Prehospital rapid sequence induction by emergency physicians: Is it safe?(Statistical Data Included)

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 having Cormack and Lehane grade 3 or 4 laryngoscopy than anaesthetists (p[less than]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 different pulse, blood pressure, oxygen saturation or end tidal [CO.sub.2] to patients treated by anaesthetists at any time after intubation. Emergency physicians were more likely to anaesthetise patients with a Glasgow Coma Score [greater than]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 [less than]2% of each group.

Conclusion--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.

(Emerg Med J 2001;18:20-24)

Keywords: rapid sequence intubation

Airway management is a priority in the resuscitation of the trauma patient. Endotracheal intubation provides optimal airway control but often requires the use of sedative and muscle relaxant drugs in patients with intact upper airway reflexes. [1,2] Attempted intubation without these drugs may lead to a rise in intracranial pressure during laryngoscopy, which should be avoided in patients with head injury. [3,4]

Rapid sequence induction of anaesthesia and intubation (RSI) have been shown to be safe when performed by emergency physicians in hospital [5,6] 6 but are predominantly carried out by anaesthetists in most UK accident and emergency (A&E) departments. Prehospital RSI is performed by aeromedical teams in the USA [7-10] but literature on prehospital anaesthesia in Britain is limited. [11,12]

The Helicopter Emergency Medical Service (HEMS) attends to trauma patients in the Greater London area and provides a doctor capable of performing rapid sequence induction of anaesthesia and advanced airway skills. Doctors working for HEMS in recent years have a background of either A&E or anaesthesia and are at the end of specialist registrar training.

Our aim was to study prehospital rapid sequence induction of anaesthesia to determine if there were differences in practice between anaesthetists and A&E physicians and to document difficulties encountered and intubation mishaps.

Methods

A retrospective review of case notes was carried out to identify all patients who underwent RSI from 1 May 1997 to 30 April 1999. Patients who did not receive an induction agent or muscle relaxant were excluded from the analysis.

POPULATION AND SETTING

HEMS is based at the Royal London Hospital and is tasked by paramedics on the special incident desk at the London Ambulance Service control room. …