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RSA… I do not know if I like this one

By •• Posted in SGA, Techniques, Trauma

Several posts in this site have dealt with controversies surrounding RSI. There are many unsolved issues (cric vs. no cric, ventilate vs. not ventilate, to use N.M relaxants outside the O.R vs. not use them, etc…) the truth is that more questions than answers exist. But how about this new concept coined in 2007 by E.D’s and paramedics during rescue operations. I hope to hear your comments (any comments).

Prehospital Airway (RSA)

5 Responses to “RSA… I do not know if I like this one”

  1. Felipe Urdaneta says:

    I understand them needing to get some sort of airway, and if they think they can’t get an ETT, then an LMA/combitube is better than nothing, but why did they give a paralytic if they were just going to put in an LMA? And then they didn’t give any sedation after paralyzing the patient w/ rocuronium- yikes. 🙁 If they opt to not intubate and just to place an LMA, why give roc?
    RG (U of F)

  2. Felipe Urdaneta says:

    I agree with you. I am not completely crazy about their idea either, but some members of SAM loved it!

  3. Dietrich Gravenstein says:

    This is certainly interesting. The authors describe some of the weaknesses – unsecured airway and lower leak pressures. They also make the point that LMA is where one would end up if unable to intubate anyway. But I did not see one compelling argument for the use of relaxants with SGA I had expected – namely that in addition to improving ease of insertion, it also favorably decreases ventilation pressures. This would be an admirable goal if concerned about pneumo or other airway disruption. It also may reduce the chance of stomach insufflation, regurgitation and aspiration – a significant objective in the trauma patient. I was astonished (don’t quite believe)that they have had no regurge/aspiration events with this technique – I would expect at least a few even if conventional intubation was done.

    Ultimately, I would echo other’s remarks : why not try to secure the airway definitively if you have already given the meds? Unless the neck is compromised, the practioner’s skill is limited, or some other barrier to performing a safe intubation exists, I would think intubation is the prefered result. Maybe they should incorporate an Airtraq into their algorithm?

  4. Dietrich Gravenstein says:

    You know, this has continued to bother me. Maybe the RSA is not such a bad idea. The data I am sure exist, but I don’t know if I would trust them – I wonder what is the incidence of arrival in ED with an esophageal intubation? I would bet it is in the whole numbers range. If so, what is the incidence of regurgitation-aspiration with a SGA? That is one relevant factor in considering the appropriateness of RSA. Another might be what is the incidence of “inadequate” ventilation – as measured by CO2 over some threshold number … maybe 60 Torr. It may just be that neither inadequate ventilation nor regurg/aspiration are as significant as is the incidence of esophageal or failed intubation when emergency transportation times are short.

  5. Felipe Urdaneta says:

    Excellent points. If you look at the recent study published from the Ryder trauma center in Miami there where 30% FI’s in the field with 12% EI’s; then in a metaanalysis of neurologic trauma there was no clear consensus that intubating -or rather- attempting to intubate in the field is better, than to place LMA’s or Mask ventilate. I am adding these two articles plus an editorial on this topic to the classic article section for everyone to review. Look for them in a section called field airway management.


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