Rapid Sequence Intubation Protocol Research Articles

Comparison of rocuronium priming vs. standard rapid sequence intubation technique in emergency department patients requiring intubation.

In our study, we aimed to compare the effect of standard rapid sequence intubation protocol and the application of rocuronium priming technique on the procedure time and hemodynamic profile. Patients who applied to the emergency department and needed rapid sequence intubation were included in our study, which we conducted with a randomized controlled design. Randomization in the study was made according to the order of arrival of the cases. Rapid sequence intubation was performed in the standard group. In the priming group, 10% of the rocuronium dose was administered approximately 3 min before the induction agent. Intubation time, amount of drug used, vital signs, and end-tidal CO2 level before and after intubation used to confirm intubation were recorded. A total of 52 patients were included in the study, of which 26 patients were included in the standard group and 26 patients in the priming group. While intubation time was 121.2±21.9 s in the standard group, it was calculated as 68.4±11.6 s in the priming group (p<0.001). While the mean arterial pressure was 58.3±26.6 mmHg in the standard group after intubation, it was 80.6±21.1 mmHg in the priming group (p=0.002). It was observed that priming with rocuronium shortened the intubation time and preserved the hemodynamic profile better. NCT05343702.

The Optimal Preoxygenation Target to Avoid Desaturation During Pediatric Rapid Sequence Intubation

<h3>Background</h3> Rapid sequence intubation (RSI) is a critical procedure in the resuscitation of critically ill and injured patients but carries an important risk of oxygen desaturation. In the adult population, a target preoxygenation threshold of >93% has been defined. However, it is not known whether this is an appropriate target for pediatric patients. <h3>Objective</h3> To define a target preoxygenation threshold for pediatric RSI. <h3>Methods</h3> Our air medical agency includes 150 bases, with a flight RN/flight paramedic crew configuration. The pediatric RSI protocol includes the use of etomidate or ketamine for induction and either succinylcholine or rocuronium for paralysis. Up to 120 data elements are entered into the Institutions Airway Database for each RSI procedure. For this analysis, all pediatric patients (age <18 years) undergoing RSI between January 2015 and September 2019 were included. Separate analysis was performed for infants (0-2 years), young children (3-8 years), and older children (9-17 years). Patients werestratified by highest pre-attempt SpO2 value, with the rate of desaturation identified as the primary outcome measure. Desaturation was defined as decrease in SpO2 to <94% or a continued decrease by at least 2% if pre-attempt SpO2 value was <94%. A graphical analysis was performed to identify an inflection point below which substantially higher desaturation rates were observed. The desaturation rate for patients with pre-attempt SpO2 values above that threshold were compared to those below that threshold using chi-square analysis, with significance was set at p<0.05. <h3>Results</h3> A total of 1,116 patients were identified over the 57-month period (infant n=247, young children n=250, older children n=619). A clear desaturation rate inflection point was observed with pre-attempt SpO2 values of 97% or greater. For patients with pre-attempt SpO2 values of <97%, the desaturation rate was 59.2% as compared to 12.8% with pre-attempt SpO2 values of 97% or greater (OR 9.8, 95% CI 6.9-14.1, p<0.0001). These results were similar across the three age groups. <h3>Conclusions</h3> These data support a higher preoxygenation target of 97% or greater with pediatric RSI. Limitations include the observational nature of the analysis and the possibility that lower pre-attempt SpO2 is a surrogate for more a difficult airway.

Can lactate clearance used to as a determinant of survival in mechanical ventilation follow up of critically ill patients?

Aim: Serum lactate level is known to have prognostic value in critical patients. Tissue hypoxia is a cause of an increase in lactate levels. A decrease in excretion and metabolism of lactate can increase lactate levels. In this study, we have investigated whether clearance of serum lactate could be a predictor of mortality in critically ill intubated patients at the emergency room.Materials and Methods: Study Groups. Data of 205 critically ill patients requiring intubation, admitted to the emergency department of Haydarpasa Numune Training and Research Hospital between January 2011 and December 2015 have been scanned retrospectively. The intubations were performed according to the latest rapid sequence intubation protocols. Results: There were 100 (48.8%) male and 105 (51.2%) female patients. Median, minimum, and maximum age were 76,19, and 104, respectively. The number of patients who could not survive was 157 (76.6%). The median, maximum, and minimum age in the non-survivor group were 78,31, and 104, while they were 70,19, and 90 in the survivor group, respectively. The difference was statistically significant (p0.001). Final diagnoses and mortality rates of the critically ill patients requiring intubation in the emergency department are shown in Table 1. Conclusion: We have found out that lactate clearance has no statistically significant relationship with mortality (p=0.5). However, lactate levels were higher in the groups with mortality, and the difference was statistically significant for both referral time and 4th-hour blood samples (p=0.024 and 0.014, respectively).

