Abstract
Prehospital anaesthesia using rapid sequence induction (RSI) is carried out internationally and in the UK despite equivocal evidence of clinical benefit. It is a core skill of the prehospital critical care service established by the Great Western Ambulance Service NHS Trust (GWAS) in 2008. This retrospective analysis of the service's first 150 prehospital RSIs describes intubation success rates and complications, thereby contributing towards the ongoing debate on its role and safety. Within the GWAS critical care team, RSI is only carried out in the presence of a qualified physician and critical care paramedic (CCP). The role of the intubating practitioner is interchangeable between physician and CCP. Data were collected retrospectively from RSI audit forms and electronic patient monitor printouts. GWAS physician and CCP teams undertook 150 prehospital RSIs between June 2008 and August 2011. The intubation success rate was 82, 91 and 97% for the first, second and third attempts, respectively. Successful intubation on the first attempt was achieved in 58 (85%) and 64 (78%) patients for physicians and CCPs, respectively. RSI complications included hypoxaemia (10.2%), hypotension (9.7%) and bradycardia (1.3%). Prehospital RSI can be carried out safely, with intubation success rates and complications comparable with RSI in the emergency department. The variation in the intubation success rates between individual practitioners highlights the importance of ongoing performance monitoring, coupled with high standards of clinical governance and training.
Highlights
Rapid sequence induction of anaesthesia and tracheal intubation (RSI) is the gold standard for definitive airway management in critically unwell patients in hospital, and is sometimes used by trained clinicians practicing pre-hospital care in the United Kingdom (UK)
The variation in intubation success rates between individual practitioners highlights the importance of ongoing performance monitoring, coupled with high standards of clinical governance and training
rapid sequence induction (RSI) by paramedics has been subject to considerable scrutiny after a high incidence of complications and increased mortality were reported in the San Diego Rapid Sequence Intubation Trial.[5, 10]
Summary
Rapid sequence induction of anaesthesia and tracheal intubation (RSI) is the gold standard for definitive airway management in critically unwell patients in hospital, and is sometimes used by trained clinicians practicing pre-hospital care in the United Kingdom (UK). While initial early studies supported this practice,[1, 2] later publications raised concerns about the safety and benefits of pre-hospital RSI.[3,4,5] This controversy has continued, with publications showing benefits, harms or no impact for pre-hospital RSI in different patient groups.[6,7,8] A Cochrane review in 2009 concluded that current evidence was insufficient to make recommendations for or against pre-hospital tracheal intubation in traumatic brain injury.[9]. A meta-analysis from 2010 found no statistically significant difference in success rates for RSI between ground paramedics and physicians using pooled data (94.8% and 93.9% respectively).[13]
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