Report: Prehospital RSI for Head Trauma Safe

[mediccjh]

Report: Prehospital RSI for Head Trauma Safe

2006 JUL 10 - (NewsRx.com) -- Prehospital rapid sequence intubation (RSI) for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport when a select experienced staff are properly trained.

According to a recent study from the United States, "Recent reports have questioned the safety and efficacy of prehospital RSI for patients with head trauma. The purpose of this study is to determine the rate of successful prehospital RSI, associated complications, and delays in transport of critically injured trauma patients treated by a select, well-trained group of paramedics with frequent exposure to this procedure and a rigorous quality control system. A helicopter paramedic group's database of patient flight records (1999 to 2003) was merged with registry data of a suburban Level I trauma center."

S.M. Fakhry and colleagues, Inova Fairfax Hospital, wrote, "Both databases included comprehensive performance improvement data. After Institutional Review Board approval, data were analyzed to determine RSI success rate, impact on oxygenation, delays in transport and complications associated with attempted RSI. Attempted RSI was defined as any insertion of the laryngoscope into the oropharynx. In all, 1,117 trauma patients were transported. One hundred and seventy-five had attempted RSI (74% male, mean age 31.1±19.2 years, 91% blunt trauma, 88% with Head/Neck AISgreater than or equal to2, mean Injury Severity Score 25.6, mean scene Glasgow Coma Scale score 4.8±2.4)."

They continued, "One hundred and sixty-nine patients (96.6%) had successful scene RSI. Seventy percent were intubated on the first attempt, 89% by the second attempt, and 96% by the third attempt. Of the six patients (3.4% overall) who failed RSI, (2.3% overall) had scene cricothyroidotomy and two (1.1% overall) were managed by bag-valve mask.

"Complications included five (2.9%) right mainstem intubations and 2 (1.2%) endotracheal tube dislodgments en route. There were no esophageal intubations. Four patients in extremis (2.3%) had arterial desaturations associated with RSL arterial blood gas analyzed upon arrival revealed (mean pCO2 36.6±8, median 37). Attempted RSI was associated with a mean of 6 minutes of added scene time. Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport."

The researchers concluded, "This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure. This is particularly important given the high rates of traumatic brain injury encountered."

Fakhry and colleagues published their study in the Journal of Trauma - Injury Infection and Critical Care (Prehospital rapid sequence intubation for head trauma: Conditions for a successful program. J TRAUMA, 2006;60(5):997-1001).

For additional information, contact S.M. Fakhry, Inova Fairfax Hospital, Trauma Service, Inova Regional Trauma Center, 3300 Gallos Rd., Falls Church, VA, USA.

Publisher contact information for the Journal of Trauma - Injury Infection and Critical Care is: Lippincott Williams & Wilkins, 530 Walnut St., Philadelphia, PA 19106-3621, USA.

OK boys and girls, have at it.

[Ace844]

"Medic ccj"

Thanks for the great post and info. It isa positive piece of literature although it should be noted. This study supports what we all know to be true anecdotally. Also, it was a retrospective chart review, not an active blinded outcome study...

Complications included five (2.9%) right mainstem intubations and 2 (1.2%) endotracheal tube dislodgments en route. There were no esophageal intubations. Four patients in extremis (2.3%) had arterial desaturations associated with RSL arterial blood gas analyzed upon arrival revealed (mean pCO2 36.6±8, median 37). Attempted RSI was associated with a mean of 6 minutes of added scene time. Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport."

also this was done before the widespread advent of 'real time' monitoring ETCO2 as well...Perhaps these numbers would also be different?

Food for thought,

Ace844

[Ridryder 911]

So what they are saying is we can RSI, or elective intubate; but we cannot routinely intubate with sucess?.. hmmm...

Yeah, this is dome good news, maybe the use of more skilled Paramedics, the use of EtCo[sub:2cabb00a31]2[/sub:2cabb00a31] monitoring. Maybe we can get our act together!

R/r 911

[flight-lp]

Key words, "select, experienced staff properly trained"!

"A helicopter paramedic group's database of patient flight records (1999 to 2003) was merged with registry data of a suburban Level I trauma center."