Implementation of a Neonatal RSI Pre-sedation Protocol and Effect on First Attempt Endotracheal Intubation Attempts for Neonatal Transport Team Members

Implementation of a Neonatal RSI Pre-sedation Protocol and Effect on First Attempt Endotracheal Intubation Attempts for Neonatal Transport Team Members PURPOSE In pediatric and adult transport environments, strong evidence demonstrates that Rapid Sequence Intubation (RSI) Protocols improve first attempt endotracheal intubation success rates. While RSI Protocols are used in hospital-based Neonatal lntensive Care Units (NICU), their use during neonatal transport is just emerging. Using Quality Improvement (QI) …

Use a Non-Rebreather Mask for Preoxygenation for Rapid Sequence Intubation

Many intubators using the rapid sequence intubation protocol use a bag-valve-mask (BVM) for preoxygenation. But in the absence of a good mask seal, a

Tips to Improve Success Rate of Intubation: A Standardized Rapid Sequence Intubation Protocol Attached to the Resuscitation Cart.

The purpose of this study was to determine whether the implementation of a standardized rapid sequence intubation (RSI) protocol easily accessed on the resuscitation cart increased the success rate of intubation and reduced intubation-related complications in the emergency department (ED). This work was a retrospective study of patients who were intubated in the ED between February 2006 and June 2007. The RSI protocol and a dosage cross-table were attached to the resuscitation cart beginning in January 2007. Intubated patients before and after application of the protocol were sorted into two groups: pre-intervention and post-intervention. A total of 147 patients were enrolled in the study, including 72 patients in the pre-intervention group and 75 patients in the post-intervention group. After application of the standardized protocol prompted on the resuscitation cart. The adherence rates to pre-treatment agents (69% vs. 90%; p < 0.01) and neuromuscular blocking agents (NMBA) (72% vs. 90%; p < 0.01) significantly improved. The first-attempt success rate was 57 of 72 (79%) in the pre-intervention group versus 70 of 75 (93%) in the post-intervention group (p = 0.016). The time to intubation did not differ signifi cantly, but the preintervention group had a higher percentage of prolonged time to intubation (13% vs. 3%; p = 0.029). The implementation of a standardized RSI protocol did not induce signifi cant adverse effects. Our study demonstrated implementation of a standardized RSI protocol, improved clinician adherence to the RSI, increased success of first-attempt ED intubation and led to a decline in the rate of prolonged time to intubation.

Apneic Oxygenation May Not Prevent Severe Hypoxemia During Rapid Sequence Intubation: A Retrospective Helicopter Emergency Medical Service Study

ObjectiveThis study sought to determine the effectiveness of apneic oxygenation in preventing hypoxemia during prehospital rapid sequence intubation (RSI). MethodsWe performed a case-cohort study using a pre-existing database looking at intubation management by a single helicopter emergency medical service between July 2013 and June 2015. Apneic oxygenation using high-flow nasal cannula (15 L/min) was introduced to the standard RSI protocol in July 2014. Severe hypoxemia was defined as an incidence of oxygen saturation less than 90%. We compared patients who received apneic oxygenation during RSI with patients who did not using the Fisher exact test. ResultsNinety-three patients were identified from the database; 29 (31.2%) received apneic oxygenation. Nineteen patients had an incidence of severe hypoxemia during RSI (20.43%; 95% confidence interval, 12.77%-30.05%). There was no statistically significant difference between the rate of severe hypoxemia between patients in the apneic oxygenation group versus the control group (17.2% vs. 21.9%, P = .78). ConclusionIn this study, patients who received apneic oxygenation did not show a statistically significant difference in severe hypoxemia during RSI.

