Prehospital Rapid Sequence Induction Research Articles

Pre-hospital rapid sequence induction by paramedics: A scoping review

Background: There is conflict in the literature addressing the role of paramedics in the outcomes and potential complications of rapid sequence induction (RSI) in pre-hospital settings. Objective: This review aims to describe the common indications, complications, anesthetic agents, and success rate of RSI, as performed by paramedics at a pre-hospital setting. Method: This scoping review utilized the PRISMA® flow diagram to guide the literature searching process across multiple resources. MEDLINE, Google Scholar, and PubMed search engines were accessed and searched for related articles using different combinations of keywords. The quality of the selected articles was assessed via the critical appraisal skills program. Results: Twenty-seven articles were included in this review. The main indication of RSI was the loss of consciousness due to different physical disorders. Potential complications include hypoxia, hypotension, and hypo-/hypercapnia. Anesthetic agents ketamine and succinylcholine were extensively used. Success rates of RSI, if performed by paramedics, ranged from 45% to 92%. Conclusion: Endotracheal intubation (ETI) with RSI has various indications and sedative agents that, if used appropriately, increase the victim’s survival rates. Also, ETI with RSI is associated with several complications and challenges that affect the success rate, especially for the first intubation attempt.

Haemodynamic effects of a prehospital emergency anaesthesia protocol consisting of fentanyl, ketamine and rocuronium in patients with trauma: a retrospective analysis of data from a Helicopter Emergency Medical Service

ObjectivesPrehospital rapid sequence induction (RSI) of anaesthesia is an intervention with significant associated risk. In this study, we aimed to investigate the haemodynamic response over time of a prehospital RSI...

Effect of Suction Assisted Laryngoscopy Airway Decontamination (SALAD) Training on Intubation Quality Metrics

VCU Health Critical Care Transport Network paramedics and nurses staff three rotary-wing aircraft and one ground ambulance that provide scene response and interfacility transports throughout Virginia. Prehospital rapid sequence induction and intubation are among the highest risk procedures employed by these providers, particularly when the airway is massively contaminated with blood or vomit. A quality assurance review of attempted prehospital intubations determined issues with suction to be a key factor in those requiring more than one attempt. A targeted training session introducing Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) was implemented and quality improvement data collected. SALAD was introduced during scheduled quarterly training. In attendance were 15 nurses and 10 paramedics for a total of 25 participants. With no prior notice, training or cognitive priming each participant attempted intubation using videolaryngoscopy on a custom high fidelity training mannequin designed to emit 650 ml per minute of simulated vomit into the airway. Following their first attempt, participants were instructed on SALAD technique by an EMS-fellowship trained emergency physician. Participants then had another opportunity to intubate the mannequin using SALAD technique. Data was collected on number of attempts and time to successful intubation before and after training. Mean time to successful intubation improved from 68.28 seconds to 49.76 seconds (95% confidence interval [CI], -34.976 to -2.064; P = 0.0282). There was a trend toward improvement in mean number of intubation attempts overall from 1.12 per participant to 1.0 (CI, -0.0135 to 0.2535; P = <0.0001). Subgroup analysis, however, found there to be significant improvement for participants whose first attempt time was greater than 91 seconds, from a mean of 127.40 seconds to 53.80 seconds (CI, -116.674 to -30.526; P = 0.043) and 1.6 attempts per participant to 1.0 (CI, -1.165 to -0.0349; P = 0.0400) post intervention. In a controlled environment, SALAD training improves both first pass success and total time to successful intubation. The greatest improvement was observed in the group with the most difficulty and longest time to intubation prior to the targeted educational intervention. This indicates that the introduction of an effective, standardized suction technique for massively contaminated airways can significantly improve quality metrics for intubation by prehospital providers. Further research is needed to determine skill retention and generalizability to an uncontrolled environment.

Changes in anaesthetic use for trauma patients in German HEMS \u2013 a retrospective study over a ten-year period

