A retrospective data analysis on the induction medications used in trauma rapid sequence intubations and their effects on outcomes

Abstract

Purpose Rapid sequence intubation (RSI) in trauma patients is common; however, the induction agents used have been debated. We determined which induction medications were used most frequently for adult trauma RSIs and their associations with hemodynamics and outcomes. We hypothesized that etomidate is the most commonly used induction agent and has similar outcomes to other induction agents. Methods This retrospective review at two U.S. level I trauma centers evaluated adult trauma patients undergoing RSI within 24 h of admission, between 01/01/2016 and 12/31/2017. We compared patient characteristics and outcomes by induction agent. Comparisons on the primary outcome of in-hospital mortality and secondary outcomes of peri-intubation hypotension, hospital and ICU length of stay (LOS), ventilator days, and complications used logistic regression or negative binomial regression. Regression models adjusted for hospital site, age, patient severity measures, and intubation location. Results Among 1303 trauma patients undergoing RSI within 24 h of admission, 948 (73%) were intubated in the emergency department (ED) and 325 (25%) in the operating room (OR). The most common induction agents were etomidate (68%), propofol (17%), and ketamine (11%). In-hospital mortality was highest in the etomidate group (25.5%), followed by ketamine (17%), and propofol (1.8%). Conclusion Etomidate was most commonly used in ED intubations; propofol was most used in the OR. Compared to propofol, patients induced with etomidate had higher mortality and complication rates. Findings should be interpreted with caution given limited generalizability and residual confounding by indication.

The Effect of Propofol on Peri-Induction Hemodynamics and Resuscitation in Operative Penetrating Trauma

“…Interestingly, they too noted a trend in the use of non-propofol RSI agents in sicker patients. 7 This mirrors our own experience where ketamine and etomidate appeared to be used preferentially in patients with higher ISS and shock index. Similarly, in their eight-center retrospective review, Leede et al reported no reductions in systolic blood pressure following the use of ketamine, etomidate, or propofol.…”

“…This aligns with previously published literature on the topic, demonstrating the overall safety of propofol for RSI in trauma patients. 3,7 To our knowledge, this is the first study to focus on the interaction between RSI agent choice and its effect on patient physiology in the setting of acute hemorrhage. The management of hemorrhaging patients comprises a balance of high-risk and high-stakes interventions with little margin for error to maximize survival and minimize morbidity.…”

“…Due to the time-sensitive and physiologically tenuous nature of care for acutely injured trauma patients, significant work has been done evaluating the impact of induction agent choice on patient outcomes during RSI. [1][2][3][4][5][6][7] Patients in hemorrhagic shock represent an extreme example of those requiring swift interventions and most impacted by induction agent choice. Therefore, within these patients, the pharmacological profile of any induction agent needs to be weighed against patient physiology, the potentiation of hypotension, and worsening hemorrhagic shock.…”

L’intubation chez l’adulte à l’urgence : une séquence à respecter (partie 1)

“…Bref, l'étape de la préoxygénation est importante, puisque la survenue d'une désaturation et d'une hypoxémie sont associées à l'apparition d'arythmies, de décompensation hémodynamique, d'hypoxie cérébrale et d'arrêt cardiaque(12). Toutes les mesures doivent donc être mises en place de façon à éviter la désaturation durant tout le processus d'ISR.Il est également important de traiter l'hypotension lorsque présente avant l'intubation, puisqu'elle est associée à une augmentation de la mortalité post-intubation(25). Selon les situations, un bolus de soluté physiologique ou l'administration d'un vasopresseur seront nécessaires pour la renverser(26,27).…”