Rapid Sequence Intubation for Head Injury Patients. A Practice

Rapid Sequence Intubation is one of most commonly applied procedures for trauma patient in emergency practice such as Medical Rescue Service as Emergency Hospital Ward, but in the case of patients with maxillofacial trauma it is usually complicated. Firstly the trauma directly involves the airway, but also the commonly associated injuries and conditions, such as craniocelebrar injuries often limit the options in management. The aim of this article is to describe rapid sequence intubation protocol for this group of critical injured patients. (JNNN 2016;5(1):28–30)

Use of Etomidate for Rapid Sequence Intubation (RSI) in Pediatric Trauma Patients: An Exploratory National Survey.

Objective, To survey the pediatric trauma programs to ascertain if and how etomidate is being used for rapid sequence intubation (RSI) in pediatric trauma patients. Design, A 25 question survey was created using REDCaps. A link to the survey was emailed to each of the pediatric and adult trauma programs that care for pediatric patients. Setting, Pediatric trauma programs and adult trauma programs caring for pediatric patients. Intervention, None. Measurements and Main Results, A total of 16% of programs responded (40/247). The majority of the centers that responded are urban, academic, teaching Level 1 pediatric trauma centers that provide care for > 200 pediatric trauma patients annually. The trauma program directors were the most likely to respond to the survey (18/40). 33/38 respondents state they use etomidate in their RSI protocol but it is not used in all pediatric trauma patients. 26/38 respondents believe that etomidate is associated with adrenal suppression and 24/37 believe it exacerbates adrenal suppression in pediatric trauma patients yet 28 of 37 respondents do not believe it is clinically relevant. Conclusions, Based on the results of the survey, the use of etomidate in pediatric trauma patients is common among urban, academic, teaching, level 1 pediatric trauma centers. A prospective evaluation of etomidate use for RSI in pediatric trauma patients to evaluate is potential effects on adrenal suppression and hemodynamics is warranted.

Use of the Airtraq® device for airway management in the prehospital setting – a retrospective study

BackgroundDifficulties with prehospital intubations have encouraged the development of indirect laryngoscopy techniques, facilitating laryngeal visualization. Airtraq® is a relatively new single-use indirect laryngoscope. The Airtraq® has been evaluated in several prehospital mannequin intubation trials. However, prehospital clinical experience with the device is limited.MethodsA retrospective medical chart review was performed for patients who underwent prehospital endotracheal intubation in the Stockholm County between January 2008 and December 2012. Both anaesthesiologists and nurse anaesthetists performed prehospital intubations during the study period. All Airtraq® intubations during this period were included in the analysis. The objective was to estimate the success rate of Airtraq® used in a prehospital setting.ResultsDuring the 5-year period (January 2008- December 2012), 2453 tracheal intubations were performed. Airtraq® was used in 28 cases (1%). The overall Airtraq® intubation success rate was 68%. Among patients with anticipated or unexpected difficult airway (23/28) the Airtraq® success rate was 61% (14/23). Among patients who underwent drug facilitated or rapid-sequence intubation protocols 4/5 (80%) were successfully intubated with Airtraq®.ConclusionIn conclusion, this retrospective study showed a higher Airtraq® success rate than previous prospective prehospital trials. However, compared to other prehospital direct and indirect intubation methods the Airtraq success rate is low. Further clinical trials are necessary to evaluate the role of Airtraq® in the prehospital airway management.

4,871 Emergency Airway Encounters by Air Medical Providers: A Report of the Air Transport Emergency Airway Management (NEAR VI: "A-TEAM") Project

IntroductionPre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system.MethodsWe retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant.Results4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway.ConclusionAirway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.

Evaluation of Paramedic Utilization of the Intubating Laryngeal Mask Airway in High-Fidelity Simulated Critical Care Scenarios