Kinda biased in IMHO, where is the data from the rural backwoods EMS service, the urban 911 service, and the routine interfacility transfer service. Hell, most people in the critical care realm focus heavily on airway management, lets see the data from those who do not necessarily receive the same advanced training............

[AZCEP]

I can see the extrapolation coming.

If one group can successfully perform RSI, then all should be able to. Flight crews can do it, why not ground medics, then why not all providers that have intubation in their scope? It won't take long to teach a couple of new drugs to people. Then everyone would be able to use it. Great idea. :roll:

Using this procedure as a merit badge isn't the best idea either, but it has to be controlled somehow. How much credibility do we give this study, when there is much more against prehospital intubation, than there is for it? We can't turn a blind eye, but at the same time don't hurt yourself jumping on the bandwagon.

[Ace844]

Hello Everyone,

Here's the full text of this study in case you were interested.

(Prehospital Rapid Sequence Intubation for Head Trauma: Conditions for a Successful Program

[Original Articles)

Fakhry, Samir M. MD, FACS; Scanlon, James M. MD; Robinson, Linda MA, MS; Askari, Reza MD; Watenpaugh, Rolland L. NREMT-P; Fata, Paola MD, FRCSC; Hauda, William E. MD; Trask, Arthur MD, FACS

From Trauma Services (S.M.F., J.M.S., L.R., R.A., P.F., A.L.T.), Inova Regional Trauma Center, Inova Fairfax Hospital, Falls Church, Virginia; the Department of Surgery (J.M.S., R.A.), George Washington University Medical Center, Washington, DC; and the Fairfax County Police Helicopter Division (R.L.W., W.E.H.), Fairfax, Virginia.

Submitted for publication June 3, 2005.

Accepted for publication February 16, 2006.

Presented as a poster at the 18th Annual Meeting of the Eastern Association for the Surgery of Trauma, January 12–15, 2005, Ft. Lauderdale, Florida.

Address for reprints: Samir M. Fakhry, MD, FACS, Trauma Services, Inova Regional Trauma Center, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA; email: samir.fakhry@inova.com.]

Abstract

Background: Recent reports have questioned the safety and efficacy of prehospital rapid sequence intubation (RSI) for patients with head trauma. The purpose of this study is to determine the rate of successful prehospital RSI, associated complications, and delays in transport of critically injured trauma patients treated by a select, well-trained group of paramedics with frequent exposure to this procedure and a rigorous quality control system.

Methods: A helicopter paramedic group’s database of patient flight records (1999 to 2003) was merged with registry data of a suburban Level I trauma center. Both databases included comprehensive performance improvement data. After Institutional Review Board approval, data were analyzed to determine RSI success rate, impact on oxygenation, delays in transport and complications associated with attempted RSI. Attempted RSI was defined as any insertion of the laryngoscope into the oropharynx.

Results: In all, 1,117 trauma patients were transported. One hundred and seventy-five had attempted RSI (74% male, mean age 31.1 ± 19.2 years, 91% blunt trauma, 88% with Head/Neck AIS >=2, mean Injury Severity Score 25.6, mean scene Glasgow Coma Scale score 4.8 ± 2.4). One hundred and sixty-nine patients (96.6%) had successful scene RSI. Seventy percent were intubated on the first attempt, 89% by the second attempt, and 96% by the third attempt. Of the six patients (3.4% overall) who failed RSI, (2.3% overall) had scene cricothyroidotomy and two (1.1% overall) were managed by bag-valve mask. Complications included five (2.9%) right mainstem intubations and 2 (1.2%) endotracheal tube dislodgments en route. There were no esophageal intubations. Four patients in extremis (2.3%) had arterial desaturations associated with RSI. Arterial blood gas analyzed upon arrival revealed (mean pCO2 36.6 ± 8, median 37). Attempted RSI was associated with a mean of 6 minutes of added scene time.

Conclusion: Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport. This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure. This is particularly important given the high rates of traumatic brain injury encountered.

