Use Of Rapid Sequence Intubation Research Articles

Combitube as Rescue Airway Device for Out-of-Hospital RSI

Concerns about rescue options in the event of failed intubation have limited prehospital use of rapid sequence intubation (RSI). In the San Diego Paramedic RSI Trial, in which investigators assessed the safety and efficacy of paramedic-performed RSI in adults with severe head injuries, paramedics were required to insert a Combitube after 3 (or fewer) unsuccessful intubation attempts. …

The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury.

To determine the effects of rapid sequence intubation in patients with severe head injury performed by paramedics on a helicopter emergency medical service. The patient care records for patients with severe head injury who underwent rapid sequence intubation between November 1999 and February 2002 (inclusive) were examined. Data were extracted on the demographics of the patients, as well as the physiological changes before and after rapid sequence intubation. There were 122 patients with severe head injury evaluated at the scene during the study period. Rapid sequence intubation was attempted in 110 patients and was successful in 107 (97%). Intubation was associated with improvements in systolic blood pressure, oxygen saturation and end-tidal carbon dioxide levels, compared with baseline levels. Rapid sequence intubation in patients with severe head injury may be safely undertaken by helicopter-based ambulance paramedics and is associated with improvements in oxygenation, ventilation and blood pressure. Further studies of this skill undertaken by road-based paramedics are warranted.

F AILED P REHOSPITAL I NTUBATIONS : A N A NALYSIS OF E MERGENCY D EPARTMENT C OURSES AND O UTCOMES

Objective. To examine the reasons for failed prehospital endotracheal intubation (ETI) and to identify how the airway was subsequently managed in the emergency department (ED). Methods. Data were collected from January to December 1998 for a county-wide paramedic system. Failed prehospital ETIs and perceived reasons for failure were identified. Subsequent ED airway management was reviewed. Results. During the study period there were 13,112 patient contacts resulting in ETI attempts on 592 patients, of whom 536 (90.5%) were successfully intubated. Of the 56 failed field intubations, 49 (87.5%) had ED charts available for review. Endotracheal intubation failure was associated with inadequate relaxation in 24 (49%), difficult anatomy in ten (20%), and obstruction in five (10%). Successful ETI was achieved in the ED in 42 cases (86%). Twenty cases (41%) were facilitated by rapid-sequence intubation (RSI) in the ED. For those with incomplete relaxation in the field, 13 of 24 (54%) were intubated in the ED using RSI. Factors associated with the use of ED RSI include attempted prehospital nasotracheal intubation or attempted prehospital midazolam-facilitated intubation (p < 0.001). The predicted need for RSI in this prehospital system is approximately 3.9%. In eight cases, three or more ETI attempts or the use of rescue airways was required in the ED. The predicted minimum incidence of “truly difficult” intubation in this system is approximately 0.8–1.6%. Conclusions. Paramedic intubation failures result from a variety of factors. Less than half of field intubation failures were remedied in the ED by the use of neuromuscular-blocking agents. A similar number were intubated without the use of RSI. A fraction of failed field ETIs may have resulted from inadequate operator training or experience. A small percentage of field patients were “truly difficult” and required advanced resources in the ED to facilitate airway management. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways.

Are Paralytic Agents Needed for Emergency Intubation

The use of rapid sequence intubation (RSI) with neuromuscular blocking agents (NMBAs) has been touted widely for endotracheal intubation (ETI) in the ED and in the field. This German trial evaluated the success of ETI in the field by physicians without the aid of NMBAs from 1993 to 1997. Physicians used midazolam (10 mg to 30 mg) and fentanyl (0.25 …