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• Prehospital rapid sequence intubation is not uncommon in unconscious stroke
  Pieter F. Fouche, Paul A. Jennings, Malcolm Boyle, Stephen Bernard and Karen Smith
  Published on: 25 September 2019
• Rapid sequence intubation (RSI) is uncommon in prehospital stroke care
  Josephine M E Gibson, Stephanie P Jones and Caroline L Watkins
  Published on: 30 August 2019

• Published on: 25 September 2019

  Prehospital rapid sequence intubation is not uncommon in unconscious stroke

  • Pieter F. Fouche, Paramedic Monash University
  • Other Contributors:
    • Paul A. Jennings, Clinical Manager
    • Malcolm Boyle, Academic Lead in Paramedic Education
    • Stephen Bernard, Medical Director
    • Karen Smith, Director of Research

  We thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.

  Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.

  Ultimately we agree with...

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  We thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.

  Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.

  Ultimately we agree with Drs Gibson, Jones and Watkins in that our statement that RSI is commonly used by paramedics for stroke is not clear without qualification, but we hope they agree that RSI is indeed commonly used in unconscious stroke patients and in the emergency setting more broadly. If it is true that RSI is frequently used, and that there is a lack of high-quality evidence to support emergency intubation in stroke patients, then it is clear that a trial is needed.

  Reference

  1. Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31(4): 533-41.

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  Conflict of Interest:
  None declared.

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• Published on: 30 August 2019

  Rapid sequence intubation (RSI) is uncommon in prehospital stroke care

  • Josephine M E Gibson, Reader in Health Services Research; Senior Research Fellow University of Central Lancashire; NIHR Collaboration for Leadership in Applied Health Research and Care, North West Coast
  • Other Contributors:
    • Stephanie P Jones, Senior Research Fellow
    • Caroline L Watkins, Professor of Stroke and Older People's Care

  As researchers with an interest in pre-hospital stroke care, we read this paper with interest, but also with some surprise at the authors’ assertion that ‘RSI is commonly used by paramedics in stroke’. On examining the cited studies and the authors’ own findings more closely, this statement is hard to justify. Although Meyer et al did indeed report that 55% of out-of-hospital haemorrhagic strokes received RSI, this actually refers to a retrospective chart review of 20 children, all of whom with a Glasgow Coma Scale ≤ 8 following acute haemorrhagic stroke from a cerebral arteriovenous malformation rupture. This small, selective paediatric sample cannot be held to be representative of all stroke patients who are conveyed to hospital by emergency medical services. The other study cited as evidence found that people with acute stroke form a substantial proportion (36.6%) of RSIs undertaken by paramedics (Fouche et al., 2017). Whilst stroke may be a common reason for paramedic RSI, it cannot therefore be inferred that paramedic RSI is common in stroke. The authors’ own findings bear this out: of their sample of nearly 44,000 stroke patients conveyed by the emergency medical services, only 2% had received paramedic RSI.

  Whilst we congratulate the authors on their comprehensive analysis of this large dataset, it is important that readers do not gain the impression that paramedic RSI is frequently indicated and performed in pre-hospital stroke care.

  Disclaimer: JG an...

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  As researchers with an interest in pre-hospital stroke care, we read this paper with interest, but also with some surprise at the authors’ assertion that ‘RSI is commonly used by paramedics in stroke’. On examining the cited studies and the authors’ own findings more closely, this statement is hard to justify. Although Meyer et al did indeed report that 55% of out-of-hospital haemorrhagic strokes received RSI, this actually refers to a retrospective chart review of 20 children, all of whom with a Glasgow Coma Scale ≤ 8 following acute haemorrhagic stroke from a cerebral arteriovenous malformation rupture. This small, selective paediatric sample cannot be held to be representative of all stroke patients who are conveyed to hospital by emergency medical services. The other study cited as evidence found that people with acute stroke form a substantial proportion (36.6%) of RSIs undertaken by paramedics (Fouche et al., 2017). Whilst stroke may be a common reason for paramedic RSI, it cannot therefore be inferred that paramedic RSI is common in stroke. The authors’ own findings bear this out: of their sample of nearly 44,000 stroke patients conveyed by the emergency medical services, only 2% had received paramedic RSI.

  Whilst we congratulate the authors on their comprehensive analysis of this large dataset, it is important that readers do not gain the impression that paramedic RSI is frequently indicated and performed in pre-hospital stroke care.

  Disclaimer: JG and CW are partly funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, North West Coast. The views expressed are those of the authors and not necessarily those of the NIHR, NHS, or Department of Health and Social Care.

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  Conflict of Interest:
  None declared.

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