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