Paramedic rapid sequence intubation in patients with non-traumatic coma

Paramedic rapid sequence intubation in patients with non-traumatic coma

© Gary Wilson

© Gary Wilson

Emerg Med J doi:10.1136

Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain.

Methods The electronic Victorian Ambulance Clinical Information System was searched for the term ‘suxamethonium’ between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients.

Results There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital.

Conclusions Paramedic RSI in patients with non-traumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes.

Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic

Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Emerg Med J 2014;31:65-68 

This paper describes the first 16-months experience of prehospital rapid sequence intubation (RSI) in a rural and suburban helicopter-based doctor-paramedic service after the introduction of a standard operating procedure (SOP) already proven in an urban trauma environment.

Method A retrospective database review of all missions between October 2010 and January 2012 was carried out. Any RSI or intubation carried out was included, regardless of age or indication. Patients who were intubated by Ambulance Service personnel prior to the arrival of the East Anglian Air Ambulance (EAAA) team were excluded.

Results The team was activated 1156 times and attended 763 cases. A total of 88 RSIs occurring within the study period were identified as having been carried out by the EAAA team and meeting inclusion criteria for review. There were no failed intubations that required a rescue surgical airway or the placement of a supraglottic airway device. For road traffic collisions (RTCs), the overall on-scene time for patients who required an RSI was 40 min (range 15–72 min). For all other trauma, the average on-scene time was 48 min (range 25–77 min), and for medical patients, the average time spent at scene was 41 min (range 15–94 min).

Conclusions The authors have demonstrated the successful introduction of a prehospital care SOP, already tested in the urban trauma environment, to a rural and suburban air ambulance service operating a fulltime doctor-paramedic model. The authors have shown a zero failed intubation rate over 16 months of practice during which time over 750 missions were flown, with 11.5% of these resulting in an RSI.

Further details on the UK air ambulances SOP for RSI can be found here: HEMS SOP and RSI checklist.  The research article lists “six indications for an RSI in the prehospital setting:

(1) actual or impending airway failure;
(2) ventilatory failure;
(3) unconsciousness;
(4) humanitarian indications;
(5) injured patients who are unmanageable or severely agitated after a head injury and
(6) anticipated clinical course.

“The patient is placed in a position away from direct sunlight, ideally with 360o access space. After adequate preoxygenation, a standard sequence of etomidate followed by suxamethonium is administered, and the tracheal tube is placed under direct vision and always over an intubating bougie. Following confirmation of correct tracheal tube placement, anaesthesia is maintained with boluses of morphine and midazolam, and neuromuscular blockade is continued with pancuronium. In the event of a failed intubation, there is a well-rehearsed sequence of immediate ‘drills’ to perform in order to improve intubation conditions, and after a second failed attempt, or if there is failure to adequately oxygenate or ventilate at any time, a supraglottic airway is placed, or a surgical airway is performed.”