Tag Archives: RSI

EM trainee RSI experience

A single centre observational study of rapid sequence intubation (RSI) was performed in a Scottish Emergency Department (ED) over four and a quarter years, followed by a postal survey of ED RSI operators.
There were 329 RSIs during the study period. RSI was performed by emergency physicians (both trained specialists and training grade, or ‘registrar’ doctors) in 288 (88%) patients. Complication rates were low and there were only two failed intubations requiring surgical airways (0.6%). ED registrars were the predominant RSI operator, with 206 patients (63%). ED consultants performed RSIs on 82 (25%) patients, anaesthetic registrars on 31 (9.4%) patients, and anaesthetic consultants on 8 (2.4%) patients. An ED consultant was present during every RSI performed and an anaesthetist was present during 72 (22%). The average number of ED registrars during this period of training was 8. This equates to each ED trainee performing approximately 26 ED RSIs (6.5 RSIs/year). On average, ED consultants performed 14 RSIs during this period (approx 3.5 RSIs/year). Of the 17 questionnaires, 12 were completed, in all of which cases the trainees were confident to perform RSI independently at the end of registrar training. Interestingly, 45 (14%) of the RSIs in the study were done in the pre-hospital environment by ED staff, two thirds of which were done by ED consultants.
Training and competency in rapid sequence intubation: the perspective from a Scottish teaching hospital emergency department
Emerg Med J. 2010 Sep 15. [Epub ahead of print]

Roc quicker when bicarb added

Interesting…a randomised trial compared rocuronium mixed with saline against rocuronium mixed 1:1 with 8.4% sodium bicarbonate.
The principal finding was that rocuronium mixed with sodium bicarbonate 8.4% is more potent than that of rocuronium alone; it resulted in a more rapid onset time, and a prolonged recovery from the neuromuscular blockade.
It is likely that this effect is because the drug is weakly basic, and the change in pH from 4.01 to 7.78 seen after the addition of sodium bicarbonate 8.4% to rocuronium increases the amount of unionised rocuronium in the solution.
I suppose we could just give a bigger dose if we need to though.
Potency and recovery characteristics of rocuronium mixed with sodium bicarbonate
Anaesthesia. 2010;65(9):899–903

Unexpected survivors after pre-hospital intubation

Data on patients with moderate to severe traumatic brain injury from the San Diego Trauma Registry were analysed using modified TRISS methodology to determine predicted survival, from which an observed-predicted survival differential (OPSD) was calculated. The mean OPSD was calculated as the primary outcome for the following comparisons: intubated versus nonintubated, air versus ground transport, eucapnia (PCO2 30–50 mm Hg) versus noneucapnia, and hypoxemia (PO<90 mm Hg) versus nonhypoxemia. Of note in this region is that ground EMS staff intubate without drugs, whereas air medical services use rapid sequence intubation with suxamethonium plus either etomidate or midazolam. The rationale behind this methodology was to eliminate the possible selection bias present in previous studies linking pre-hospital intubation with mortality (sicker patients are able to be intubated without drugs). A total of 9,018 TBI patients had complete data to allow calculation of probability of survival using TRISS. A total of 16.7% of patients were intubated in the field; 49.6% of these were transported by air medical providers. Patients undergoing prehospital intubation, transported by ground, with arrival eucapnia, and without arrival hypoxemia had higher mean OPSD values. Intubated patients were more likely to be “unexpected survivors” and live to hospital discharge despite low predicted survival values; patients transported by air medical personnel had higher OPSD values and had a higher proportion of unexpected survivors. No statistically significant differences were observed between air- and ground-transported patients with regard to arrival PCO2 values arrival PO2 values. Prehospital Airway and Ventilation Management: A Trauma Score and Injury Severity Score-Based Analysis
J Trauma. 2010 Aug;69(2):294-301

