Prehospital Rapid Sequence Intubation Research Articles

The Effect of Full-Dose Versus Half-Dose Ketamine for Induction During Rapid Sequence Intubation on Patient Outcomes.

Prehospital rapid sequence intubation (RSI), like inpatient RSI, is not without risk of adverse effects to the patient. The most notable of these adverse effects is postintubation hemodynamic instability. Air medical providers choose induction agents for critically ill patients who require emergent airway management, some of whom may already be hemodynamically unstable prior to RSI. Ketamine is often selected as the induction agent of choice for patients who are either unstable before RSI or have a high index of suspicion of becoming unstable in the postintubation period. Although widely considered to have a good safety profile for induction, ketamine administration has been correlated with episodes of postintubation hypotension. In this retrospective literature review, the effect of using half-dose ketamine for induction in patients who show pre-RSI instability (systolic blood pressure <90 mm Hg or body mass index >30) on postintubation hemodynamics is examined.

The effectiveness of prehospital rapid sequence intubation in critically ill patients

Background Tracheal intubation in critically sick patients presents a significant risk of complications attributable to variables such as respiratory failure, hemodynamic instability, and drug sensitivity. Present recommendations mostly depend on expert opinion and data from elective intubations, lacking substantial evidence from randomized controlled trials (RCTs) in critical care environments (ICU, ED, general wards). This systematic review sought to assess high-quality evidence-based methods for intubation in critically sick patients, concentrating on pharmacological agents, techniques, and equipment. Methods A thorough search of PubMed, BioMed Central, Embase, and the Cochrane Central Register of Clinical Trials found pertinent randomized controlled trials examining treatments aimed at enhancing the success rate and safety of tracheal intubation in critically sick patients. A meta-analysis was conducted when applicable. Results Intubation problems in critically sick patients vary from 4.2% to 39%. Pre-oxygenation by non-invasive ventilation (NIV) has shown enhanced effectiveness over conventional techniques in extending safe apnea duration and minimizing desaturation. Although high-flow nasal cannula (HFNC) enhanced comfort, its advantages for apneic oxygenation were restricted in this demographic. Etomidate and ketamine had equivalent safety and effectiveness as sedatives, whilst succinylcholine and rocuronium showed similar success rates as neuromuscular blocking drugs. The sniffing position outperformed the ramping position for laryngoscopy.

Factors Associated With Desaturation in Prehospital Rapid Sequence Intubation in a Helicopter Emergency Medical Service

ObjectiveDesaturation during prehospital rapid sequence intubation (RSI) is common and is associated with patient morbidity. Past studies have identified oxygen saturations at induction, the grade of laryngoscopy, and multiple attempts to intubate as being associated with desaturation. This study aimed to investigate whether there are other factors, identifiable before RSI, associated with desaturation. MethodsThis was a study of a physician-paramedic critical care team operating as Aeromedical Operations, NSW Ambulance. Prehospital RSIs (using paralysis) were studied retrospectively via patient case notes, monitor data, and an airway database. The review occurred between April 1, 2016, and December 31, 2018. Desaturation was defined as monitor recordings of saturations ≤ 92%. Logistic regression was performed for factors likely to be associated with desaturation. ResultsDesaturation occurred in 67 of 350 (19.1%) RSIs. Factors significantly associated with desaturation included male sex, a chest injury, increased weight, and lower saturations pre-RSI. ConclusionIncreased weight, chest injuries, and lower oxygen saturations are associated with desaturation at RSI. The variable male sex may be a surrogate for other as-yet unidentified factors.

Comparison of Intubating Conditions with Succinylcholine Versus Rocuronium in the Prehospital Setting

Objective Rapid sequence intubation (RSI) is frequently performed by emergency medical services (EMS). We investigated the relationship between succinylcholine and rocuronium use and time until first laryngoscopy attempt, first-pass success, and Cormack-Lehane (CL) grades. Methods We included adult patients for whom prehospital RSI was attempted from July 2015 through June 2022 in a retrospective, observational study with pre-post analysis. Timing was verified using recorded defibrillator audio in addition to review of continuous ECG, pulse oximetry, and end-tidal carbon dioxide waveforms. Our primary exposure was neuromuscular blocking agent (NMBA) used, either rocuronium or succinylcholine. Our prespecified primary outcome was the first attempt Cormack-Lehane view. Key secondary outcomes were first laryngoscopy attempt success rate, timing from NMBA administration to first attempt, number of attempts, and hypoxemic events. Results Of 5,179 patients in the EMS airway registry, 1,475 adults received an NMBA while not in cardiac arrest. Cormack-Lehane grades for succinylcholine and rocuronium were similar: grade I (64%, 59% [95% CI 0.64–1.09]), grade II (16%, 21%), grade III (18%, 16%), grade IV (3%, 3%). The median interval from NMBA administration to start of the first attempt was 57 s for succinylcholine and 83 s for rocuronium (mean difference 28 [95% CI 20–36] seconds). First attempt success was 84% for succinylcholine and 83% for rocuronium. Hypoxemic events were present in 25% of succinylcholine cases and 23% of rocuronium cases. Conclusions Prehospital use of either rocuronium or succinylcholine is associated with similar Cormack-Lehane grades, first-pass success rates, and rates of peri-intubation hypoxemia.

