Paramedic-performed rapid sequence intubation of patients with severe head injuries

doi:10.1067/mem.2002.126397

Annals of Emergency Medicine

Volume 40, Issue 2, August 2002, Pages 159-167

Presented at the National Association of EMS Physicians annual meeting, Fort Myers, FL, January 2001.

https://doi.org/10.1067/mem.2002.126397 Get rights and content

Abstract

Study objective: We evaluate the ability of paramedic rapid sequence intubation (RSI) to facilitate intubation of patients with severe head injuries in an urban out-of-hospital system. Methods: Adult patients with head injuries were prospectively enrolled over a 1-year period by using the following inclusion criteria: Glasgow Coma Scale score of 3 to 8, transport time of greater than 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy, and rocuronium was given after tube placement was confirmed by means of capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. Outcome measures included intubation success rates, preintubation and postintubation oxygen saturation values, arrival arterial blood gas values, and total out-of-hospital times for patients intubated en route versus on scene. Results: Of 114 enrolled patients, 96 (84.2%) underwent successful endotracheal intubation, and 17 (14.9%) underwent Combitube intubation, with only 1 (0.9%) airway failure. There were no unrecognized esophageal intubations. On arrival at the trauma center, median oxygen saturation was 99%, mean arrival PO₂ was 307 mm Hg, and mean arrival PCO₂ was 35.8 mm Hg. Total out-of-hospital times were higher when RSI was performed on scene (26 versus 13 minutes). Conclusion: Paramedics can use RSI protocols that include neuromuscular blocking and sedative agents to facilitate intubation of patients with head injuries. [Ochs M, Davis D, Hoyt D, Bailey D, Marshall L, Rosen P. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med. August 2002;40:159-167.]

Introduction

More than 2 million patients are transported annually in the United States by emergency medical services (EMS) after traumatic brain injury (TBI), with approximately 200,000 of these dying or experiencing permanent disability and another 50,000 being declared dead in the field.1, 2, 3 Although irreversible primary injury is sustained at the moment of impact, with anatomic and physiologic disruption of tissue, secondary injury occurs as a result of subsequent insults, such as hypoxia and hypotension.4, 5, 6, 7 Chesnut et al⁵ reported an increase in mortality from 27% to 33% with out-of-hospital hypoxia alone, a doubling of mortality with out-of-hospital hypotension alone, and a tripling of mortality with both hypoxia and hypotension. Stochetti et al⁴ reported preintubation oxygen saturation values of less than 90% in half of the patients with head injuries who were transported by helicopter, with a significant association observed between hypoxia and poor outcome.

This detrimental effect of out-of-hospital hypoxia has been used to justify an aggressive approach to airway management by paramedics and flight nurses. In a retrospective review, Winchell and Hoyt⁸ demonstrated an overall decrease in mortality from 36% to 26% with out-of-hospital intubation of patients with multiple trauma and a decrease from 49% to 23% in patients with isolated severe TBI. Under paramedic protocols that do not allow the use of neuromuscular blocking agents, many patients with severe head injuries cannot be intubated because of jaw clenching, combativeness, or airway reflexes.8, 9, 10, 11 This is especially true for patients with Glasgow Coma Scale (GCS) scores of greater than 3, who also might be the most salvageable and might derive the greatest benefit from aggressive airway management.8, 9, 11, 12 Out-of-hospital rapid sequence intubation (RSI) has been demonstrated to be safe when performed by trained flight nurses and in several small paramedic agencies under close medical supervision.13, 14, 15, 16, 17, 18, 19, 20 Our primary objective was to demonstrate the feasibility of paramedic use of RSI that included neuromuscular blocking and sedative agent administration, with particular focus on intubation success, physiologic parameters, and complications.

Section snippets

Materials and methods

San Diego County has a population of 2.79 million, with an area of 4,261 square miles. Advanced life support is provided by 12 different providers in 15 different jurisdictions, with San Diego County EMS as the lead agency. There are 813 emergency medical technician-paramedics (EMT-P) accredited in San Diego County. In fiscal year 1996-1997, there were 116,615 emergency transports (67% medical, 29% trauma, and 4% unspecified). Although the EMS response varies in different jurisdictions, 2

Results

During the study period, 7,649 patients with major trauma were transported in San Diego County. Four thousand six hundred twenty-nine met modified Major Trauma Outcome Study criteria, consisting of admission to the hospital for at least 3 days, admission to an ICU or intermediate care unit, interfacility transfer to or from an acute care hospital, or death from traumatic injuries. Two hundred forty-nine patients had GCS scores of 3 to 8 and a mechanism of injury consistent with potential TBI.