Etomidate in RSI – systematic review

A systematic review of 20 included studies comparing a bolus dose of etomidate for rapid sequence induction with other induction agents resulted in the following conclusion:
“The available evidence suggests that etomidate suppresses adrenal function transiently without demonstrating a significant effect on mortality. However, no studies to date have been powered to detect a difference in hospital, ventilator, or ICU length of stay or in mortality”
The Effect of a Bolus Dose of Etomidate on Cortisol Levels, Mortality, and Health Services Utilization: A Systematic Review
Ann Emerg Med. 2010 Aug;56(2):105-13

Less RSI desaturation with Roc

Some of my pre-hospital critical care colleagues in the UK exclusively use rocuronium in preference to suxamethonium for rapid sequence induction (RSI) of anaesthesia in critically ill patients. I couldn’t see a good reason to switch although now there’s some evidence that adds to the argument.
The muscle fasciculations caused by the depolarising effect of suxamethonium may increase oxygen consumption, which may shorten the apnoea time before desaturation. Non-depolarising neuromuscular blockers such as rocuronium should allow a longer apnoea time after RSI. In addition, drugs which reduce fasciculations (such as lidocaine and fentanyl) should delay the the onset of desaturation when given prior to suxamethonium.

A large dose of Roc

These hypotheses were tested in a blinded, randomised controlled trial in 60 ASA-1 or -2 patients, who were scheduled for elective surgery under general anaesthesia. All patients received 2mg/kg propofol. One group was randomised to receive suxamethonium 1.5 mg/kg, a second group received rocuronium 1mg/kg plus lidocaine 1.5mg/kg and fentanyl 2mcg/kg, and a third group was given suxamethonium 1.5 mg/kg plus lidocaine 1.5mg/kg and fentanyl 2mcg/kg. The facemask was removed 50 seconds after the neuromuscular blocker was given and patients were intubated; the tube was then left open to air until desaturation to 95% occurred, which was timed.
Desaturation occurred significantly sooner in the suxamethonium-only group, followed by the sux/lido/fentanyl group, followed by the roc/lido/fentanyl group.
Of course these results are not necessarily directly applicable to the critically ill patient, and in this study there was no direct comparison between induction agent + rocuronium only and induction agent + suxamethonium only. Nevertheless the argument that suxamethonium-induced muscle fasciculations contribute to an avoidable increase in oxygen consumption is persuasive.
Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction
Anaesthesia. 2010 Apr;65(4):358-61

Pre-hospital RSI successes

A couple of papers in Prehospital Emergency Care this month contribute to the pre-hospital airway management / rapid sequence intubation (RSI) literature.
Intensive physician oversight of a pre-hospital RSI program increased the prescription of post-intubation morphine and midazolam, and decreased vecuronium use, although did not significantly increase the successful intubation rate in a before-and-after study. There was also an improvement in patient selection for RSI.
Effect of intensive physician oversight on a prehospital rapid-sequence intubation program
Prehosp Emerg Care. 2010 Jul-Sep;14(3):310-6
A prospective study examined intubation success rates and peri-intubation hypoxaemia in critical care transport (CCT) services in North America, whose services are mainly crewed by registered nurses (RNs) and emergency medical technicians–paramedic (EMT-Ps).
There was a mixture of pre-hospital and interhospital work: 51.9% of the 603 patients studied were intubated at the trauma scene, 27% were intubated inside a hospital, and interestingly 21.1% were intubated inside a vehicle (most of which were helicopters).
Neuromuscular blockade was used to facilitate intubation in only 428 patients (71%). Endotracheal intubation (ETI) was successful in 582 patients (96.5% of 603, 95% CI 94.7-97.8%). There was a greater need (p < 0.001) for multiple attempts at ETI when CCT crews performed the procedure in transport (37.3%) as compared with rate of requirement for multiple ETI attempts while in hospital (16.6%) or on scene (19.4%). Logistic regression identified a three-fold increase in the odds of requiring multiple attempts for intratransport ETI as compared with in-hospital ETI (OR 3.0, 95 CI 1.7–5.2, p < 0.001). 21 patients (3.5%) could not be intubated by the CCT crews resulting in a number of different rescue modalities including 3 cricothyroidotomies. At least there were no unrecognised oesophageal intubations. There were low rates of new hypoxaemia but peri-ETI SpO2 was only recorded for 494 patients (82%).
Airway management success and hypoxemia rates in air and ground critical care transport: a prospective multicenter study
Prehosp Emerg Care. 2010 Jul-Sep;14(3):283

