Randomized, Double-Blind Study on Sedatives and Hemodynamics During Rapid-Sequence Intubation in the Emergency Department: The SHRED Study☆,☆☆,★,★★
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INTRODUCTION
Endotracheal intubation is an essential component of the resuscitation of critically ill patients in the emergency department. In the absence of anticipated upper airway anomaly, use of neuromuscular blockade (NMB) to facilitate and expedite intubation of nonarrested patients has become standard practice among emergency physicians possessing adequate technical skill.1, 2, 3 Based on the experience of anesthetists during urgent “full stomach” intubations, techniques that use short-onset sedating
MATERIALS AND METHODS
All adult patients, including those transferred from other hospitals, who required intubation in the ED were eligible for participation. Exclusion criteria were as follows: cardio pulmonary arrest present or imminent (immediate intubation without medication indicated), status asthmaticus (ketamine sedative of choice), anticipated anatomic difficulties with the airway (paralysis relatively contraindicated), and known hypersensitivity to study medications (eg, porphyria). Every intubation
RESULTS
From May 1992 to June 1993, 120 patients underwent intubation in the ED; of these, 86 patients (72%) were enrolled and completed the study. Of the remainder, 18 patients (15%) met exclusion criteria (8 moribund, 2 status asthmaticus, 1 gunshot wound to larynx, 6 no study kit available, 1 sphygmomanometer malfunction); 11 (9%) were eligible but were excluded because of lack of familiarity with study inclusion criteria; and 5 (4%) were excluded for unknown reasons. In all, 96 (80%) of the 120
DISCUSSION
Based on the range of recommendations and on observed practice, one of the most poorly understood components of RSI is the role of the sedative agent used. As defined historically, RSI refers to rapid and simultaneous production of a sufficiently deep level of unconsciousness (induction) and neuromuscular relaxation to permit endotracheal intubation, ideally without intervening positive-pressure bag-mask–valve ventilation. Many discussions of “RSI” (usually described as rapid sequence
Acknowledgements
The authors wish to thank Richard Bondy, MD, FRCPC, for seminal discussions during the construction of the study, and Charlene Barber, RN, for assistance with data collection.
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From the Department of Emergency Medicine, Royal Victoria Hospital, McGill University, Montreal, Canada.
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This project was supported by a grant from l'Association des médecins d'urgence du Québec. Medication costs were partly defrayed by a donation from Hoffmann-La Roche Ltd.
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Address for reprints: Marco Sivilotti, MD, Department of Emergency, Medicine, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, Massachusetts 01655, 508-856-4101, Fax 508-856-6902, E-mail [email protected]
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