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Capnography Flatline Beats Gestalt for Paralysis in RSI

November 16, 2017

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Using loss of wave capnography rather than gestalt assessment of relaxation after paralytic administration for RSI in the ED led to shorter time to intubation and increased first-pass success.

Why does this matter?
It can be hard to tell when a patient is adequately paralyzed for RSI.  Your best look is your first look.  The more attempts at intubation, the more complications.  But taking too long before starting increases the risk of desaturation.  Allowing sufficient time for paralysis is important, but what is the best measure – loss of blink reflex, mandible relaxation, fasciculations, subjective arm floppiness?  What about wave capnography (WC – not water closet) as a measure of apnea?

Are we there yet?
This was a prospective pilot study, a convenience sample of 100 consecutive intubations in the ED – 50 with WC and 50 without – chosen in an alternating fashion.  Paralysis was determined on WC by flatline for 10 seconds.  Those with WC were intubated 20 seconds faster and had 4% higher first-pass success than the gestalt group.  From my vantage point, what is the downside?  I think I will start doing this on my next shift.

Waveform capnography: an alternative to physician gestalt in determining optimal intubating conditions after administration of paralytic agents.  Emerg Med J. 2017 Oct 10. pii: emermed-2017-206922. doi: 10.1136/emermed-2017-206922. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

What are your thoughts?