Discussion

Despite the detrimental effects of hypoxia and hypotension on head injury, the apparent benefits of early intubation, and the limited success in intubating patients with higher GCS scores, there is reluctance in allowing paramedics to use neuromuscular blocking agents.9, 10, 21, 22, 23, 24 Concerns have focused on 2 major issues: the lack of an appropriate salvage airway device and the possibility of unrecognized esophageal intubations. The development of airway adjuncts, such as the Combitube,

Acknowledgements

We acknowledge the contributions made by the San Diego County Base Hospital and Trauma Departments, American Medical Response, San Diego Medical Services Enterprise, Mercy Air, county flight nurses, the RSI Educational Task Force and trainers, paramedic provider agency coordinators, Palomar and Southwestern Colleges, the County of San Diego Division of EMS biostatistical team, the California EMS Authority, and especially the paramedics throughout San Diego County, whose enthusiastic support

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Bispectral index scores predicting complications after tracheal intubation
2021, Trends in Anaesthesia and Critical Care
Tracheal intubation is a procedure that may cause various complications. The primary aim of this study is to investigate whether the Bispectral Index™ (BIS) can predict tracheal intubation complications sooner than other monitoring parameters.
A total of 55 consecutive patients were intubated. Sociodemographic data, the reason for tracheal intubation, diagnosis, starting dose or dose increase of a vasopressor drug, use of sedatives and muscle-relaxing agents, vital signs, BIS scores, and end-tidal CO₂ values before the procedure, during laryngoscopy, and within 30 min after tracheal intubation were recorded along with their tracheal intubation-related complications.
The mean age of the patients was 75.1 ± 14.4 years. Pneumonia (n = 17, 30.9%) and sepsis (n = 14, 25.5%) were found to be the two most prominent diagnoses. The most common indications for intubation were a low Glasgow Coma Scale score of ≤8 (67.3%) and respiratory failure (61.8%). Postintubation hemodynamic instability developed in 38 patients (69.1%).The BIS value obtained at minute 3 was the lowest among all measurements. Significantly lower values of BIS (minute 3) were found for patients with postintubation hemodynamic instability (46 vs. 72, p = 0.039). Using ketamine (OR = 8.99, 95% CI: 1.60–50.47, p = 0.013) and systoloc blood pressure (OR = 1.03, 95% CI: 1.01–1.05, p = 0.017) were found to be significant risk factors for the development of postintubation hemodynamic instability.
In this study, the lowest BIS values were detected at minute three after intubation. The BIS values obtained at minute three were found to be significantly associated with the development of postintubation hemodynamic instability.
A descriptive analysis of endotracheal intubation in a South African Helicopter Emergency Medical Service
2018, African Journal of Emergency Medicine
Citation Excerpt :
Comparable reported data on hypoxia during ETI range between 0% [24] and 62% [12], with this study’s hypoxaemia prevalence (13%) at the lower end of this range. Lastly, comparable reported rates of bradycardia and cardiac arrest range between 1% [7] and 35% [25], and 0% [26] and 4% [27], respectively. The current study’s data thus falls within the middle to lower range of these reported AEs.
Helicopter Emergency Medical Services (HEMS) exists to supplement the operations of ground-based emergency care providers, mainly in high acuity cases. One of the important procedures frequently carried out by HEMS personnel is endotracheal intubation. Several HEMS providers exist in South Africa, with a mix of advanced life support personnel, however intubation success rates and adverse events have not been described in any local HEMS operation.
This was a retrospective chart review of intubation-related data collected by a HEMS operation based in Johannesburg over a 16-month period. First-pass and overall success rates were described, in addition to perceived airway difficulty, adverse events and other data.
Of the 49 cases recorded in the study period, one was excluded leaving 48 cases for analysis. Most cases (n = 34, 71%) involved young male trauma patients who were intubated with rapid sequence intubation. The first pass success rate was 79% (n = 38) with an overall success rate of 98% (n = 47). At least one factor suggesting airway difficulty was present in 29% (n = 14) of cases, with most perceived airway difficulty related to the high prevalence of trauma cases. At least one adverse event occurred in 27% (n = 13) of cases with hypoxaemia, hypotension and bradycardia most prevalent.
In this small sample of South African HEMS intubation cases, we found overall and first-pass success rates comparable to those reported in similar contexts.
Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis
2017, Annals of Emergency Medicine
Rapid sequence intubation performed by nonphysicians such as paramedics or nurses has become increasingly common in many countries; however, concerns have been stated in regard to the safe use and appropriateness of rapid sequence intubation when performed by these health care providers. The aim of our study is to compare rapid sequence intubation success and adverse events between nonphysician and physician in the out-of-hospital setting.
