AboutRonald Levy, M.D. Expertise Associate Professor of Anesthesiology, University of Texas Medical Branch at Galveston. I am a board certified anesthesiologist who can answer all questions related to any type of Anesthesia with the exception of Pain Management.
I'm not sure if this is an appropriate question for someone in this field or in emergency care but here goes. I work as a paramedic for a very busy, yet fairly rural EMS service which recently added RSI (rapid sequence induction) to our protocols, using it to replace our previously established PAI (pharmacological assisted intubation) standard. Previously we were allowed to administer versed and/or fentanyl to assist with intubation of patients that are nearly out, but not quite. Our current protocols now include the use of paralytics. However, the one thing that concerns me is the instructions that we were given regarding trauma patients and the use of sedation when they are paralyzed. Our protocols do not mention the continued use of sedation following intubation with paralytics, but does address continued use of the paralytics. I was always under the impression never to paralyze a patient without sedation, can you give me some reasoning for this? It is an issue I have addressed with our chief, who will present it to our medical director but we do not have an answer on this yet. It makes me hesistant to use it for two reasons, pt awareness during the use of paralytics as well as possible protocol deviation. Any insight you could give me for the reasoning behind this would be appreciated. Thank you.
Answer For the purpose of intubation you want to use an induction agent and succinylcholine (RSI). You don't use sedation at this point because if you can't intubate them, you want them to breathe and wake up so you can try something else. Once they are intubated you should sedate them (particularly if they are paralyzed) because you don't want a person paralyzed and awake. It is a frightening thing for the person. If the person is not paralyzed, then it is debatable but if they are paralyzed they should definitely be sedated.
Hope this answers your question,
Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston