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More than 2 million patients are transported annually in the United States by emergency medical services (EMS) after traumatic brain injury (TBI). In-field mortality approaches 50,000 and another 200,000 either die later or experience permanent disability at great economic and social expense.1 Historically, recommendations for the prehospital care of the severely head injured patient included acute airway management with rapid sequence intubation (RSI). This recommendation has recently received increased scrutiny and has been questioned as potentially deleterious.2–7 EMS personnel have demonstrated their ability to safely and effectively perform rapid sequence intubation (RSI) in several studies.1,7–9 Airway control in head injured patients is critical in avoiding the deleterious effects of “secondary brain injury.”10–12 Despite the apparent advantages of quickly and safely establishing a definitive airway in TBI patients, recent studies have unexpectedly reported worse outcomes for these patients.5–6 The reasons for these findings are not entirely clear but could include differences in patient and/or EMS provider groups and/or a negative effect of field RSI.

Our experience with prehospital RSI performed by two aeromedical groups serving our 750-bed regional Level I trauma center suggested very low rates of complications and high success rates in achieving prehospital RSI. Our experience differed from most reports of suboptimal outcomes after field RSI for TBI in that our prehospital airway management and RSI were performed by a small group of well-trained, closely supervised paramedics with frequent opportunities to perform the procedure. The primary purpose of this study was to formally review the procedural experience and outcomes of one of these prehospital units with RSI in severely injured patients with high rates of TBI. A secondary purpose was to explore possible explanations for divergent results between our program and other recent reports.

PATIENTS AND METHODS

This study was a retrospective analysis of EMS and hospital patient data collected over a 4-year period (1999–2003) in a large suburban, American College of Surgeons verified, Level I trauma system that provides care to over 3,500 trauma patients a year. Data from the aeromedical group serving this cachement area of 1 million residents was chosen for analysis because of uniformity of prehospital care provided, very short transport times, and quality of data. Any trauma patient who underwent attempted RSI by this aeromedical group and was transported to the study hospital, regardless of age, was included in the study. Patients received lidocaine 1.5 mg/kg then either midazolam 0.1 mg/kg (to a max of 5 mg) or etomidate 0.3 mg/kg (to a max of 20 mg) and vecuronium 0.15 mg/kg (to a maximum of 10 mg). The protocol utilized by the aeromedical group is attached as Appendix A. The prehospital data included preintubation vital signs, pulse-oximetry, and Glasgow Coma Score (GCS). Postintubation data consisted of the same information as well as a detailed RSI procedure narrative providing additional data including the name of the operator, number of RSI attempts, drugs administered, and details of the patient’s condition during transport. An intubation “attempt” was defined as any insertion of the laryngoscope into the oropharynx. These data are routinely collected by the paramedics on each patient encounter. Registry/medical record variables included arrival vital signs, pulse oximetry, GCS, endotracheal tube (ETT) placement (as determined by an attending anesthesiologist and trauma surgeon), arterial blood gas (ABG) drawn within 15 minutes of arrival, injury severity score (ISS), abbreviated head injury score (H-AIS), intensive care unit (ICU) length of stay, total length of stay, and mortality. The aeromedical and Trauma Registry databases were merged. Additional or confirming information was obtained from medical records as needed.

When data compilation was complete, all data were deidentified. All study procedures and data protection methods were approved by the Institutional Review Board before data compilation and analysis.

RESULTS

Between 1999 and 2003, 1,117 trauma patients were transported by the aeromedical service, and of these, 175 had attempted RSI (Table 1). This group of patients was predominantly male (74%) and had a mean age of 31.1 ± 19.2 years. The mechanism of injury was 91% blunt trauma and 9% penetrating trauma. Motor vehicle collisions accounted for over 80% of the blunt trauma patients. As a result, 88% of all the patients had a Head/Neck Abbreviated Injury (AIS) Score >=2. This was a severely injured group with a mean Injury Severity Score (ISS) of 25.7 ± 13.9 and a mean scene Glasgow Coma Score (GCS) of 4.8 ± 2.4. Of the 175 patients who underwent attempted RSI, 169 patients (96.6%) were successful with 70% intubated on the first attempt, 89% by the second attempt, and 96.6% by the third attempt. (Table 2). Of the six patients (3.4% overall) with failed RSI, four (2.3% overall) received successful scene cricothyroidotomy and two (1.1% overall) were managed by bag-valve mask (BVM). The protocols used by this group allowed three attempts at orotracheal intubation before other means (i.e. surgical airway or BVM) were employed. An attempt was defined as any insertion of the laryngoscope into the oropharynx. Complications included five (2.9%) right mainstem bronchus intubations and two (1.2%) ET tube dislodgements en route (Table 3). There were no esophageal intubations. Continuous pulse oximetry was used during the prehospital RSI procedure and during transport to the trauma center. Four patients (2.3%) had arterial desaturations (SaO2 < 92%) associated with RSI and all were receiving CPR at the time. Arterial blood gas, analyzed upon arrival to the trauma center, revealed mean pCO2 36.6 ± 8. Overall mortality was 31%. Comparison with non-RSI patients transported by this same helicopter group revealed that attempted RSI was associated with a mean of 6 minutes of added scene time.