A systematic literature search of key databases including MEDLINE, EMBASE, and the Cochrane Library was conducted. Eligibility, data extraction, and assessment of risk of bias were assessed independently by 2 reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success and for adverse events when possible.
Eighty-three studies were included in the meta-analysis. There was a 2% difference in successful intubation proportion for physicians versus nonphysicians, 99% (95% confidence interval [CI] 98% to 99%) versus 97% (95% CI 95% to 99%). A 10% difference in first-pass rapid sequence intubation success was noted between physicians versus nonphysicians, 88% (95% CI 83% to 93%) versus 78% (95% CI 65% to 89%). For airway trauma, bradycardia, cardiac arrest, endobronchial intubation, hypertension, and hypotension, lower prevalences of adverse events were noted for physicians. However, nonphysicians had a lower prevalence of hypoxia and esophageal intubations. Similar proportions were noted for pulmonary aspiration and emesis. Nine adverse events estimates lacked precision, except for endobronchial intubation, and 4 adverse event analyses showed evidence of possible publication bias. Consequently, no reliable evidence exists for differences between physicians and nonphysicians for adverse events.
This analysis shows that physicians have a higher rapid sequence intubation first-pass and overall success, as well as mostly lower rates of adverse events for rapid sequence intubation in the out-of-hospital setting. Nevertheless, for all success and adverse events no firm conclusion for a difference could be drawn because of lack of precision of meta-analytic estimates or selective reporting. First-pass success could be an area in which to focus quality improvement strategies for nonphysicians.
Airway management with simultaneous cervical spine immobilisation: A comparison between the Macintosh laryngoscope and the Airtraq<sup>®</sup> optical laryngoscope used by experienced paramedics – A manikin study
2017, Trends in Anaesthesia and Critical Care
Airway management in patients with suspected or actual injury to the cervical spine remains a top priority. The aim of this study was to evaluate two different intubating devices in the hands of experienced paramedics during simulated conditions of reduced cervical spine mobility.
Forty experienced paramedics participated in this manikin study (F = 10, M = 30). The time required to obtain the laryngeal inlet view as well as successful ventilation time were recorded. Cormack-Lehane laryngoscopic view and dental damage were also assessed. The two devices were used by each participant and they were randomly chosen. All paramedics participating in the study had never used the Airtraq^® device before the study but possessed intubation skills.
The mean time required to obtain the laryngeal inlet view and the mean intubation-to-successful-ventilation time were significantly shorter when the Airtraq^® device was used, 5.5 s (±1.5) and 9.8 s (±2.7) respectively (p = 0.003 and 0.0006). There were no failed intubation attempts in the Airtraq^® group and the use of this device had the lowest incidence of incisors damage (2 in 40 intubations, 5%). The best view of the entry to the larynx was obtained by the Airtraq^® device.
The Airtraq^® device shows advantages over the Macintosh laryngoscope in manikins and may be a good alternative in situations when reduced neck mobility is present. The use of the Airtraq^® device in manikins was associated with a shorter time for intubation and successful ventilation. It also improves the laryngoscopic view and the rate of successful intubation.
Student paramedic rapid sequence intubation in Johannesburg, South Africa: A case series
2017, African Journal of Emergency Medicine
Pre-hospital rapid sequence intubation was introduced within paramedic scope of practice in South Africa seven years ago. Since then, little data has been published on this high-risk intervention as practiced operationally or by students learning rapid sequence intubation in the pre-hospital environment. The objective of this study was to describe a series of pre-hospital rapid sequence intubation cases, including those that South African University paramedic students had participated in.
A University clinical learning database was searched for all endotracheal intubation cases involving the use of neuromuscular blockers between 1 January 2011 and 31 December 2015. Data from selected cases were extracted and analysed descriptively.
Data indicated that most patients were young adult trauma victims with a dominant injury mechanism of vehicle-related accidents. The majority of cases utilised ketamine and suxamethonium, with a low rate of additional paralytic medication administration. 63% and 72% of patients received post-intubation sedation and analgesia, respectively. The overall intubation success rate from complete records was 99.6%, with a first pass success rate of 87.9%. Students were successful in 92.4% of attempts with a first-pass success rate of 85.2%. Five percent of patients experienced cardiac arrest between rapid sequence intubation and hospital arrival.
Students demonstrated a good intubation success and first pass-success rate. However, newly qualified paramedics require strict protocols, clinical governance, and support to gain experience and perform pre-hospital rapid sequence intubation at an acceptable level in operational practice. More research is needed to understand the low rate of post-intubation paralysis, along with non-uniform administration of post-intubation sedation and analgesia, and the 5% prevalence of cardiac arrest.
