Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia

Abstract

IntroductionRapid Sequence Induction of anaesthesia (RSI) is the recommended method to facilitate emergency tracheal intubation in trauma patients. In emergency situations, a simple and standardised RSI protocol may improve the safety and effectiveness of the procedure. A crucial component of developing a standardised protocol is the selection of induction agents. The aim of this study is to compare the safety and effectiveness of a traditional RSI protocol using etomidate and suxamethonium with a modified RSI protocol using fentanyl, ketamine and rocuronium.MethodsWe performed a comparative cohort study of major trauma patients undergoing pre-hospital RSI by a physician-led Helicopter Emergency Medical Service. Group 1 underwent RSI using etomidate and suxamethonium and Group 2 underwent RSI using fentanyl, ketamine and rocuronium. Apart from the induction agents, the RSI protocol was identical in both groups. Outcomes measured included laryngoscopy view, intubation success, haemodynamic response to laryngoscopy and tracheal intubation, and mortality.ResultsCompared to Group 1 (n = 116), Group 2 RSI (n = 145) produced significantly better laryngoscopy views (p = 0.013) and resulted in significantly higher first-pass intubation success (95% versus 100%; p = 0.007). A hypertensive response to laryngoscopy and tracheal intubation was less frequent following Group 2 RSI (79% versus 37%; p < 0.0001). A hypotensive response was uncommon in both groups (1% versus 6%; p = 0.05). Only one patient in each group developed true hypotension (SBP < 90 mmHg) on induction.ConclusionsIn a comparative, cohort study, pre-hospital RSI using fentanyl, ketamine and rocuronium produced superior intubating conditions and a more favourable haemodynamic response to laryngoscopy and tracheal intubation. An RSI protocol using fixed ratios of these agents delivers effective pre-hospital trauma anaesthesia.

Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists

“…Standardisation of the procedure6 through the use of checklists and standard operating procedures (SOPs) can improve the safety and effectiveness of PHEA 7. The purpose of a checklist is to improve the performance of a complex procedure by providing a reminder of the most critical and important steps 8.…”

Haemodynamic changes to a midazolam–fentanyl–rocuronium protocol for pre‐hospital anaesthesia following return of spontaneous circulation after cardiac arrest

“…Two definitions of hypotension were analysed separately, consistent with two different approaches used in previous studies [5][6][7][8]. Our secondary outcome measures were the proportion of patients experiencing new hypotension or hypertension at each 3-min interval, as well as adherence to the RSI protocol.…”

Current evidence for the use of C-MAC videolaryngoscope in adult airway management: a review of the literature

“…It has been emphasized that for the results of a comparative study to be valid, participants must be equally proficient with each airway device to avoid bias 72. Fourth, the use of neuromuscular blocking agents has been shown to improve the first-attempt success rate of emergency intubation,73,74 but this factor is significantly different among studies. Fifth, some studies exclude patients with anticipated or known difficult airways, though C-MAC videolaryngoscope is more effective than direct laryngoscopy for such conditions 50,51…”