Successful oxygenation and ventilation can mean the difference between life and death in the prehospital setting. While airway challenges can be numerous within the confines of the emergency department, there are many additional confounding difficulties in the prehospital setting, which include limited access to equipment, poor lighting, extreme environments, limited personnel to assist, no immediate backup, and limited rescue airway options. The concept of an easy, reliable, and rapidly deployable alternative rescue airway device is critical, especially when considering the addition of rapid sequence intubation protocols in the prehospital setting. Hypothesis The primary objective of this study was to ascertain whether paramedics can be trained to deploy this alternative airway device with an acceptable success rate in a simulated critical care airway scenario. The secondary objective was to determine whether the previously-trained paramedics were able to retain their ability to deploy the device successfully at one year. This was a prospective, observational, single-group, descriptive cohort, educational trial. Forty paramedics were trained in the use of the Intubating Laryngeal Mask Airway (I-LMA) in a simulation medicine curriculum culminating in a simulated critical care difficult airway scenario requiring urgent oxygenation and ventilation after failed traditional endotracheal intubation. An emergency medicine physician proctor determined successful airway management. Repeat testing was then performed at approximately one year out, challenging the medics to intubate a mannequin using the I-LMA during an unrelated training session. Of the 40 paramedics who underwent complete simulation training, 39 were able to intubate and ventilate the simulated difficult airway using the I-LMA during the critical care scenario. This yields a success rate of 97.5% (95% CI, 87.1%-99.4%). At approximately one year out, 35 out of 35 medics were able to intubate the mannequin using the I-LMA, resulting in a success rate of 100% (95% CI, 91.4%-100%). In this study, paramedics were able to deploy the I-LMA with a high degree of success in a simulated difficult airway, with a high degree of skill retention at one year out.

Two Hundred Sixty Pediatric Emergency Airway Encounters by Air Transport Personnel

Effective airway management is the cornerstone of resuscitative efforts for any critically ill or injured patient. The role and safety of pediatric prehospital intubation is controversial, particularly after prior research has shown varying degrees of intubation success. We report a series of consecutive prehospital pediatric intubations performed by air-transport providers. We retrospectively reviewed intubation flight records from an 89-rotorcraft, multistate emergency flight service during the time period from January 1, 2007, to December 31, 2009. All patients younger than 15 years were included in our analysis. We characterized patient, flight, and operator demographics; intubation methods; success rates; rescue techniques; and adverse events with descriptive statistics. We report proportions with 95% confidence intervals and differences between groups with Fisher exact and χ tests; P < 0.05 was considered significant. Two hundred sixty pediatric intubations were performed consisting of 88 medical (33.8%) and 172 trauma (66.2%) cases; 98.8% (n = 257) underwent an orotracheal intubation attempt as the first method. First-pass intubation success was 78.6% (n = 202), and intubation was ultimately successful in 95.7% (n = 246) of cases. Medical and trauma intubations had similar success rates (98% vs 95%, Fisher exact test P = 0.3412). There was no difference in intubation success between age groups (χ = 0.26, P = 0.88). Three patients were managed primarily with an extraglottic device. Rescue techniques were used in 11 encounters (4.2%), all of which were successful. Cricothyrotomy was performed twice, both successful. Prehospital pediatric intubation performed by air-transport providers, using rapid sequence intubation protocols, is highly successful. This effect on patient outcome requires further study.

A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients

In the emergency department (ED) of a teaching hospital, rapid sequence intubation (RSI) is performed by physicians with a wide range of experience. A variety of medications have been used for RSI, with potential for inadequate or excessive dosing as well as complications including hypotension and the need for redosing. We hypothesized that the use of a standardized RSI medication protocol has facilitated endotracheal intubation requiring less medication redosing and less medication-related hypotension. An RSI medication protocol (ketamine 2 mg/kg intravenously administered and rocuronium 1 mg/kg intravenously administered, or succinylcholine 1.5 mg/kg intravenously administered) was implemented for all trauma patients undergoing ED intubation at a Level I trauma center. We retrospectively reviewed patients for the 1-year period before (PRE) and after (KET) the protocol was instituted. Data collected included age, sex, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) score of the head/face, AIS score of the chest, RSI drugs, need for redosing, time to intubation, indication for RSI, and number of RSI attempts. During the study period, 439 patients met inclusion criteria; 266 without protocol (PRE) and 173 with protocol (KET). Patients were severely injured with a mean ISS of 24 and median AIS score of the head/face of 3. Dosing in the KET group was appropriate with a mean dose of 1.9-mg/kg ketamine administered. Compliance after KET introduction approached 90%. Fifteen patients in the PRE group required redosing of medication versus three in the KET group (p < 0.05, χ). For patients younger than 14 years, (26 in PRE and 10 in KET), 2 patients in the PRE group required redosing and none in the KET group (not significant). In all patients, mean time from drug administration to intubation decreased from 4 minutes to 3 minutes. A standardized medication protocol simplifies RSI and allows efficient airway management of critically injured trauma patients in the ED of a teaching hospital. Incorporation of ketamine avoids potential complications of other commonly used RSI medications. Therapeutic study, level IV.

