Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial

Abstract

BACKGROUND: Critically injured patients who are agitated and delirious on arrival do not allow optimal preoxygenation in the emergency area. We investigated whether the administration of intravenous (IV) ketamine 3 minutes before administration of a muscle relaxant is associated with better oxygen saturation levels while intubating these patients. METHODS: Two hundred critically injured patients who required definitive airway management on arrival were recruited. The subjects were randomized as delayed sequence intubation (group DSI) or rapid sequence intubation (group RSI). In group DSI, patients received a dissociative dose of ketamine followed by 3 minutes of preoxygenation and paralysis using IV succinylcholine for intubation. In group RSI, a 3-minute preoxygenation was performed before induction and paralysis using the same drugs, as described conventionally. The primary outcome was incidence of peri-intubation hypoxia. Secondary outcomes were first-attempt success rate, use of adjuncts, airway injuries, and hemodynamic parameters. RESULTS: Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02). A significant improvement in mean oxygen saturation levels from baseline values was seen in group DSI only. There was no incidence of hemodynamic instability. There was no statistically significant difference in airway-related adverse events. CONCLUSIONS: DSI appears promising in critically injured trauma patients who do not allow adequate preoxygenation due to agitation and delirium and require definitive airway on arrival.

Emergency airway management: a EUSEM statement with regard to the guidelines of the Society of Critical Care Medicine

“…Whereas the SCCM recommendation regarding preoxygenation is dependent on the severity of hypoxia, we recommend to optimize preoxygenation by either using high-flow nasal oxygen or, if no contraindications exist, delayed sequence intubation using noninvasive positive-pressure ventilation [3–5]. Similar to optimal preoxygenation in the operating room, this should be mandatory in the emergency department as well.…”

“…Similar to optimal preoxygenation in the operating room, this should be mandatory in the emergency department as well. Pharmacologically assisted preoxygenation may be necessary due to agitation, under these circumstances we primarily recommend the use of Ketamine with its properties of preserving respiratory drive and being relatively hemodynamically stable [ 5 ].…”