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Journal update monthly top five
  1. Daniel Horner1,2,3,
  2. Christopher Ambrose1,
  3. Luke Mills1,
  4. Ruby Blevings1,
  5. Sayyid Raza4,
  6. Elfateh Ibrahim4,
  7. Peter Michael Kilgour5,
  8. Gabrielle Prager6
  1. 1 Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
  2. 2 Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
  3. 3 Emergency Department, Manchester Royal Infirmary, Manchester, UK
  4. 4 Critical Care Unit, Northern Care Alliance NHS Foundation Trust, Salford, UK
  5. 5 Emergency Department, Salford Royal Hospital, Salford, UK
  6. 6 Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  1. Correspondence to Dr Daniel Horner, Emergency Department, Manchester Royal Infirmary, Manchester, M13 9WL, UK; danielhorner{at}

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This month’s update is from the emergency department and critical care unit at Salford Care Organisation, within the Northern Care Alliance NHS Foundation Trust. We used a multimodal search strategy, drawing on free open-access medical education resources and focused literature searches. We identified the five most interesting and relevant papers (decided by consensus, with editorial oversight) and highlight the main findings, key limitations and clinical bottom line for each paper.

The papers are ranked as

  • Worth a peek: interesting, but not yet ready for prime time

  • Head turner: new concepts

  • Game changer: this paper could/should change practice.

Peri-intubation hypoxia after delayed versus rapid sequence intubation in critically injured patients on arrival to trauma triage: a randomized controlled trial

Topic: rapid sequence induction

Outcome rating: head turner

Conventional rapid sequence induction (RSI) is a familiar technique for definitive airway management in the agitated trauma patient. However, agitation often interferes with adequate preoxygenation and preparation, increasing the risk of complications. Delayed sequence induction (DSI) has been described as a potentially safer option and recently supported by international recommendations.1 2

In this trial, 236 trauma patients with a median GCS of 6 were randomised to conventional RSI or DSI. RSI comprised attempted preoxygenation for 3 min followed by intravenous bolus dose of 1.5 mg/kg ketamine, 1.5 mg/kg succinylcholine and attempted endotracheal intubation.DSI involved initial administration of ketamine in 0.5 mg/kg increments (maximum of 1.5 mg/kg) until dissociation was achieved (calm with spontaneous breathing), followed by 3 min of optimal preoxygenation, prior to administration of 1.5 mg/kg succinylcholine and attempted endotracheal intubation.3

The primary outcome, was the incidence of peri-intubation hypoxia (oxygen saturation of <93%). Secondary outcomes included first-pass success rate and adverse events. Patients with anticipated anatomical difficulty, vomiting or cardiac arrest were excluded.

There was a significantly lower incidence of peri-intubation hypoxia in the DSI group compared with the RSI group (8% vs 35%, p<0.001). First-pass success rates were …

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  • Contributors DH completed the initial literature search and submitted article suggestions to the local editorial team and editor in chief for agreement on the top 5 articles relevant to the target audience. CA, LM, RB, SR, EI and PMK completed initial drafts of article summaries after critical appraisal. GP and DH completed an initial draft and also provided oversight during manuscript development. DH collated all initial drafts and worked with the editorial team to peer review, revise and agree on the final version of the manuscript.

  • 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.

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