Abstract 308: A Preoxygenation “Bundle” Decreases Desaturation Events and Improves Intubation Success in Air Medical Rapid Sequence Intubation

Introduction: Oxygen desaturation occurs frequently in the course of prehospital rapid sequence intubation (RSI) and has been associated with increased morbidity and mortality. Preoxygenation with positive-pressure ventilation (PPV) may delay the onset of desaturation. However, PPV may not be used aggressively with emergency RSI due to concern for gastric insufflation precipitating regurgitation and aspiration events. Objective: To evaluate an aggressive preoxygenation protocol with regard to desaturation events during air medical RSI. Methods: The RSI protocol used in our air medical program airway training model was modified to employ several interventions designed to optimize preoxygenation prior to initial laryngoscopy. These included: two-person bag-valve-mask (BVM) ventilation, “two-thumbs-up” hand positioning on the mask, correct application of cricoid pressure, aggressive use of nasopharyngeal and oropharyngeal airways, small-volume assisted ventilation prior to administration of RSI medications, and large-volume ventilation following sedation/paralysis but prior to the initial laryngoscopy attempt. This algorithm identified a target SpO2 value of at least 93% based on a previous investigation. Desaturation events [decrease in SpO2 to &lt;90% or a continued decrease by at least 2% if initial SpO2 value was &lt;90%] were identified using physiologic data exported from hand held oximeter-capnometer devices. The incidence of desaturation events was established over a 2-year period prior to and the subsequent 2-year period following implementation of these algorithm changes. Results: A total of 155 RSI procedures were evaluated over the study period. Desaturation events decreased from 58% in the two years prior to the algorithm changes to 28% in the first year and 14% in the second year following implementation (chi-square test for trend p&lt;0.01). In addition, the intubation success rate increased from 94% to 97% following implementation of the protocol. There were no reports of major aspiration events during the study period. Conclusions: An aggressive preoxygenation protocol dramatically reduced the incidence of desaturation events and increased intubation success during air medical RSI without increasing aspiration events.

Emergency airway management in critically injured patients: A survey of U.S. aero-medical transport programs

Objective Pre-hospital airway management represents the intervention most likely to impact outcomes in critically injured patients. As such, airway management issues dominate quality improvement (QI) reviews of aero-medical programs. The purpose of this study was to evaluate current practice patterns of airway management in trauma among U.S. aero-medical service (AMS) programs. Methods The Association of Air Medical Services (AAMS) Resource Guide from 2005 to 2006 was utilized to identify the e-mail addresses of all directors of U.S. aero-medical transport programs. Program directors from 182 U.S. aero-medical programs were asked to participate in an anonymous, web-based survey of emergency airway management protocols and practices. Non-responders to the initial request were contacted a second time by e-mail. Results 89 programs responded. 98.9% have rapid sequence intubation (RSI) protocols. 90% use succinylcholine, 70% use long-acting neuromuscular blockers (NMB) within their RSI protocol. 77% have protocols for mandatory in-flight sedation but only 13% have similar protocols for maintenance paralytics. 60% administer long-acting NMB immediately after RSI, 13% after confirmation of neurological activity. Given clinical scenarios, however, 97% administer long-acting NMB to patients with scene and in-flight Glasgow Coma Scale (GCS) of 3, even for brief transport times. Conclusions The majority of AMS programs have well defined RSI and in-flight sedation protocols, while protocols for in-flight NMB are uncommon. Despite this, nearly all programs administer long-acting NMB following RSI, irrespective of GCS or flight time. Given the impact of in-flight NMB on initial assessment, early intervention, and injury severity scoring, a critical appraisal of current AMS airway management practices appears warranted.

