Rapid sequence intubation in a prehospital environment

Background

Rapid sequence intubation (RSI) is the gold standard procedure for performing orotracheal intubation in emergency situations. Trying to intubate without RSI can be deleterious because of the hemodynamic and central nervous system reflexes that it causes. RSI may facilitate the establishment of a definitive airway and increase the success rate. Hypoxemia is a major contributor to poor outcomes in head-injury patients, and pre-hospital intubation can improve survival. Trauma patients who are managed using early intubation have been shown to have improved outcome. RSI in a prehospital environment is still little reported and used because of concern for respiratory paralysis and the possibility of nonintubation situations with a nonanesthetist and paramedics.

Objective

To analyze the efficiency, safety and complications of RSI, in a protocol-driven study, in a prehospital environment.

Methods

A retrospective, observational, protocol-driven study, which included all RSIs from 1998 to 2003. RSI was defined when at least one sedative followed by a neuromuscular blocking agent were administered together before orotracheal intubation. Intubations with sedative or neuromuscular blocking agents alone were excluded.

Results

A total of 696 patients were enrolled. Five patients were excluded because of incomplete data. In 621 patients, trauma was the leading indication for the procedure, with a success rate of 99.1%. In 0.9% (six patients) orotracheal intubation was not possible: two cases were treated by bag–valve–mask-assisted ventilatory support and four with surgical cricotiroidostomy (all of them with facial trauma; one dead). In the remaining 70 patients with nontraumatic indications, the success rate was 100%. In 364 patients from 1998 to 2001 the RSI was performed by nonanaesthetist doctors in 95.9%. In 588 patients (except 2002), the leading sedative used was ethomidate in 68.7% whereas the neuromuscular blocking agent was succinilcholine in 74.5%. Table 1 presents a data variable comparison from RSI in trauma versus nontrauma patients. Table 2 presents a data variable comparison from RSI in successful intubation versus failed intubation groups.

Table 1 Variable comparison from RSI in trauma versus nontrauma patients (n = 691)

Table 2 Variable comparison from RSI in successful intubation versus failed intubation groups (n = 621)

Conclusion

RSI is efficient, safe and with lower incidence of complications in achieving orotracheal intubation during the prehospital environment, in a protocol-driven series, and could be performed by nonanaesthetist doctors. In cases of trauma, mainly facial, and failure of orotracheal intubation, a surgical airway should be promptly available as a rescue technique.