BackgroundAirway management and use of intravenous anaesthetics to facilitate tracheal intubation after major trauma remains controversial. Numerous agents are available and used for pre-hospital rapid-sequence induction (RSI). The aim was to investigate usage and potential changes in administration of intravenous anaesthetics for pre-hospital RSI in trauma patients over a ten-year period.MethodsBased on a large helicopter emergency medical service (HEMS) database in Germany between 2006 and 2015, a total of 9720 HEMS missions after major trauma leading to RSI on scene were analysed. Administration practice of sedatives and opioids were investigated, while neuromuscular blocking agents were not documented in the database.ResultsWith respect to administration of sedatives, independent from trauma mechanism and specific injury patterns the use of Etomidate decreased dramatically (52 to 6%) in favour of a more frequent use of Propofol (3 to 32%) and Ketamine (9 to 24%; all p < 0.001) from 2006 to 2015. The use of Benzodiazepines increased slightly, while the utilization rate of Barbiturates remained constant. In patients with Shock Index > 1 at initial contact, the administration rate of Etomidate dropped significantly as well. This decline was mainly substituted by Ketamine and particularly Propofol. In patients with GCS ≤ 8 upon initial contact, a similar distribution compared to the general trauma population could be observed.With respect to opioids, mainly Fentanyl has been administered for RSI in trauma patients (2006: 69,6% to 2015: 60.2%; p < 0.001), while the use of sufentanyl showed a significant increase (0.2 to 8.8%; p < 0.001).ConclusionsThis large study analysed prehospital administration of anaesthetics in trauma patients, showing a substantial change from 2006 to 2015 despite the lack of any high-level evidence. Etomidate has shifted from the main sedative substance to virtual absence, indicating that the recommendation of an established national guideline was transferred into clinical practice, although based on weak evidence as well. The pre-hospital use of Propofol showed a particular increase. Fentanyl has been the main opioid drug for RSI in trauma, however Sufentanyl has become increasingly popular. The mechanisms and advantages of the different substances still have to be elucidated, especially in head injury and bleeding trauma.

Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study

ObjectivesPatients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness...

Prehospital rapid sequence induction following trauma in the era of regional networks for major trauma.

Rapid sequence induction (RSI) provides prompt airway control during emergency evacuation of trauma patients. Physicians may be tasked to travel with paramedic ambulance crews to the scene of injury when RSI is more likely to be required. This study investigates whether there are any differences in the practice of prehospital RSI during emergency retrievals for trauma since the establishment of the regional Major Trauma Network (MTN) in March 2012. A retrospective observational study examined prehospital records for all trauma patients from September 2010 to January 2015 at a Major Trauma Centre in Birmingham, UK. Prehospital physician availability increased from 12 to 24 h after March 2012, and tasking became centralized. Data included demographics, mechanism of injury, crew personnel, and details of RSI. The periods before and after the establishment of the regional MTN were compared. There were 5244 patients: 1432 (27.3%) before and 3812 (72.7%) after March 2012. Of the patients, 67.2% were male. The most common injuries were road traffic collisions (45.0%). Physicians were more likely to be present after (2345 missions, 61.5%) than before (529 missions, 36.9%) March 2012 (P<0.01). RSI was performed 434 (8.3%) times and was more likely during the latter than the former period [359 (9.4%) vs. 75 (5.2%), P<0.01]. Successful tracheal intubation was achieved in 99% of occasions. The establishment of regional MTNs enables centrally tasked, 24-h physician availability for emergency trauma patients. There has been an increase in physician presence on emergency missions and increased frequency of RSI for at-risk trauma patients at times when there may previously have been an unmet requirement.

Hypotension following pre-hospital rapid sequence induction of anaesthesia: a retrospective database analysis

AbstractIntroductionRecent trends in Pre-Hospital Emergency Medicine (PHEM) have demonstrated the potential benefit of using fentanyl, ketamine and rocuronium for pre-hospital rapid sequence induction of anaesthesia (RSI). Isolated cases of potentially significant hypotension have been reported. This study aimed to establish a potential link between the incidence of hypotension and the dose and combination of anaesthetic induction agents used.MethodsA retrospective database review was undertaken of all cases attended by the Great North Air Ambulance Service requiring RSI during a 25-month period. The blood pressure (BP) before and after RSI and doses of drugs were recorded. Cases were divided into three groups based on changes in BP: group 1 (increase in BP post induction &gt;20% or more), group 2 (between 20% increase and 20% fall in BP) and group 3 (fall in BP of 20% or more).Results105 cases were included in the analysis. Group 1 included 11 cases (range 23% to 106% increase in BP), group 2 included 57 cases (19% increase to 18% decrease) and group 3 included 37 cases (20% fall to 63% fall in BP).There was no statistically significant link to rocuronium (p=0.46) or ketamine (p=0.054) but the dose of fentanyl administered was highly significant (p&lt;0.001).DiscussionThis review showed a potential link between fentanyl dose and the degree of hypotension during RSI. Although this is a small study with some limitations it gives an indication that dose ratios in RSI may need to be reviewed.

Pre-Hospital Anaesthesia

Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.

SPEEDBOMB: a simple and rapid checklist for Prehospital Rapid Sequence Induction.

Prehospital emergency medical services often operate in the most challenging and austere environments. Checklist use for complex tasks in these circumstances is useful but must make task completion simpler, faster and more effective. The SPEEDBOMB checklist for Prehospital Rapid Sequence Induction (PRSI) management rapidly addresses critical steps in the RSI process, is designed to improve checklist compliance and patient safety, and is adaptable for local circumstances.

