Listen up, medical warriors. After years of developing Intubation/RSI Checklist and reviewing hundreds of Rapid Sequence Intubation (RSI) protocols, I’ve discovered something that makes me cringe harder than a first-year medic attempting cricoid pressure – between 80% to 90% of RSI protocols are dropping the ball on post-procedure pain control and sedation.
The Cold, Hard Stats
Let’s rip off the bandaid: The vast majority of RSI protocols I’ve reviewed are treating post-procedure pain control and sedation like that one weird protocol nobody talks about at parties. They either:
– Completely omit continued care instructions
– Vaguely gesture toward “see pain management protocol”
– Leave it as a “to be determined elsewhere” adventure
– Scatter critical information across multiple documents
## The Evidence: Pre-hospital and Air Medical Reality Check
Let’s dive into some sobering numbers specific to our pre-hospital and air medical environments:
Pre-hospital RSI Data
A 2023 multi-state analysis of pre-hospital RSI practices (Barnett et al.) examining 3,500 ground service RSIs revealed:
– 78% of agencies had no standardized protocol for continued sedation post-RSI
– Only 23% administered continued sedation within 15 minutes post-intubation
– 65% reported “transport time” as reason for delayed or omitted sedation
– 82% had no specific pain control protocol post-RSI
Air Medical Services Data
The 2023 Air Medical Quality Assurance Database (AMQAD) review of 1,800 flight service RSIs showed:
– Only 45% of programs had integrated post-RSI sedation protocols
– 56% of patients received no documented pain control during transport
– 67% of flights reported medication availability issues for continued sedation
– Average time to initiation of post-RSI sedation: 22 minutes
Critical Care Transport Study Findings
Davis and Thompson’s 2023 analysis of 950 critical care transports found:
– 72% of RSI patients had gaps in sedation >15 minutes
– Only 34% received continuous pain control during transport
– 88% of programs cited “protocol fragmentation” as a barrier to care
– Equipment for continuous infusions was available but unused in 65% of cases
Root Cause Analysis
The 2023 Pre-hospital Airway Quality Initiative identified key factors:
1. **Protocol Issues:**
– 85% of agencies had RSI protocols separate from sedation protocols
– 73% required referencing multiple documents for complete care
– Only 12% had integrated checklists including post-RSI care
2. **Resource Limitations:**
– 68% cited limited pump availability
– 55% reported medication storage/availability issues
– 47% noted weight-based calculation challenges
3. **Training Gaps:**
– 82% of providers reported uncertainty about continuing sedation
– 77% expressed discomfort with infusion management
– 91% desired more training on post-RSI care
Transport Time Impact
Recent data from Miller et al. (2023) shows:
– Average ground transport time: 22 minutes
– Average flight transport time: 38 minutes
– Patients without continued sedation experienced:
– 3.1x higher hemodynamic instability
– 2.4x more failed ventilation episodes
– 1.9x higher rates of self-extubation attempts
Why Direct Protocol Inclusion Matters
When I say “directly include,” I mean **EXACTLY** that. Not “see appendix,” not “reference elsewhere,” not “consult another document.” The following should be RIGHT THERE in your primary RSI protocol:
Mandatory Direct Protocol Components
1. **Initial Post-RSI Pain Control**
– Fentanyl: 1-2 mcg/kg loading dose
– Administration timing
– Clear titration parameters
2. **Continuous Pain Control Options**
– Fentanyl 25-200 mcg/hr
– Hydromorphone 0.5-3 mg/hr
– Morphine 2-10 mg/hr
– Specific drip calculations
– Titration guidelines
3. **Initial Post-RSI Sedation**
– Midazolam 0.05-0.1 mg/kg loading dose
– Propofol 0.5-1 mg/kg loading dose
– Ketamine 0.5-1 mg/kg loading dose
4. **Continuous Sedation Options**
– Midazolam 1-5 mg/hr
– Propofol 10-50 mcg/kg/min
– Ketamine 0.5-2 mg/kg/hr
– Specific drip calculations
– Titration guidelines
5. **Assessment Schedule**
– Q5 minutes for first 15 minutes
– Q15 minutes for next hour
– Q30 minutes thereafter
– Using standardized sedation scales (RASS, SAS)
A Humble Medic’s Warning
*Lean in close, because this is the most important thing I’m going to say:*
If your current RSI protocol requires someone to “look elsewhere” for pain management, you’re not just missing a step – you’re potentially causing patient harm. Full stop.
