Prehospital rapid sequence induction by emergency physicians: Is it safe?

Abstract

Objectives-To determine if there were differences in practice or intubation mishap rate between anaesthetists and accident and emergency physicians performing rapid sequence induction of anaesthesia (RSI) in the prehospital setting. Methods-All patients who underwent RSI by a Helicopter Emergency Medical Service (HEMS) doctor from 1 May 1997 to 30 April 1999 were studied by retrospective analysis of in-flight run sheets. Intubation mishaps were classified as repeat attempts at intubation, repeat drug administration and failed intubation. Results-RSI was performed on 359 patients by 10 anaesthetists (202 patients) and nine emergency physicians (157 patients). Emergency physicians recorded a larger number of patients as havingCormack and Lehane grade 3 or 4 laryngoscopy than anaesthetists (p<0.0001) but were less likely to use a gum elastic bougie to assist intubation (p=0.024). Patients treated by emergency physicians did not have a significantly diVerent pulse, blood pressure, oxygen saturation or end tidal CO 2 to patients treated by anaesthetists at any time after intubation. Emergency physicians were more likely to anaesthetise patients with a Glasgow Coma Score >12 than anaesthetists (p=0.003). There were two failed intubations (1%) in the anaesthetist group and four (2.5%) in the emergency physician group. Repeat attempts at intubation and repeat drug administration occurred in <2% of each group. Conclusions-RSI performed by emergency physicians was not associated with a significantly higher failure rate or an increased number of intubation mishaps than RSI performed by anaesthetists. Emergency physicians were able to safely administer sedative and neuromuscular blocking drugs in the prehospital situation. It is suggested that emergency physicians can safely perform rapid sequence induction of anaesthesia and intubation.

Success in physician prehospital rapid sequence intubation: what is the effect of base speciality and length of anaesthetic training?

“…A previous retrospective study of our service17 on 359 patients demonstrated six failed intubations (1.7%) with four requiring surgical airway (1.1%); all for failed oral intubations. In this study period, eight (2.2%) surgical airways were performed in total compared with three (0.75%) in the current study.…”

Patient Safety in Emergency Medical Services: A Systematic Review of the Literature

“…Data (population, intervention, control, outcomes) were abstracted and are presented in Tables 3-9. The heterogeneity of the methods, populations, interventions, controls, and outcome [94][95][96][97][98][99][100][101][102][103][104][105][106][107][108][109] The systematic review yielded 88 papers describing these seven themes of patient safety in emergency medical services.…”

Anaesthetic priorities in pre- hospital trauma care

“…Physician-based HEMS have reported 98-100% success rate, but with up to 2% of cases needing three attempts at intubation. 2,4 Indications for pre-hospital anaesthesia comprise the following (from HEMS, London): 5 • actual or impending airway compromise • ventilatory failure • airway soiling • unconsciousness • humanitarian indications • patients unmanageable or severely agitated after head injury A Glasgow Coma Score (GCS) of 8 or less is widely used as an indication for rapid-sequence induction, but more recently a GCS of 13 or 14 in patients who have suffered major trauma has been suggested as an indication for pre-hospital intubation because there is a high incidence of intracranial pathology in this group. 5…”