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[Email Jumpstart To Image] Table 1 Characteristics of Study Population (n = 175)

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[Email Jumpstart To Image] Table 2 Results of Rapid Sequence Intubation (n = 175)

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[Email Jumpstart To Image] Table 3 Results of RSI

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DISCUSSION

Primary brain injury has been shown to cause hypoventilation and inability to protect the airway. This and other factors place these patients at very high risk for the deleterious effects of secondary brain injury.13 Secondary injury, including systemic hypoxemia, hypercapnia, acidosis and hypotension, can worsen brain injury and has been shown to increase mortality.9–10,12

Several studies have shown that endotracheal intubation can be safely and effectively performed by prehospital caregivers.1,7–8,14 Properly trained prehospital personnel can perform this procedure with a degree of accuracy equal to anesthesiologists in the more ideal setting of an emergency room.4,14,15 It would seem reasonable to assume that properly trained EMS personnel who maintain their skill set should perform RSI for appropriately selected patients in the field for the same reasons that a physician would perform RSI upon the patient’s arrival in the trauma bay.

Two recent studies examined the effect of pre-hospital RSI on the outcomes of trauma patients with TBI. Bochicchio et al.5 described their experience with 192 TBI patients. Forty-one percent were intubated in the field by paramedics and the rest were intubated on arrival by anesthesiology. Although air crews (responsible for 67% of transports) received training at the authors’ facility, the ground providers had varying levels of training and experience. Although field intubated patients had significantly higher mortality than those receiving in-hospital intubations (23% vs. 12%), longer hospital and ICU stays, and higher rates of pneumonia, differences in both the emergency medical services (EMS) operators and patient groups limit this study. The aeromedical group was likely more thoroughly trained and experienced than the ground crews. Further, patients in the field intubation group had a lower rate of surgically remediable brain injuries and were significantly less likely to have undergone early operative decompression despite similar head AIS. Given the limitations of the study design, this study does not provide conclusive data on the effects of RSI in TBI patients.

Davis et al.6 prospectively enrolled patients having suspected severe TBI (scene GCS 3 to 8), transport times of greater than 10 minutes, and inability to intubate without RSI. In all, 209 field intubated patients (the trial group) were “hand-matched” to 627 unintubated historical patients (the control group) from the previous 10 years of the trauma registry. The trial group had an in-hospital mortality of 41.1% versus 24.2% for the controls. Rates of “inadvertent hyperventilation,” scene times, and ED arrival oxygen levels were also higher in the trial group. A critical limitation of this study is the number of individuals trained for RSI versus the number of potential RSI experiences available. Over 500 paramedics received a single 8-hour class before data collection and the procedure was performed on only 250 patients, a ratio of two paramedics for every intubation available in a 1-year period. Additional potential confounders include the use of historical controls, the lack of end-tidal CO2 monitoring and the inclusion of 12% Combitube insertions. These studies and others have raised important questions about the role of prehospital RSI for severe TBI. These questions can be best addressed by a large, well-designed, and well- conducted randomized clinical trial that could discriminate between the effects of the procedure itself, the performance of the operator and the setting in which the procedure is performed. Studies such as those quoted above report on the performance of large cohorts of prehospital personnel who receive variable (usually modest) training in the procedure and its indications, little or no follow-up instruction, and relatively infrequent opportunities to actually perform the procedure under difficult circumstances. It is important to note that earlier studies have shown that repeated exposure and opportunity to perform RSI led to improved performance and safety.11,16

