The effect of paramedic rapid sequence intubation on outcome in trauma patients

Abstract

Study objectives: The objective of this study is to evaluate the effect of paramedic rapid sequence intubation (RSI) on trauma patient outcome.Methods: Consecutive major trauma patients were prospectively enrolled in 2 phases, the first before and the second after the implementation of a paramedic RSI program. Paramedics with experience in this mixed suburban and rural emergency medical services (EMS) system were eligible for RSI training. RSI training consisted of 6 hours of didactic and mannequin training. Operating room intubation experience is required for oral intubation clearance in the system but is not used for RSI training. All trauma patients with a Glasgow Coma Scale (GCS) score between 3 and 8 and for whom resuscitation was indicated were eligible for inclusion. Exclusion criteria included death in the field or ED and inability to obtain outcome information. For both phases, intubation was indicated for trauma patients with a GCS score of 3 to 8. For phase 2, oral intubation was attempted for all patients before RSI. Etomidate and succinylcholine were administered for RSI. RSI was not attempted for patients for whom the alternative airways, esophageal-tracheal twin-lumen airway device (Combitube), cricothyrotomy, or bag-valve-mask ventilation was judged not feasible. The Combitube was used as the primary salvage airway device. Method of airway control, intubation success rates, and survival to hospital discharge were determined.Results: There were 134 patients with outcomes in phase 1: 19 of 21 (90.5%) in arrest at presentation had a definitive airway established, and 19 had additional exclusion criteria, leaving 94 for analysis. There were 386 patients with outcomes in phase 2: 85 of 94 (90.4%) in arrest at presentation had a definitive airway established, and 65 had additional exclusion criteria, leaving 227 for analysis. The oral intubation success rate was improved for phase 2 study versus phase 1 control patients (53.3% versus 14.9%); total definitive airway rate was also greater (59.5% versus 40.4%). RSI was used in 112 patients; 11 were excluded. Oral intubation success for RSI patients was 87.5%; 91.1% had definitive airways established. Survival for patients with oral intubation without RSI was similar for both phases (42.4% versus 42.9%). Survival for study patients was improved during phase 2 (78.0% versus 67.3%). Survival for study RSI patients was 85.1%.Conclusion: EMS protocols for paramedic RSI resulted in improved intubation success rates and improved survival to hospital discharge.