Role Allocation and Team Dynamics during Pre-Hospital Rapid Sequence Induction of Anaesthesia by a Physician-Critical Care Paramedic Team in the United Kingdom: A 12 Months Review of Practice

Background: Critical care paramedics working alongside physicians in the West Midlands MERIT scheme Medical Emergency Response Incident Team (MERIT) have been shown to demonstrate high levels of proficiency in laryngoscopy during Rapid Sequence Induction of anaesthesia (RSI). The MERIT SOP does not stipulate the team member who should be allocated the role of laryngoscopy during RSI. The aim of this study is to analyse and identify factors that influence role allocation in pre-hospital RSI performed by MERIT scheme personnel in the West Midlands. Methods: We conducted a retrospective review from 12 months of our mission database for patients who had undergone pre-hospital RSI performed by MERIT. Data collected included the indication for RSI, the number of intubation attempts (including documented failures to intubate), documentation of predicted difficulty in intubation and the degree of airway soiling prior to RSI. The clinical role of the operator performing laryngoscopy was recorded for each attempt. Results: 113 cases or pre-hospital RSI were identified. Critical care paramedics successfully intubated 49/58 (84.48%) cases in which they were allocated the first attempt at laryngoscopy. Success at first attempt lower for physicians (76.92%) but greater proportions of such cases involved patients at the extremes of age and heavy airway soiling with a wider range of indications. Conclusions: As part of a multidisciplinary team working alongside physicians, Critical Care Paramedics successfully intubate the majority of patients at the first attempt in carefully selected groups. Further research to investigate other factors at scene that influence role allocation and team dynamics in pre-hospital RSI is required.

Pharmacologically assisted laryngeal mask insertion: a consensus statement

Management of the pre-hospital airway can be challenging.1 A range of techniques and adjuncts are available to the pre-hospital clinician to aid in their efforts to maximise oxygenation and support ventilation. When measures fail, management is escalated through a series of increasingly complex and invasive procedures (‘the airway management ladder’) with the aim of establishing a definitive airway secured with an endotracheal tube or other surgical airway. In the non-arrested patient the gold standard for definitive pre-hospital airway management is pre-hospital rapid sequence induction and tracheal intubation (RSI) delivered by a competent clinical team. There may, however, be circumstances in which a pre-hospital RSI cannot be delivered, whether due to lack of clinical capability or lack of access to the patient. Some of these patients may benefit from advanced airway management, with the aim of promoting oxygenation, through the technique of pharmacologically assisted laryngeal mask (PALM) insertion. This technique involves sedating the trauma patient and inserting a supraglottic airway device (SAD) with the aim of improving their oxygenation and providing a degree of protection from ongoing airway contamination. This article reports the conclusions of a consensus meeting held in April 2012. The meeting followed a full literature search which was presented to the meeting, to which there was an open invitation to all relevant stakeholders. The meeting examined the PALM technique and its indications and outlined the competencies required of practitioners performing the procedure. Representatives from across the pre-hospital community and emergency care who contributed to the meeting are listed in box 1. A draft document was produced reflecting the conclusions from the meeting; this document was then reviewed by the attendees prior to a final review by the key colleges, faculties and other organisations within pre-hospital care. The Royal College of Anaesthetists, although represented at the initial …

Prehospital anaesthesia by a physician and paramedic critical care team in Southwest England

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.

Pre-hospital rapid sequence induction: Factual inaccuracies?

This distinction is of some importance when considering the educational background of those practicing RSI, as ECPs hold a four-year degree in emergency medical care (EMC). On page 633, and again on page 636, the authors describe RSI training as being a ‘two day university course’ and that they consider this to be insufficient. [1] I agree that two days of training on RSI is insufficient. However, this is not an accurate description of current RSI education at all institutions offering the EMC degree programme. The ‘two day university course’ was offered once in 2009 by one institution for those who already held an EMC degree, as a way of incorporating RSI (which was newly-approved at the time) into their clinical practice. The important point is that it was a ‘once-off ’ arrangement intended to update those who qualified with an EMC degree before RSI was approved for ECP scope of practice; it has not been the approach followed for undergraduate students since 2010. At the University of Johannesburg (UJ), RSI has been incorporated into an educational strategy on airway management which spans four years. Our approach in designing and implementing RSI education since 2010 has involved advice, input and involvement from specialists in both anaesthesiology and emergency medicine. Assessments include a mix of theory, objective structured clinical evaluations, simulations and assessments carried out in the emergency centre and pre-hospital environments. While we would like all of our students to have clinical experience in RSI before qualifying as independent practitioners, there is a very real problem of access to critical procedures. The healthcare system caters for a large number of students from a variety of fields and institutions. All compete for clinical experience in a small number of facilities that have suitable levels of clinical supervision. Given these constraints, we are currently implementing the approach outlined in the position statement referred to by the authors in their