It may be appropriate to conclude that the approach to disseminating prehospital RSI reported in these studies is not optimal for improving the prehospital management of patients with severe TBI. The issue may thus be who is doing the intubation (and how) and not whether intubation is appropriate. This seems reasonable in light of the current standard of intubating patients with severe TBI on arrival in the trauma bay. The goal of our study was to examine whether the application of prehospital RSI by a small, well-trained group of paramedics could be accomplished with success rates similar to those achievable in the trauma bay without undue complications. We reasoned that providing evidence of equivalence to the accepted standard of care in the trauma bay was important, especially in the absence of a well-constructed randomized clinical trial. Our RSI program operates in a densely populated area (1 million people in 395 square miles) where no point is further than 12 minutes by air from the trauma center. This aeromedical group responds to the scene when EMS has determined an airway problem is present or anticipated, or transport to the trauma center is longer than 10 minutes by ground. Most significant is that only six paramedics were responsible for 175 intubations during the period of the study. These paramedics are rigorously trained in RSI and the program includes regular continuing education and quality improvement (Table 4). The end result is a small, highly trained, highly experienced, and proficient group of paramedics who are quickly available to perform this procedure on injured patients within their jurisdiction.

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[Email Jumpstart To Image] Table 4. Fairfax Training Model

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Our study demonstrates a very high success rate for RSI (96.6%). This rate compares very favorably with other series.1,14,16,17 Complication rates in our series were very low. Among the most serious complications reported in other studies is esophageal intubation with rates as high as 9%.18 There were no esophageal intubations in our series. In this study, RSI added only 6 minutes of scene time, a value on the lower end of the ranges reported.5,6,16,18 The incidence of hypoxemia was minimal. Pre, post, transport and arrival pulse oximeter readings revealed only four patients had a worsening of their oxygen saturation, all of whom had no signs of life at the scene and were receiving cardiopulmonary resuscitation. Arterial blood gas samples drawn within 5 to 10 minutes of arrival in the trauma bay showed that intubated patients were not being hyperventilated. This is likely due to the use of continuous end-tidal capnometry by this paramedic group to guide ventilation.18 The average pCO2 on arrival was 36 mm Hg, well within acceptable ranges.

CONCLUSION

The high rate of successful prehospital RSI and the low rates of associated complications in this series are comparable to rates for in-hospital airway management, and support the continued use of prehospital RSI by trained providers for TBI patients. This is especially true in the absence of Class 1 data ascribing deleterious effects to the procedure itself and not to the circumstances under which it is performed. In our experience, prehospital RSI for trauma patients can be safely and effectively performed with low rates of complications and without significant delays in transport. This study strongly suggests that resources for prehospital airway management should be focused on training, regular experience and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure. This is particularly important given the high rates of traumatic brain injury encountered.

APPENDIX: PARAMEDIC RSI PROCEDURE

1. Perform an assessment of the patient and attempt to obtain any pertinent medical history. If the patient is conscious, attempt to explain the procedure to the patient.

2. Verify that the patient has oxygen applied, patent IV access, the cardiac monitor applied, and that suction is available and working.

3. Prepare the intubation equipment.

4. Preoxygenate the patient utilizing the bag-valve mask (BVM) in a patient requiring ventilation assistance or high flow oxygen in the spontaneously breathing patient with adequate respiratory effort.

5. Cricoid pressure should be initiated and maintained before administration of medications.

6. If IV or IO access is established:

a. In the head-injured patient, administer lidocaine 1.5 mg/kg

b. In the patient less than 8 years old, administer atropine 0.02 mg/kg, with a minimum dose of 0.1 and a maximum of 1 mg

c. Administer a sedative:

(1) Midazolam 0.1 mg/kg to a maximum of 5 mg

(2) Etomidate 0.3 mg/kg to a maximum of 20 mg

d. Administer vecuronium 0.15 mg/kg to a maximum of 10 mg

7. If no IV or IO access can be established quickly:

a. Administer midazolam 0.3 mg/kg IM

b. In the patient less than 8 years old, administer atropine 0.02 mg/kg IM, with a minimum dose of 0.1 mg and a maximum dose of 1 mg

8. After the medication administration, continue to assist the ventilations with the BVM or begin assistance with ventilation when the patient’s respiratory effort declines. Once the medication has taken effect, intubate the patient via the oral route. There will be a maximum of three attempts of direct laryngoscopy by the flight crew. If unable to intubate the patient then follow the Difficult Airway section.