Video Documentation as a Measure of Written Documentation Accuracy in Emergency Medical Service Field Intubations.

Quality improvement (QI) is a major focus of all departments and fields of health care, including emergency medical services. The chaotic and rapidly evolving atmosphere in which paramedics must practice can lead to inconsistency between what is documented and the actual events. This leads to difficulty when trying to evaluate the practitioners and when implementing a QI program. In this study, we evaluated the prevalence of discrepancy between the video and written record for Rapid Sequence Intubation (RSI) performed in the field as a demonstration of the utility of video documentation in QI. We used a systematic retrospective chart review to compare written with video documentation in 100 consecutive prehospital RSI encounters in a single EMS agency. Of the patient care records (PCRs), only 6% matched the video record for all quality measures tracked. The largest reason for the discrepancy was in the time required to intubate (58%) whether LEMON was evaluated (42%), total number of intubation attempts (36%), first attempt success (24%), BVM used (18%), and whether an airway introducer device was used (12%). Written documentation is inaccurate compared to video documentation when used as a quality improvement process for EMS prehospital RSI encounters.

Accuracy of prehospital clinicians’ perceived prognostication of long-term survival in critically ill patients: a nationwide retrospective cohort study on helicopter emergency service patients

ObjectivesPrehospital critical care physicians regularly attend to patients with poor prognosis and may limit the advanced therapies. The aim of this study was to evaluate the accuracy of poor prognosis...

A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients

In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50–64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69–0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.

Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist

<h3>Background</h3> Checklists have been adopted in various acute care settings with reasonable compliance and acceptance. In the Air Medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation (RSI). However, compliance and attitudes toward these Human Factors innovations in the critical care transport setting are not well-described. <h3>Methods</h3> We conducted an IRB-exempt, retrospective review of checklist usage to assess compliance with a required RSI checklist by critical care transport providers. We also conducted an IRB-exempt survey of critical care transport providers with 5 questions based on Rogers' theory of diffusion of innovation that had graded responses on a 1-5 Likert scale. The distribution of responses for each question was determined and summarized using means and standard deviations. A free-marginal Kappa along with 95% confidence interval was determined to measure inter-rater consistency. <h3>Results</h3> Checklist compliance was 92% over the period reviewed after checklist implementation. There was a 10% response to the survey questions and a total of 314 individual responses were recorded. Questions regarding compatibility with practice and difficulty of use were favorable. The response to how the checklist flows with current RSI performance was 4.07 (SD 1.060). The average response to the questions regarding difficulty of learning the list and teaching the list were 4.53 (SD 0.861) and 4.10 (SD 1.056) respectively. But, with questions regarding observable change to practice, there was slight difference. The response to the question regarding the checklist effect on reduction of cognitive load was less strong at 3.74 (SD 1.290). Crew members, however, did believe that helped make sure they did not miss anything during the RSI procedure with an average response of 4.10 (SD 1.125) <h3>Conclusions</h3> Process compliance with checklist implementation was excellent. Most respondents felt that the innovation of using the checklist fit well into their existing practice and was not difficult to learn or teach. The majority of respondents also felt it was helpful at preventing procedural errors.

Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist

Human factors engineering innovations, such as checklists, have been adopted in various acute care settings to improve safety with reasonable compliance and acceptance. In the air medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation. However, compliance and attitudes toward these human factors engineering innovations in the critical care transport setting are not well described. In this institutional review board–exempt, retrospective review of checklist usage, we assessed rapid sequence intubation checklist compliance and surveyed providers with 5 questions based on Rogers’ theory of diffusion of innovation to examine why or why not there was compliance. Our results indicated that compliance with checklist implementation was excellent. The survey questions were consistent with process improvement factors that enhance the spread and acceptance of innovation.

Temporal changes in blood pressure following prehospital rapid sequence intubation

BackgroundRapid Sequence intubation (RSI) is an airway procedure that uses sedative and paralytic drugs to facilitate endotracheal intubation. It is known that RSI could impact blood pressure in the peri-intubation...