Pre-hospital RSI

Physicians from HEMS London document their experience of 400 pre-hospital rapid sequence induction / intubations. Their data are consistent with the experience of other similar services and with the emergency airway management literature in general:

  • Failure to intubate is rare
  • Removing cricoid pressure often improves the view
  • A BURP manoeuvre can improve the view and facilitate intubation, but bimanual laryngoscopy / external laryngeal manipulation is better
  • Having an SOP optimises first-pass success rate

Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: Essential safety measure or a hindrance to rapid safe intubation?
Resuscitation 2010(81):810–816

Guideline improved pre-hospital RSI in kids


French physicians provide pre-hospital critical care in medical teams of regional SAMU (service d’aide me ́dicale urgente). A national guideline was introduced in France to guide the management of traumatic brain injury (TBI), which included airway management. A study was conducted which examined the practice of paediatric pre-hospital intubation in TBI in comatose children both before and after the introduction of the guideline.
After the guideline there were more pre-hospital intubations, with more standardised approach to rapid sequence induction(RSI). There were fewer complications and a 100% intubation success rate. Despite an increase in portable capnography use, PaCO2 was measured outside the recommended range of 35– 40 mmHg (3.5-4.5 kPa) in 70% of the cases upon arrival.
Emergency tracheal intubation of severely head-injured children: Changing daily practice after implementation of national guidelines
Pediatr Crit Care Med. 2010 May 13. [Epub ahead of print]

Pre-hospital intubation experience and outcomes

Hospitals and medical personnel performing high volumes of procedures demonstrate better patient outcomes and fewer adverse events. The relationship between rescuer experience and patient survival for out-of-hospital endotracheal intubation is unknown.
An American study analysing 3 statewide databases with 26,000 records aimed to determine the association between endotracheal intubation experience and patient survival.
In-the-field intubators were EMS paramedics, nurses, and physicians, although paramedics performed more than 94% of out-of-hospital tracheal intubations. Although all air medical rescuers may use neuromuscular- blockade-assisted (rapid sequence) tracheal intubation, select ground EMS units are allowed to use tracheal intubation facilitated by sedatives only; the rest are done ‘cold’.

Patients in cardiac arrest and medical nonarrest experienced increased odds of survival when intubated by rescuers with high procedural experience. In trauma patients, survival was not associated with rescuer experience.
The odds of survival for air medical trauma patients were almost twice that of other patients, which may be related to the use of neuromuscular- blocking agents by air medical crews, or due to more specialised critical care training. The authors suggest that rescuers should perform at least 4 to 12 annual tracheal intubations.
Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes
Ann Emerg Med. 2010 Jun;55(6):527-537

The myth of ketamine and head injury

A literature review addresses the myth that ketamine is contraindicated in head injured patients. They summarise articles from the 1970’s which identified an association between ketamine and increased ICP in patients with abnormal cerebrospinal fluid pathways (such as those caused by aqueductal stenosis, obstructive hydrocephalus and other mass effects). In more recent studies no statistically significant increase in ICP was observed following the administration of ketamine in patients with head injury; some of the studies showed a net increase in CPP following ketamine administration. They list ketamine’s stable haemodynamic profile and potential neuroprotective effects as further rationale for its use.
The authors boldly summarise:
Based on its pharmacological properties, ketamine appears to be the perfect agent for the induction of head-injured patients for intubation.’
Myth: ketamine should not be used as an induction agent for intubation in patients with head injury
CJEM. 2010 Mar;12(2):154-7