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The association of paramedic rapid sequence intubation and survival in out-of-hospital stroke
  1. Pieter Francsois Fouche1,
  2. Karen Smith2,
  3. Paul Andrew Jennings3,
  4. Malcolm Boyle4,
  5. Stephen Bernard5
  1. 1 Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
  2. 2 Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
  3. 3 Ambulance Victoria, Doncaster, Victoria, Australia
  4. 4 Paramedicine, Griffith University School of Medicine, Southport, Queensland, Australia
  5. 5 Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
  1. Correspondence to Mr. Pieter Francsois Fouche; Pieter.Fouche{at}


Introduction Ambulance transport of patients with stroke is common, with rapid sequence intubation (RSI) to secure the airway used regularly. Randomised controlled trial evidence exists to support the use of RSI in traumatic brain injuries (TBIs), but it is not clear whether the RSI evidence from TBI can be applied to the patient with stroke. To this end, we analysed a retrospective stroke dataset to compare survival of patients with RSI compared with patients that did not receive RSI.

Methods This study was a retrospective analysis of 10 years of in-hospital and out-of-hospital data for all patients with stroke attended by Ambulance Victoria, in Victoria Australia. Generalised boosted logistic regression was used to predict propensity scores, with initial vital signs, age and demographic variables as well as measures of illness severity and comorbidity included in the prediction model. This analysis employed a 1:1 nearest-neighbour matching which was applied to generate a dataset from which we calculated the OR of survival to hospital discharge of patients receiving RSI versus no-RSI. The sensitivity of these results to unmeasured confounding was assessed with deterministic sensitivity analysis.

Results The propensity score-matched cohort showed a decreased survival for RSI in strokes with an OR 0.61 (95% CI 0.45 to 0.82; p=0.001) when compared with no-RSI. A subgroup analysis showed no significant survival difference for ischaemic strokes: OR 0.66 (95% CI 40 to 1.07; p=0.09). The survival for haemorrhagic stroke was OR 0.60 (95% CI 0.41 to 0.90; p=0.01) lesser for RSI. Results were likely robust to unmeasured confounding and missing data.

Conclusions Our retrospective analysis shows a decrease in survival when RSI is utilised by paramedics for stroke. Since RSI is commonly used for strokes, controlled trial evidence to support this practice is urgently needed.

  • airway
  • emergency ambulance systems

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  • Contributors PFF conceived of the study, KS and PF collected data and PF analysed all data. All authors contributed to the manuscript. PF takes responsibility for the paper as a whole.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval This study has received ethics approval. Monash University Human Research Ethics Committee gave ethics approval for this study (ref. no. 8618).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.