Feasibility of Prehospital Rapid Sequence Intubation in the Cabin of an AW169 Helicopter

ObjectivePrehospital rapid sequence intubation (RSI) is an important aspect of prehospital care for helicopter emergency medical services (HEMS). This study examines the feasibility of in-aircraft (aircraft on the ground) RSI in different simulated settings. MethodsUsing an AW169 aircraft cabin simulator at Air Ambulance Kent Surrey Sussex, 3 clinical scenarios were devised. All required RSI in a “can intubate, can ventilate” (easy variant) and a “can't intubate, can't ventilate” scenario (difficult variant). Doctor-paramedic HEMS teams were video recorded, and elapsed times for prespecified end points were analyzed. ResultsEndotracheal intubation (ETI) was achieved fastest outside the simulator for the easy variant (median = 231 seconds, interquartile range = 28 seconds). Time to ETI was not significantly longer for in-aircraft RSI compared with RSI outside the aircraft, both in the easy (p = .14) and difficult variant (p = .50). Wearing helmets with noise distraction did not impact the time to intubation when compared with standard in-aircraft RSI, both in the easy (p = .28) and difficult variant (p = .24). ConclusionIn-aircraft, on-the-ground RSI had no significant impact on the time to successful completion of ETI. Future studies should prospectively examine in-cabin RSI and explore the possibilities of in-flight RSI in civilian HEMS services.

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.

Prehospital Ground Transport Rapid Sequence Intubation for Trauma and Traumatic Brain Injury Outcomes

Prehospital Ground Transport Rapid Sequence Intubation for Trauma and Traumatic Brain Injury Outcomes

Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists

IntroductionPrehospital emergency anaesthesia (PHEA or ‘prehospital rapid sequence intubation’) is a high-risk procedure. Standard operating procedures (SOPs) and checklists within healthcare systems have been demonstrated to reduce human error and...

Efficacy of pre-hospital rapid sequence intubation in paediatric traumatic brain injury: A 9-year observational study

IntroductionPrehospital airway management of the paediatric patient with traumatic brain injury (TBI) is controversial. Endotracheal intubation of children in the field requires specific skills and has potential benefits but also carries potentially serious complications. We aimed to compare mortality and functional outcomes after six months between children with TBI who either underwent prehospital rapid sequence intubation (RSI) by trained Intensive Care paramedics (ICP) or received no intubation. MethodsWe conducted a retrospective study of patients aged ≤14 years with suspected TBI in Victoria, Australia. Patients were either transported via helicopter and received RSI by an ICP (2005–2013) or via road ambulance and received no intubation (2006–2013). Prehospital data was linked to hospital and 6-month follow-up data to assess mortality and functional outcome. ResultsA total of 106 patients were included in the study of which 87 received RSI by paramedics and 19 did not receive intubation. Overall, the intubation success rate was 99% (86/87), with a first-pass success rate of 93% (81/87). In total, 67% of patients (n = 41) receiving RSI had a favourable functional outcome, compared with 54% of non-intubated patients (n = 7) (p = 0.36). In the 75 children with major trauma, prehospital RSI was associated with a significant decrease in length of hospital stay (523 h vs. 1939 h, p = 0.03). In the 53 children in this subgroup with available six months data the difference in favourable functional outcome increased to 66% (n = 31)vs. 17% (n = 1) (p = 0.06). DiscussionPrehospital RSI in paediatric patients with TBI can safely be performed by highly trained paramedics. Overall, we observed more favourable long-term outcomes in patients who received prehospital intubation than those who did not, however our study is not powered to detect a significant difference. Intubation prior to transport might be beneficial for major trauma patients.

Prehospital Rapid Sequence Intubation by Intensive Care Flight Paramedics

ABSTRACTObjective: Rapid sequence intubation (RSI) is an advanced airway procedure for critically ill or injured patients. Paramedic-performed RSI in the prehospital setting remains controversial, as unsuccessful or poorly conducted RSI is known to result in significant complications. In Victoria, intensive care flight paramedics (ICFPs) have a broad scope of practice including RSI in both the adult and pediatric population. We sought to describe the success rates and characteristics of patients undergoing RSI by ICFPs in Victoria, Australia. Methods: A retrospective data review was conducted of adult (≥ 16 years) patients who underwent RSI by an ICFP between January 1, 2011, and December 31, 2016. Data were sourced from the Ambulance Victoria data warehouse. Results: A total of 795 cases were included in analyses, with a mean age of 45 (standard deviation = 19.6) years. The majority of cases involved trauma (71.7%), and most patients were male (70.1%). Neurological pathologies were the most common clinical indication for RSI (68.3%). The first pass success rate of intubation was 89.4%, and the overall success rate was 99.4%. Of the 5 failed intubations (0.6%), all patients were safely returned to spontaneous respiration. Two patients were returned via bag/valve/mask (BVM) support alone, two with BVM and oropharyngeal airway, and one via supraglottic airway. No surgical airways were required. Overall, we observed transient cases of hypotension (5.2%), hypoxemia (1.3%), or both (0.1%) in 6.6% of cases during the RSI procedure. Conclusion: A very high RSI procedural success rate was observed across the study period. This supports the growing recognition that appropriately trained paramedics can perform RSI safely in the prehospital environment.