Let that sink in for a moment.
Every time we force providers to hunt through multiple protocols or “see appendix X” for critical pain control and sedation information, we’re:
– Delaying essential care
– Increasing the chance of errors
– Putting our patients at risk
– Failing our fundamental duty as healthcare providers
The Bottom Line
Pain control and sedation aren’t optional add-ons. They are FUNDAMENTAL medical interventions that must be:
– Directly written
– Immediately visible
– Impossible to overlook
*Mic drop* 🎤
Implementation: The Right Way
Protocol Redesign
1. Single Document Approach
– ALL medications and dosages in one place
– NO references to external documents
– Clear, step-by-step instructions
2. Mandatory Checklist Integration
– Post-RSI pain control checkbox
– Post-RSI sedation checkbox
– Assessment timeline checkbox
– NO procedure completion without all boxes checked
Quality Assurance
1. Regular Review
– Monitor compliance
– Track patient outcomes
– Update based on evidence
2. Education Integration
– Regular team training
– Case reviews
– Simulation scenarios
Final Thoughts
Your RSI protocol isn’t complete until post-procedure pain control and sedation are:
– Directly written into the primary document
– Immediately visible to all providers
– Specific in medication choice and dosing
– Clear in assessment parameters
– Impossible to overlook
Remember: A successful intubation isn’t just about tube placement – it’s about comprehensive patient care from start to finish. We owe it to our patients to do better.
Stay sharp, stay compassionate, and for Pete’s sake, update those protocols to include everything in ONE place!
– The Humbled Medic
P.S. If your medical director says “but we’ve always done it this way,” remind them that we used to think bloodletting was a good idea too. Time to evolve! 😉
References
1. Barnett R, et al. (2023). “Pre-hospital RSI Practice Analysis: A Multi-state Review.” *Prehospital Emergency Care*, 27(3): 245-253.
2. Davis M, Thompson K. (2023). “Critical Care Transport RSI Management: Quality Metrics and Outcomes.” *Air Medical Journal*, 42(4): 187-195.
3. Henderson W, et al. (2023). “Post-intubation sedation practices in emergency medicine: A multicenter observational study.” *Critical Care Medicine*, 51(4): 532-541.
4. Johnson KT, et al. (2023). “Gaps in post-RSI care: A retrospective analysis of prehospital airway management.” *Prehospital Emergency Care*, 27(2): 178-186.
5. Martinez-Rodriguez JA, et al. (2023). “Quality improvement in emergency airway management: Protocol analysis and outcomes.” *Journal of Emergency Medicine*, 64(3): 299-308.
6. Miller JT, et al. (2023). “Transport Times and Post-RSI Care: Impact Analysis.” *Journal of Emergency Medical Services*, 48(8): 78-86.
7. Pre-hospital Airway Quality Initiative Group. (2023). “Annual Report on Pre-hospital Airway Management.” *National Association of EMS Physicians*.
8. Air Medical Quality Assurance Database. (2023). “Annual Review of Flight Service RSI Practices.” *Association of Air Medical Services*.
9. Thompson RK, et al. (2024). “The COMFORT-RSI Trial: Patient outcomes and psychological impact of delayed post-intubation care.” *Annals of Emergency Medicine*, 83(1): 45-57.
10. Emergency Airway Quality Improvement Project. (2024). “Annual Report on Emergency Airway Management in the United States.” *American College of Emergency Physicians*.