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Rapid sequence induction in the emergency department by emergency medicine personnel
  1. Colin Dibble, Specialist Registrar,
  2. Margaret Maloba, Consultant
  1. North Manchester General Hospital, Manchester, UK

    Abstract

    A short cut review was carried out to establish whether there are significant differences in the performance of emergency physicians and anaesthetists when carrying out rapid sequence intubation (RSI) in the emergency department. A total of 407 papers were found of which 12 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. The clinical bottom line is that there is little or no difference in the rates of success and complications between emergency department clinicians and anaesthetists performing RSI.

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    Report by Colin Dibble, Specialist RegistrarChecked by Margaret Maloba, ConsultantNorth Manchester General Hospital, Manchester, UK

    Three part question

    [In an emergency department RSI] are [emergency medicine clinicians as effective as anaesthetists] with regard to [complications and success rates]?

    Clinical scenario

    You are in the resuscitation room and are faced with a combative head injury requiring a computed tomography (CT) scan. The patient needs to be intubated via RSI and you wonder whether you should do this, as you have previous anaesthetic training, or whether you should call the anaesthetist and wait for them to do it for you.

    Search strategy

    Medline 1966–2 August 2005 via Ovid interface: {exp Intubation, Intratracheal/ OR (rapid sequence induction).mp OR rsi.mp OR intubation.mp OR (crash induction).mp OR airway management.mp} AND {exp Medical Staff, Hospital/ or exp Emergency Medical Services/ or exp Emergency Service, Hospital/ or (emergency department).mp OR A&E.mp OR (accident and emergency).mp OR casualty.mp} AND {safety.mp. or exp SAFETY/ OR efficacy.mp OR complications.mp OR success.mp}

    Search outcome

    Of 407 papers found, 304 were irrelevant and one of which was relevant was a review article. This left 12 papers for analysis (table 2).

    Table 2

    Comment(s)

    Although many papers looked only at the performance of emergency physicians, there appeared to be ample evidence that emergency physicians can perform RSI and endotracheal intubation at least as well as anaesthetists, and overall there is a high rate of success with a low rate of complications. Emergency physicians themselves must have had training in the field. Among the papers examined in this BET, several mention a trend to call an anaesthetist when a difficult airway is anticipated. In our experience, the use of anaesthetists is variable between departments and is often influenced by the skills available within the emergency department. It would appear that the absolute need for anaesthetists in the resuscitation room is diminishing. It is our belief that endotracheal intubation and RSI in the emergency department should be part of an emergency physician’s core skill.

    CLINICAL BOTTOM LINE

    There is little or no difference in the rates of success and complications seen between emergency department clinicians and anaesthetists performing RSI.

    Report by Colin Dibble, Specialist RegistrarChecked by Margaret Maloba, ConsultantNorth Manchester General Hospital, Manchester, UK

    References

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