9. If the intubation is successful, verify the tube placement by one or more of the following:

a. Visualization of the tube passing through the vocal cords

b. End-tidal CO2 detection

c. Esophageal detector device

d. Condensation in the tube

e. Symmetric bilateral breath sounds

f. Lack of epigastric sounds during positive pressure ventilation

g. Adequate chest rise during positive pressure ventilation

h. Improvement in pulse oximetry

i. Improvement in patient’s clinical condition

10. Secure the tube:

a. Intraoral tube holding device (e.g., Thomas Tube Holder)

b. Tape affixed to the endotracheal tube and the patient’s face

11. Maintain adequate sedation

a. Repeat midazolam dose every 15 minutes

b. If etomidate was used for intubation, administer midazolam 0.05 mg/kg within 10 minutes of intubation. Repeat midazolam dose every 15 minutes.

[Context Link]

REFERENCES

1. Ochs M, Davis D, Hoyt D, et al. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med. 2002;40:159–167. Bibliographic Links [Context Link]

2. Wang H, Yealy D. Out-of-hospital rapid sequence intubation: is this really the “success” we envisioned? Ann Emerg Med. 2002;40:168–171. Bibliographic Links [Context Link]

3. Murray JA, Demetriades D, Berne TV, et al. Prehospital intubation in patients with severe head injury. J Trauma. 2000;49:1065–1079. Ovid Full Text Bibliographic Links [Context Link]

4. Sloane C, Vilke G, Chan T, et al. Rapid sequence intubation in the field versus hospital in trauma patients. J Emerg Med. 2000;19:259–264. Bibliographic Links [Context Link]

5. Bochicchio G, Ilahi O, Joshi M, et al. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. J Trauma. 2003;54:307–311. Ovid Full Text Bibliographic Links [Context Link]

6. Davis D, Hoyt D, Ochs M, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;54:444–453. Ovid Full Text Bibliographic Links [Context Link]

7. Helm M, Hauke J, Lampl L. A prospective study of the quality of pre-hospital emergency ventilation in patients with severe head injury. Br J Anes. 2002;88:345–334. [Context Link]

8. Winchell R, Hoyt D. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg. 1997;132:592–595. Ovid Full Text Bibliographic Links [Context Link]

9. Davis D, Ochs M, Hoyt D, et al. Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients. J Trauma. 2003;55:713–719. Ovid Full Text Bibliographic Links [Context Link]

10. Chesnut R, Marshall L, Klauber M, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216–222. Bibliographic Links [Context Link]

11. Manley G, Knudson M, Morabito D, et al. Hypotension, hypoxia, and head injury. Arch Surg. 2001;136:1118–1123. [Context Link]

12. Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in head injury. J Trauma. 1996;40:764–767. Ovid Full Text Bibliographic Links [Context Link]

13. Atkinson J. The neglected prehospital phase of head injury: apnea and catecholamine surge. Mayo Clin Proc. 2000;75:37–47. Ovid Full Text Bibliographic Links [Context Link]

14. Dunham C, Barraaco R, Clark D, et al. Guidelines for emergency tracheal intubation immediately after traumatic injury. J Trauma. 2003;55:162–179. Ovid Full Text Bibliographic Links [Context Link]

15. Ummenhofer W, Scheidegger D. Role of the physician in prehospital management of trauma: european perspective. Curr Op Crit Care. 2002;8:559–565. [Context Link]

16. Eckstein M, Chan L, Schneir A, et al. Effect of prehospital advanced life support on outcomes of major trauma patients. J Trauma. 2000;48:643–648. Ovid Full Text Bibliographic Links [Context Link]

17. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma. 2000;49:584–599. Ovid Full Text Bibliographic Links [Context Link]