A before-and-after observational study of a protocol for use of the C-MAC videolaryngoscope with a Frova introducer in pre-hospital rapid sequence intubation.

Results using videolaryngoscopy in pre-hospital rapid sequence intubation are mixed. A bougie is not commonly used with videolaryngoscopy. We hypothesised that using videolaryngoscopy and a bougie as core elements of a standardised protocol that includes a drugs and a laryngoscopy algorithm would result in a high first-pass tracheal intubation success rate. We employed videolaryngoscopy (C-MAC) combined with a bougie (Frova intubating introducer) in an anaesthetist-staffed helicopter emergency medical service. Data for adult tracheal intubation were collected prospectively as part of the airway registry of our unit for 22months after implementation of the protocol (n=543) and compared with controls (n=238) treated in the previous year before the implementation. The mean first-pass success rate (95%CI) was 98.2% (96.6-99.0%) in the study group and 85.7% (80.7-89.6%) in the control group, p<0.0001. Combining C-MAC videolaryngoscopy and bougie with a standardised rapid sequence induction protocol leads to a high first attempt intubation success rate when performed by an anaesthetist-led helicopter emergency medical service team.

Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation

Objective: Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. Methods: Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. Results: Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO2 decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. Conclusions: In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.

Application of a Healthcare Failure Modes and Effects Analysis to Identify and Mitigate Potential Risks in the Implementation of a National Prehospital Pediatric Rapid Sequence Intubation Program.

Rapid sequence intubation (RSI) has become the de facto airway method of choice in the emergency airway management of adult and pediatric patients. There is significant controversy regarding pediatric RSI in the prehospital setting, given not only the complexities inherent in both the procedure and patient population, but in variations in emergency medical service models, prehospital qualifications, scope of practice, and patient exposure too. A Healthcare Failure Mode and Effects Analysis was conducted to identify and mitigate potential hazards in the national implementation of a prehospital pediatric RSI program. A process map and potential failure points were developed and identified. Probabilities, severity, and hazards scores were calculated for each failure point, and actions items developed to address these. One hundred four potential failure points were identified among 44 subprocesses, divided between nine major processes. In terms of severity, most were classified as either major (n = 39 [37.5%]) or catastrophic (n = 35 [33.7%]) with just more than half falling within the uncommon category (n = 56 [53.9%]) in terms of probability. Five strategic actions items were identified to mitigate against the failure points meeting criteria for action. To monitor the success of these, 11 quality and performance indicators were developed for concurrent implementation. The Healthcare Failure Mode and Effects Analysis represents a simple yet comprehensive first step toward risk analysis of complex procedures within the prehospital emergency care setting. Application of the methodology provided guidance for the consensus identification of hazards associated with prehospital pediatric RSI and appropriate actions to mitigate them.

Ketamine-induced Changes in Blood Pressure and Heart Rate in Pre-hospital Intubated Patients

When a patient experiences trauma, pre-hospital rapid sequence intubation (RSI) is often the course of action. While RSI is associated with favorable neurological outcomes among traumatic brain injury patients, it also carries the risk of increased hypotension and bradycardia. Ketamine is a fast-acting anesthetic agent used in RSI, attractive due to its ability to raise heart rate (HR) and blood pressure (BP) and thus potentially lessening the severity of RSI-related hypotension and bradycardia. However, research in support of its use is inconclusive, with different studies reporting increases or decreases in BP and HR after ketamine administration. To study the effect of ketamine on HR and BP during RSI, we analyzed the data obtained from 1,516 patients who received trauma and non-trauma medical care including RSI from first responders and emergency personnel using two different statistical methods. We determined if there was any association between the vital signs prior to administration of ketamine and outcomes such as bradycardia and/or hypotension post-ketamine administration in patients undergoing RSI. We found that the vital signs prior to administration of ketamine (i.e. BP and HR) predict the development of bradycardia and/or hypotension in patients undergoing RSI and the relationship between baseline vital signs and the development of bradycardia and/or hypotension is moderated by the dose of ketamine. Results obtained from this study may help responders and emergency care personnel to identify the patients that are likely to benefit from ketamine as an anesthetic agent.