P Reventable M Orbidity and M Ortality From P Rehospital P Aralytic a Ssisted I Ntubation : C an W E E Xpect O Utcomes C Omparable to H Ospital-Based P Ractice ?

Abstract

The use of prehospital rapid-sequence intubation (RSI) has become an accepted regimen in many parts of the United States, with 29 of 50 states reporting RSI use in 1996 and 1997. 1 The National Association of EMS Physicians states that "the scope of modern prehospital medicine may include rapid-sequence intubation and the use of neuromuscular-blocking agents to facilitate ETI (endotracheal intubation)." 2 The three cases we describe below illustrate the potential for severe morbidity and mortality with prehospital RSI. CASE REPORTS Case 1A 36-year-old man suffered a flash burn from a propane gas line explosion. On emergency medical services (EMS) arrival, the patient was awake and alert, and had no respiratory difficulty, a Glasgow Coma Scale score (GCS) of 15, and "full recall of events." The patient denied loss of consciousness and had clear speech. Lip swelling with seconddegree burns to the left forearm was noted. There was no stridor or wheezing. Initial vital signs were a blood pressure of 161/111 mm Hg, pulse 74 beats/min, and respiratory rate 22 breaths/min with an oxygen saturation of 100%. The EMS air crew performed RSI using etomidate and succinylcholine, reportedly to protect the patient's airway due to their concern for impending airway swelling. After three unsuccessful intubation attempts, the patient was bag--mask-ventilated until spontaneous respirations returned.On emergency department (ED) arrival, the patient awoke and began to speak. Initial vital signs were a blood pressure of 160/104 mm Hg, heart rate of 90 beats/min, respiratory rate of 20 breaths/min, and oxygen saturation of 100% on 2 liters per nasal cannula. Examination revealed partial-thickness burns on his lips and nose without singing of nasal hairs. His eyebrows and some facial hair were singed but there were no other burns on his face. His total face and forearm burns comprised 3% total body surface area. The patient complained of severe dysphagia, mouth pain, and throat pain; however, there were no intraoral burns and no carbonaceous sputum. Direct examination revealed multiple contusions and bleeding of the oropharynx and hypopharynx. Cervical spine films showed a large amount of air in the prevertebral soft tissues. Chest radiography revealed a pneumomediastinum and pneumopericardium with clear lungs and no pneumothorax. The surgical burn unit attending felt that all burn injuries could be managed on an outpatient basis; however, the patient was admitted for evaluation of airway trauma. Subsequent gastrograffin and barium esophagrams revealed no perforation. Prophylactic antibiotics were initiated for a presumed microscopic esophageal tear until the patient's symptoms improved with discharge six days later. Case 2A 42-year-old man was an ejected unrestrained driver of a truck involved in a head-on collision. The patient initially had clear speech and was able to independently maintain his airway. Facial contusions, lacerations, and abrasions were noted. Suctioning was required to clear his airway, and his oxygen saturation w...

Procedural experience with out-of-hospital endotracheal intubation*

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