18. Helm M, Schuster R, Hauke J, et al. Tight control of prehospital ventilation by capnography in major trauma victims. Br J Anes. 2003;90:327–332. [Context Link]

[Ace844]

LETTER

Prehospital Intubation – Delving deeper into the evidence

R J Dawes

Correspondence to:

R J Dawes

Training Officer, Hampshire BASICS; rob.d@doctors.org.uk

May I thank Ayan Sen and Raj Nichani for their recent "Best Bet" on prehospital intubation in head injury.1 It was a pity however, that they neglected to look deeper into the reasons why their conclusion, at least at this point in time, was that there is insufficient evidence to support its use. The very topic of prehospital rapid sequence induction (RSI), was the subject of a panel discussion and presentation at the National Association of Emergency Medical Service Physicians annual meeting in Arizona in 2004.2 They, fortunately, delved deeper into the issues surrounding RSI in head injured patients. One of the most important findings from this discussion was that most of the ambulance services involved in studies surrounding RSI/sedation assisted intubation, did so without the benefit of End-Tidal Carbon Dioxide (ETCo2) or even oxygen saturation monitoring. This, coupled with the widespread use of hyperventilation and inadequate preoxygenation went some way to explain the adverse findings found.

In one of the largest studies, the San Diego Paramedic RSI study, when one ambulance service introduced the use of ETCo2 monitoring, further analysis found hyperventilation (<30 mmhg) occurred in 79% and severe hyperventilation (<25 mmhg) occurred in 59% of intubated patients.3 Post introduction of ETCo2 monitoring, the incidence of inadvertent hyperventilation was significantly reduced. The only RSI subgroup without increased mortality were in those patients who underwent paramedic RSI but were then transported by air medical crews who had substantial experience using ETCo2 to guide ventilation.

The San Diego trial uncovered many adverse findings, but in a positive light, many important lessons were learned. First, advanced monitoring including pulse oximetry and ETCo2 should be mandatory when performing ETI with or without RSI. Second, adequate preoxygenation prior to RSI and close oxygen saturation monitoring during laryngoscopy should be routine. Third, hyperventilation should be avoided. In stark contrast to the San Diego study, the Whatcom Medic One program in Washington has experienced none of the desaturation/bradycardia issues and has an intubation success rate of 96.6%. All failed intubations were successfully managed. This successful RSI program is as a result of rigorous training, clinical governance, medical oversight, continuous quality assurance and of course the investment in adequate monitoring including ETCo2.

The most startling contrast between the USA and the UK, is that only physicians here undertake RSI. The monitoring described above is now mandatory in the emergency department (ED) and the anaesthetic room after a position statement by both the Royal College of Anaesthetists and our own faculty. In my scheme (Hampshire) and many others, we fully extend this to the prehospital theatre. In conclusion, if we are to accept that RSI in traumatic brain injury is a valid and meaningful intervention in the ED, then would it not follow that this is also true prehospital?

References

Sen A, Nichani R. Prehospital endotracheal intubation in adult major trauma patients with head injury. Emerg Med J 2005;22.

Wang HE, et al. Prehospital Rapid Sequence Intubation – What does the evidence show? : Proceedings from the 2004 national association of EMS physicians annual meeting, Prehospital Emergency Care Volume 8 No 4.

Position Statement 1: Confirmation of endotracheal tube placement with end tidal CO2 detection: March 2001. Emerg Med J 2001;18:329.

[AZCEP]

:shock: :shock: :shock: :shock: :shock:

I'm I reading that right? A physician is saying that if one group of paramedics can do it then so should another group?

:shock: :shock: :shock: :shock: :shock: :shock:

Did I miss something? Where am I? What happened to "paramedics can't intubate"?

I feel dizzy all of a sudden. I better step away from the internet for a moment.

[Ace844]

:shock: :shock: :shock: :shock: :shock:

I'm I reading that right? A physician is saying that if one group of paramedics can do it then so should another group?

:shock: :shock: :shock: :shock: :shock: :shock:

Did I miss something? Where am I? What happened to "paramedics can't intubate"?

I feel dizzy all of a sudden. I better step away from the internet for a moment.

I knew you would like that.... :shock: 8)