L'intubation en séquence rapide (ISR) pré-hospitalière a été introduite dans le champ d'activité des auxiliaires médicaux en Afrique du Sud il y a sept ans. Depuis, peu de données ont été publiées sur cette intervention à haut risque telle qu'elle est pratiquée de manière opérationnelle ou par des étudiants apprenant l'ISR dans l'environnement pré-hospitalier. L'objectif de cette étude était de décrire une série de cas d'intubation en séquence rapide pré-hospitalière, y compris des cas auquels des étudiants ambulanciers des universités sud-africaines avaient participé.
Une base de données universitaire sur l'apprentissage clinique a été consultée afin d'identifier tous les cas d'intubation endotrachéale impliquant le recours à des inhibiteurs neuromusculaires entre le 1er janvier 2011 et le 31 décembre 2015. Les données de cas sélectionnés ont été extraites et analysées de manière descriptive.
Les données indiquaient que la plupart des patients étaient de jeunes adultes victimes de traumatismes, le mécanisme de blessure dominant étant les accidents de la route. La majorité des cas utilisaient la kétamine et le suxaméthonium, et un faible taux d'administration de substances paralysantes. 63% et 72% des patients ont respectivement reçu une sédation post-intubation et des analgésiques. Le taux de réussite global de l'intubation à partir des archives complètes s'élevait à 99,6%, avec un taux de réussite au premier passage de 87,9%. Les étudiants réussissaient dans 92,4% de leurs tentatives, avec un taux de réussite au premier passage de 85,2%. Cinq pour cent des patients ont été victimes d'un arrêt cardiaque entre l'intubation à séquence rapide et leur arrivée à l'hôpital.
Les étudiants ont obtenu un bon taux de réussite à l'intubation et un bon taux de réussite au premier passage. Cependant, les auxiliaires médicaux jeunes diplômés ont besoin de protocoles strictes, d'une gestion clinique et de soutien pour acquérir de l'expérience et réaliser des intubations à séquence rapide pré-hospitalières à un niveau acceptable dans la pratique opérationnelle. Des études supplémentaires sont nécessaires pour comprendre le faible taux de paralysie post-intubation, parallèlement à l'administration non uniforme de la sédation et des analgésiques post-intubation, ainsi que la prévalence d'arrêt cardiaque de 5%.
Should laryngeal tubes or masks be used for out-of-hospital cardiac arrest patients?
2015, American Journal of Emergency Medicine
Few studies have compared airway management via laryngeal masks (LM) or laryngeal tubes (LT) in patients with out-of-hospital cardiac arrest (OHCA). This study evaluated whether LT insertion by emergency medical service (EMS) personnel affected ventilation and outcomes in OHCA patients (vs. the standard LM treatment).
This prospective, cluster-randomized, and open-label study evaluated data that were collected by the Sapporo Fire Department between June 2012 and January 2013. We selected the 14 EMS teams that treated the greatest number of OHCA patients in Sapporo, Japan during 2011, and randomized the teams into Groups A and B. In the first study period (June 2012 to September 2012), Group A treated OHCA patients via LT and Group B treated OHCA patients via LM. In the second period (October 2012 to January 2013), Group A treated OHCA patients via LM and Group B treated OHCA patients via LT. If necessary, both groups were allowed to use an esophageal obturator airway (EOA) kit. The primary endpoints were time from cardiopulmonary resuscitation to device insertion and the rate of successful pre-hospital ventilation. The secondary endpoints were return of spontaneous circulation and survival and favorable neurological outcomes at 1 month after cardiac arrest.
LT was used in 148 OHCA patients and LM was used in 165 OHCA patients. Our intention-to-treat analyses revealed no significant differences in the primary and secondary outcomes of the LT- and LM-treated groups.
Prehospital advanced airway management via LT provides similar outcomes to those of LM in OHCA patients.

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^*: Author contributions: MO, DH, LM, and PR conceived the study and designed the trial. MO, DD, and DB supervised the paramedic training and conduct of the trial. MO and DD managed the collection and entry as well as the statistical analysis of all data. MO and DD drafted the manuscript, and all authors contributed to its revision. MO and DD take responsibility for the paper as a whole.

^**: Address for reprints: Daniel Davis, MD, Department of Emergency Medicine, University of California-San Diego, 200 West Arbor Drive, #8676, San Diego, CA 92103-8676.

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Emergency Medical Services/Original ContrbutionParamedic-performed rapid sequence intubation of patients with severe head injuries*,**

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

J Pediatr Surg

J Pediatr Surg

Am J Emerg Med

Am J Emerg Med

Ann Emerg Med

J Emerg Med

Air Med J

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Prehosp Emerg Care

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Prehosp Emerg Care

Ann Emerg Med

Monitoring the impact of traumatic brain injury: a review and update

J Neurotrauma

Emergency Medical Services/Original Contrbution
Paramedic-performed rapid sequence intubation of patients with severe head injuries*,**