of sedative or anesthetic drug to help the process, but without the use of a muscle relaxant that temporarily paralyzes the patient. This is different from a procedure called rapid sequence intubation (RSI), where both a sedative and muscle relaxant are used. These procedures are done by emergency medical services throughout the country for various reasons.
In the United States, procedures for facilitated intubation, including the rules for performing them, vary from state to state and sometimes even between different emergency medical services within the same state. This includes both facilitated intubation that uses medication, and rapid sequence intubation. Recent research showed that of all the U.S. states, 35.3%, or roughly a third, have specific rules for facilitated intubation. Out of these states, only one had set rules for the type of facilitated intubation which uses sedation. The rest had protocols for facilitated intubation that use both a sedative and muscle relaxant. It’s harder to pin down exactly how frequently these different types of intubation are used at a local level, as that information has not been widely studied or reported. The choice between facilitated intubation and rapid sequence intubation usually depends on what the patient needs and what is safest in the given situation.
Anatomy and Physiology of EMS Facilitated Intubation Without Paralytics
Doctors need to check certain factors to see if putting a breathing tube down a patient’s throat (intubation) might be difficult. These factors include: having upper front teeth, a history of difficult intubation, a Mallampati score that is not 1, and a mouth that opens less than 4 cm. The Mallampati score is a simple test doctors use to predict how easy it will be to place a breathing tube. Your risk of having difficulties with intubation increases if more of these factors are present.
But even if a person’s Mallampati score looks normal, intubation can still be tough if there’s vomit or other objects in the airway, or if the person’s throat has been surgically altered. It’s also harder when the patient can’t help out, like if they’re really drowsy or in a critical condition. So doctors also need to directly see inside the mouth and check the outside of the throat to weigh the risks and benefits of different methods: inserting a breathing tube with the help of medication, rapidly shoving a breathing tube down the throat (rapid sequence intubation), or sticking with non-invasive ways of helping the patient breathe.
Why do People Need EMS Facilitated Intubation Without Paralytics
The National Association of Emergency Medical Service Physicians (NAEMSP), an organization that provides guidance on emergency medical procedures, has published a statement about the use of drugs to assist with intubation in the field. Intubation is a procedure that involves inserting a tube into a person’s windpipe to help them breathe.
The NAEMSP’s statement focuses on sedation-facilitated intubation. This is a type of intubation where medication is used to make a patient relaxed or sleepy, to facilitate the procedure. The organization advises that the same level of training and monitoring should be required for those performing this type of intubation as for those doing a kind of intubation known as rapid sequence intubation.
The NAEMSP also mentions that the drugs used to induce relaxation or sedation in patients for this kind of procedure are often used for other medical reasons by emergency medical services. For example, midazolam, a drug often used in intubation, is also used to treat seizures. Therefore, they recommend that training should highlight the importance of understanding how these drugs contribute to managing the airway during intubation.
When a Person Should Avoid EMS Facilitated Intubation Without Paralytics
The main reason why some medications cannot be used to aid in the process of placing a tube down someone’s throat (a process called intubation) is if the person is allergic to those medications. There could also be certain illnesses or health conditions a person has which make some drugs unsuitable. The National Association of EMS Physicians (NAEMSP) suggests not using medications such as benzodiazepines and opioids to induce sleep or relaxation for this procedure, because they might not be entirely safe. Etomidate, another medication, appears to be a safer choice, but more research is needed to confirm this.
Equipment used for EMS Facilitated Intubation Without Paralytics
Doctors handle different situations that involve managing a patient’s breathing or airway. For this, they use common equipment. One important piece of equipment is a tube that provides access to your veins (IV), which is used for giving sedatives (drugs to relax you) and, if needed, drugs to relax your muscles completely. They also use tools called oral and nasal airways, as well as a mask attached to a bag (BVM) and oxygen supply to help patients breathe. Additional tools include suction and a kit for placing a tube down the throat (intubation). This kit includes differently sized tubes (endotracheal tubes) and device types (Mac and Miller blades).
The doctor always plans for unexpected issues. So, they have extra materials ready. These materials might include IV fluids for patients whose blood pressure might drop too much due to sedative drugs (a condition known as hypotension). Doctors also have additional airway tools, like a laryngeal mask airway (LMA) or King tubes. These are used for patients who are challenging to intubate (have a tube placed down their throat).
How is EMS Facilitated Intubation Without Paralytics performed
When doctors need to insert a tube into a patient’s windpipe in emergency medical situations – a procedure known as intubation – they often use sedative drugs to help. In the U.S., one common approach is to use drugs like etomidate, midazolam, or ketamine. These are known as induction agents and they help to relax the patient and make the procedure easier.
Midazolam is a type of drug called a benzodiazepine. While it can be effective for this purpose, it does have drawbacks. For example, if too much of it is used, it can possibly lower blood pressure, which can be dangerous. Its effects can vary from person to person, and it doesn’t always work as quickly as doctors would like.
Etomidate may be a more reliable alternative to midazolam. Unlike midazolam, it generally does not lower blood pressure, and it typically has a more predictable sedating effect. However, studies haven’t shown etomidate to be more successful than midazolam for intubation. In fact, the success rate was found to be roughly equal for both drugs – 83% when either is used alone and 85% when both were used together. Another study found similar results – an 82% success rate with etomidate and 75% success rate with midazolam. However, etomidate can cause muscle jerking, a condition called myoclonus, but it’s not known how this might affect the success of intubation.
There are other drugs that can facilitate intubation, but we don’t know enough about them at this point. More research is needed to determine their effectiveness and safety.
Possible Complications of EMS Facilitated Intubation Without Paralytics
There isn’t a lot of information on how successful it is to use certain medicines to help with putting a tube down a person’s throat (known as intubation). Although some studies suggest this process can be successful anywhere from 67.5% to 85% of the time. But when doctors use a method called rapid sequence intubation, the success rates are usually higher. For example, in one study of air medical crews, the success rate jumped from 25% when only one medication was used to 92% when they added a muscle-relaxing drug. Similar results were found in studies conducted by anesthesiologists in operating rooms.
Furthermore, it’s generally safer to use rapid sequence intubation compared to medication-facilitated intubation, especially in an emergency room setting. In one study, researchers found more serious complications, like accidentally inhaling stomach contents, injuring the airway, or even death, when a muscle-relaxing drug wasn’t used. Those complications didn’t happen when they used rapid sequence intubation. The same study showed that there were fewer instances of multiple intubation attempts, accidentally inserting the tube into the esophagus, and situations where the provider couldn’t insert the tube when they used rapid sequence intubation compared to medication-facilitated intubation.
What Else Should I Know About EMS Facilitated Intubation Without Paralytics ?
Rapid sequence intubation is a commonly used procedure in emergency departments. It involves quickly placing a tube in someone’s windpipe (trachea) to secure their airway. In the United States, emergency medical service agencies use this method as well as medication-helped intubation.
The need for more research is acknowledged to guide whether rapid sequence intubation should be established as a standard practice during emergency care in settings outside hospitals, such as ambulance services. From the limited studies available so far, it appears that rapid sequence intubation might have a higher success rate compared to medication-assisted intubation when it comes to managing a patient’s breathing during an emergency.