The haemodynamic response to pre-hospital RSI in injured patients

BackgroundLaryngoscopy and tracheal intubation provoke a marked sympathetic response, potentially harmful in patients with cerebral or cardiovascular pathology or haemorrhage. Standard pre-hospital rapid sequence induction of anaesthesia (RSI) does not incorporate agents that attenuate this response. It is not known if a clinically significant response occurs following pre-hospital RSI or what proportion of injured patients requiring the intervention are potentially at risk in this setting. MethodsWe performed a retrospective analysis of 115 consecutive pre-hospital RSI's performed on trauma patients in a physician-led Helicopter Emergency Medical Service. Primary outcome was the acute haemodynamic response to the procedure. A clinically significant response was defined as a greater than 20% change from baseline recordings during laryngoscopy and intubation. ResultsLaryngoscopy and intubation provoked a hypertensive response in 79% of cases. Almost one-in-ten patients experienced a greater than 100% increase in mean arterial pressure (MAP) and/or systolic blood pressure (SBP). The mean (95% CI) increase in SBP was 41(31–51) mmHg and MAP was 30(23–37) mmHg. Conditions leaving the patient vulnerable to secondary injury from a hypertensive response were common. ConclusionsLaryngoscopy and tracheal intubation, following a standard pre-hospital RSI, commonly induced a clinically significant hypertensive response in the trauma patients studied. We believe that, although this technique is effective in securing the pre-hospital trauma airway, it is poor at attenuating adverse physiological effects that may be detrimental in this patient group.

Should non-anaesthetists perform pre-hospital rapid sequence induction? an observational study

IntroductionThe use of rapid sequence induction and tracheal intubation (RSI) in the pre-hospital environment is controversial. Currently, it is felt that competence to perform RSI should be defined by skills...

Prehospital anaesthetic course

With the expected introduction of prehospital emergency medicine as a specialty in its own right and a curriculum under development, this two day course aims to cover the knowledge, skills, and human factors required for prehospital care practitioners to perform emergency anaesthesia safely in the prehospital environment. Any doctor, paramedic, or nurse who currently performs or assists with prehospital rapid sequence induction (RSI) or wishes to train in this area. The current national guidelines1 suggest that a minimum level of experience for doctors wishing to train in prehospital anaesthesia is equivalent …

Rapid sequence induction on an air ambulance service

Rapid sequence induction (RSI) is one of the key additional skills that an appropriately-trained doctor can bring to the prehospital environment. Controversy remains over the most appropriate person to perform RSI. Aims To review the scope of RSI activity on one helicopter emergency medical service (HEMS) unit and assess paramedic involvement and leadership in delivering prehospital RSI. Methods Prospective review of clinical database for air ambulance service Results Crews performed 72 RSIs over a 13-month period. Paramedics intubated 47 patients (65%). None of the intubations performed by paramedics required any intervention by the doctor. Of the RSIs 55 (76%) were performed on trauma patients and 17 (24%) for patients with medical emergencies; 31 (43%) were carried out in the presence of emergency physicians, 30 (42%) with anaesthetists present and 11 (15%) with a surgical specialist registrar. One doctor (consultant emergency physician) was present at RSIs on two patients at one scene; the paramedic intubated one of the patients. Six adverse events were reported. There were no reported serious technical complications of the RSI procedure such as incorrect tube placement or oxygen desaturation. Conclusions Our experience supports the growing recognition that appropriately-trained non-anaesthetists can perform RSI as safely as anaesthetists in both the hospital and prehospital environments. Our study also suggests that with appropriate training and supervision, paramedics carry no greater risks in RSI than their anaesthetic and non-anaesthetic medical colleagues.

Announcing the launch of a new web-based prehospital rapid sequence induction log for doctors

The provision of advanced medical intervention for victims at the “point of injury” is a topic that continues to be widely debated. Of equal controversy is the use of prehospital...

“Rap” in the streets: A retrospective look at the use of rapacuronium for prehospital rapid sequence induction

It's 9:27 PM on a Friday night. AirLife gets a page to a motor vehicle accident on an interstate—multiple patients and a critical child. On arrival at the scene, where a van was sideswiped by a semi entering the interstate, the flight team is directed to a 9-year-old girl lying on a long spine board on the pavement. This patient was the restrained mid-seat passenger in the van on the side of the impact. The first-responders are assisting the child's respirations with a bag-valve-mask (BVM) and maintaining manual cervical spine stabilization. The child has respirations at a rate of 28 through clenched teeth with a Glasgow Coma Scale of < 8. Her initial examination is unremarkable except for the altered level of consciousness. The flight paramedic asks for the “rap” as the flight nurse puts in a peripheral IV line.

Prehospital rapid sequence induction by emergency physicians: Is it safe?

Objectives—To determine if there were differences in practice or intubation mishap rate between anaesthetists and accident and emergency physicians performing rapid sequence induction of anaesthesia (RSI) in the prehospital setting....