Rapid sequence intubation in Scottish urban emergency departments

Abstract

Objective: Airway care is the cornerstone of resuscitation. In UK emergency department practice, this care is provided by anaesthetists and emergency physicians. The aim of this study was to determine current practice for rapid sequence intubation (RSI) in a sample of emergency departments in Scotland. Methods: Two year, multicentre, prospective observational study of endotracheal intubation in the emergency departments of seven Scottish urban teaching hospitals. Results: 1631 patients underwent an intubation attempt in the emergency department and 735 patients satisfied the criteria for RSI. Emergency physicians intubated 377 patients and anaesthetists intubated 355 patients. There was no difference in median age between the groups but there was a significantly greater proportion of men (73.2% versus 65.3%, p=0.024) and trauma patients (48.5% versus 37.4%, p=0.003) in the anaesthetic group. Anaesthetists had a higher initial success rate (91.8% versus 83.8%, p=0.001) and achieved more good (Cormack-Lehane Grade I and II) views at laryngoscopy (94.0% versus 89.3%, p=0.039). There was a non-significant trend to more complications in the group of patients intubated by emergency physicians (8.7% versus 12.7%, p=0.104). Emergency physicians intubated a higher proportion of patients with physiological compromise (91.8% versus 86.1%, p=0.027) and a higher proportion of patients within 15 minutes of arrival (32.6% versus 11.3%, p<0.0001). Conclusion: Anaesthetists achieve more good views at laryngoscopy with higher initial success rates during RSI. Emergency physicians perform RSI on a higher proportion of critically ill patients and a higher proportion of patients within 15 minutes of arrival. Complications may be fewer in the anaesthetists' group, but this could be related to differences in patient populations. Training issues for RSI and emergency airway care are discussed. Complication rates for both groups are in keeping with previous studies.

Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability

“…The incidence of PIHI varied widely in previous studies, ranging from 0.0 to 38.6%. [13][14][15][19][20][21][22][23][24][25][26][27][28][29][30][31] Some studies of AEs in EETI failed to evaluate PIHI, and those that did suffer from the lack of a standard definition of PIHI. Vasopressor medications included epinephrine, norepinephrine, phenylephrine, and dopamine.…”

“…Baseline SBP was defined by the average of all SBP values observed in the 30 minutes prior to EETI. [13][14][15]19,20,[22][23][24][25][26][27][28][29][30][31] Preintubation hypotension was defined as an average SBP # 90 mm Hg, MAP # 65 mm Hg in the 30 minutes prior to EETI, or the use of a vasopressor medication (bolus or infusion). Transient PIHI was defined as meeting any PIHI criterion on a single occasion during the 30-minute post-EETI study period, whereas sustained PIHI was defined as meeting any PIHI criterion for the entire duration of the 30-minute study period.…”

Incidence of postintubation hemodynamic instability associated with emergent intubations performed outside the operating room: a systematic review

“…Eighteen articles were retained for inclusion. 8,9,16,17,[20][21][22][23][24][25][26][27][28][29][30][31][32][33] Appendix 4 summarizes the clinical characteristics of the included studies. Appendix 5 outlines the epidemiologic and methodological traits of the studies included in the analysis.…”

Laryngoscopic views during rapid sequence intubation in the emergency department

“…5 The incidence of poor visualization and difficult intubation in the ED is unknown, but a recent review suggests that the rate may be between 1% and 30%. 5 In a previous prospective observational study 6 we assessed laryngoscopic views obtained by different specialists during RSI in the ED. In the present group of 735 patients, the first-attempt specialty was emergency medicine (EM) in 377 cases (51.5%) and anesthesia in 355 cases (48.5%).…”