A Comparison of Rapid-Sequence Intubation andEtomidate-Only Intubation in the Prehospital Air Medical Setting

Abstract

Objectives. To compare laryngoscopy conditions produced by etomidate-only intubation (EOI) with those produced by rapid-sequence intubation (RSI) in the prehospital air medical setting. Methods. A prospective crossover trial design used two helicopters staffed by the same flight paramedics andnurses. Each aircraft used an EOI protocol (0.3 mg/kg) for six months. An RSI protocol using the same dose of etomidate plus succinylcholine (1.5 mg/kg) was used for the alternate six months. Laryngoscopy conditions were graded by three scales: 1) a formal Laryngoscopy Grading Scale (LGS), 2) the Percentage of Glottic Opening (POGO) score, and3) subjective overall intubation difficulty using a Likert scale of 1 (very easy) to 5 (very difficult). Orotracheal intubation success was also recorded. Results. Forty-nine patients were intubated using the EOI (n = 24) andRSI (n = 25) protocols. Mean age was 38 years, 76% were male, and90% were intubated for trauma. Fifteen (63%) of the 24 EOI patients required additional etomidate (n = 3) or RSI (n = 12) to allow intubation, while one (4%) of the 25 RSI patients required additional medication dosing (p < 0.0001). Laryngoscopy conditions were assessed for all patients. Good or acceptable conditions as assessed by the LGS were seen in 79% of RSI patients and13% of EOI patients (p < 0.0001). Mean rates of POGO visualization were 60% with RSI and12% with EOI (p < 0.0001). Mean global intubation difficulty scores were 3.0 (moderate) with RSI and4.7 (difficult to very difficult) with EOI (p < 0.0001). Ninety-two percent of the patients undergoing RSI and25% of the EOI patients were successfully orotracheally intubated (p < 0.0001). Conclusions. Patients receiving RSI had better laryngoscopy conditions andwere easier to intubate than patients receiving EOI. Intubation success rate was higher with RSI.