In reply

Academic Emergency MedicineVolume 14, Issue 1 p. 100-101 Free Access In reply Xavier Combes MD, Corresponding Author Xavier Combes MD Service d'Aide Médicale Urgente (SAMU), Centre Hospitalier Universitaire (CHU) Henri Mondor, Créteil, France*Email: xavier.combes@hmn.aphp.fr)Search for more papers by this authorPatricia Jabre MD, Patricia Jabre MD SAMU 94, CHU Henri Mondor (AP-HP), Créteil, France and EA 3409, CHU Avicenne, Bobigny, FranceSearch for more papers by this authorFrederic Adnet MD, Ph.D., Frederic Adnet MD, Ph.D. SAMU 93, EA 3409, CHU Avicenne (AP-HP), Bobigny, FranceSearch for more papers by this authorGilles Dhonneur MD, Gilles Dhonneur MD Department of Anesthesia and Intensive Care Medicine, CHU Jean Verdier and EA 3409, Hospital Avicenne, Bobigny, FranceSearch for more papers by this author Xavier Combes MD, Corresponding Author Xavier Combes MD Service d'Aide Médicale Urgente (SAMU), Centre Hospitalier Universitaire (CHU) Henri Mondor, Créteil, France*Email: xavier.combes@hmn.aphp.fr)Search for more papers by this authorPatricia Jabre MD, Patricia Jabre MD SAMU 94, CHU Henri Mondor (AP-HP), Créteil, France and EA 3409, CHU Avicenne, Bobigny, FranceSearch for more papers by this authorFrederic Adnet MD, Ph.D., Frederic Adnet MD, Ph.D. SAMU 93, EA 3409, CHU Avicenne (AP-HP), Bobigny, FranceSearch for more papers by this authorGilles Dhonneur MD, Gilles Dhonneur MD Department of Anesthesia and Intensive Care Medicine, CHU Jean Verdier and EA 3409, Hospital Avicenne, Bobigny, FranceSearch for more papers by this author First published: 28 June 2008 https://doi.org/10.1197/j.aem.2006.08.014AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References Ricard-Hibon A, Chollet C, Leroy C Marty J. Succinylcholine improves the time of performance of a tracheal intubation in prehospital critical care medicine Eur J Anaesthesiol 2002; 19: 361– 367. Rose WD, Anderson LD, Edmond SA. Analysis of intubations. Before and after establishment of a rapid sequence intubation protocol for air medical use Air Med J 1994; 13: 475– 478. Konrad C, Schupfer G, Wietlisbach M Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86: 635– 639. Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg Med 2006; 47: 532– 541. Volume14, Issue1January 2007Pages 100-101 ReferencesRelatedInformation

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

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.

Comparison of intubation attempts and completion times before and after the initiation of a rapid sequence intubation protocol in an air medical transport program

The purpose of this study was to test the hypothesis that the initiation of a rapid sequence intubation (RSI) protocol would decrease the number of intubation attempts and completion times. In the summer of 2001, an RSI protocol was implemented using succinylcholine and etomidate. Before the RSI protocol, patients were sedated with versed and fentanyl for intubation and then paralyzed with succinylcholine to complete intubation, if needed. Retrospectively reviewed patient transport charts yielded 70 patients in the pre-RSI group and 70 patients in the RSI group. The number of attempts in the RSI group significantly dropped in the pre-RSI group, and the time from medication administration to intubation statistically decreased. In this study, the implementation of an RSI protocol resulted in fewer intubation attempts and more rapid intubations.

Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients.

The purpose of this study was to evaluate the effect of paramedic-administered neuromuscular blocking agents as part of a rapid-sequence intubation (RSI) protocol on successful intubation of severely head-injured patients in a large, urban prehospital system. Adult head-injured patients were prospectively enrolled over 1 year using these inclusion criteria: Glasgow Coma Scale (GCS) score of 3 to 8, transport time > 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. All adult trauma victims with a GCS score of 3 to 8 were identified during the first 12 months of the study as the trial cohort and from the preceding 12 months as the control cohort. The trial and control cohorts were compared with regard to demographic data, mechanism of injury, initial vital signs, and GCS scores. The primary outcome measure was intubation success, defined as insertion of either an endotracheal tube or a Combitube, with patients stratified by GCS score. The trial cohort (n = 249) and control cohort (n = 189) were similar with regard to demographic data, mechanism of injury, and initial vital signs and GCS scores. Intubation success rates increased significantly during the trial period for all patients and when stratified into GCS score of 3 and GCS score of 4 to 8. The percentage of patients intubated without neuromuscular blocking agents actually increased during the trial period. Although the number of intubations by helicopter flight crews decreased during the trial, the overall use of aeromedical resources did not change. Paramedic-administered neuromuscular blockade as part of an RSI protocol improves intubation success in a large, urban prehospital system.