Pre-hospital Rapid Sequence
Intubation
Dr Peter Sherren
Senior registrar Anaesthesia, Intensive Care and Pre-hospital care
The Royal London Hospital and Greater Sydney Area HEMS
Objectives
• Why?
• Who?
• How?
• Evidence
Introduction
• Controversial/Territorial/Evocative topic!
• Early appropriate airway control central to
good trauma care
• Why not bring a hospital level of care to the
roadside?
Why?
• Like haemorrhage, airway compromise is a
significant cause of preventable deaths
• Hypoxia common on scene in trauma. Stochetti et al. J
Trauma 1997
• Hypoxia and hypercarbia associated with
increased morbidity and mortality in TBI. Sherren PB et
al. Curr Opin Anesthesiol 2012
• ETI is gold standard in hospital
• Patient and pathology have no respect for
geography
How? - Intubation without drugs or
sedation only
• Successful ETI of trauma pts without drugs ~
mortality 99.8%. Lockey D et al. BMJ 2001.
• Low success rates in patients with reflexes
intact (5-30%)
• ETI with sedation
• Still a low success rate
• ↑Secondary brain injury
• ↑Mortality
SOLUTION = RAPID
SEQUENCE INTUBATION
(RSI)?
Components of RSI
•
•
•
•
•
•
•
•
Preoxygenation
Premedication
Rapid induction of Anaesthesia
MILS ± Cricoid
Rapid onset neuromuscular relaxation
Ideally no BVM ventilation
ETI and confirmation
Maintenance of Anaesthesia and paralysis
Components of RSI
•
•
•
•
•
•
•
•
Drug assisted definitive airway control
Preoxygenation
Premedication
Rapid
inductiontime
of Anaesthesia
Minimising
from induction to ETI
MILS ± Cricoid
Rapid onset
neuromuscular
relaxation
Decreased
gastric insufflation
Ideally no BVM ventilation
ETI and confirmation
Decreased risk of hypoxia and aspiration
Maintenance of Anaesthesia and paralysis
Controversies
• Optional Premedictions
• Sedate to preoxygenate (midazolam vs ketamine)
• Opioid (Fentanyl 1-3mcg/kg) to obtund hypertensive
response to laryngoscopy and ICP spikes
• Fluid/blood bolus in hypovolaemic
• Atropine in paeds
• Induction agent? (much lower doses in hypovolaemic)
•
•
•
•
•
Midazolam (0.3mg/kg)
Propofol (1.5-2.5mg/kg)
Thiopentone (3-5mg/kg) Reconstitution, SVR issues
Etomidate (0.3mg/kg) 11β/17α hydroxylase inhibition
Ketamine (1-2mg/kg) CLOSE TO IDEAL AGENT
Controversies
• Optional Premedictions
• Sedate to preoxygenate (midazolam vs ketamine)
• Opioid (Fentanyl 1-3mcg/kg) to obtund hypertensive
response to laryngoscopy and ICP spikes
• Fluid/blood bolus in hypovolaemic
• Atropine in paeds
• Induction agent? (much lower doses in hypovolaemic)
•
•
•
•
•
Midazolam (0.3mg/kg)
Propofol (1.5-2.5mg/kg)
Thiopentone (3-5mg/kg) Reconstitution, SVR issues
Etomidate (0.3mg/kg) 11β/17α hydroxylase inhibition
Ketamine (1-2mg/kg) CLOSE TO IDEAL AGENT
Controversies
• Neuromuscular blockade
• Suxamethonium (1.5-2mg/kg) – Rapid, familiarity and
obvious fasciculation end point but dirty drug
• Rocuronium (1.2mg/kg) – Rapid, improved side effect
profile and prolonged safe apnoea time
• Cricoid pressure - poor evidence & ↑ Difficult
intubation. Harris T et al. Resuscitation 2010
Bottom line
• Generally right drug, at the right time, at the
right dose………
• Pre-hospital=high risk → Simplified evidence
based Standard Operating Procedures (SOP)
• Remove individual practice in high risk
environment, improve CRM and reduce
human error
Not controversial
• Pre-hospital environment is no excuse for low
standards of care
• Rigorous training, simulation, assessment and currencies
• Trained operator and assistant
• AAGBI standard of monitoring (ECG, NiBP, SpO2, waveform
ETCO2)
• Quality control/assurance as part of good clinical
governance
• Preoxygenation
• Non-rebreath mask or BVM ± PEEP valve
• Nasal cannula oxygen 15L/min. PreO2 + DAO
• Consider OPA/NPAx2/SGA
Still not controversial
• MILS - remove C-collar
• Maximise 1st pass
intubation success
•
•
•
•
•
Control your environment
360 degree access
Optimise position
Use bougie for all cases
Standardised equipment
and techniques
• Formalised failed
intubation and
oxygenation drills
Who?
•
•
•
•
Impending or actual failure of airway patency
Failure of airway protection
Oxygenation or ventilation failure
Injured patients who are unmanageable or
severely agitated after head injury
• Humanitarian indications
• Anticipated clinical course
So we think pre-hospital RSI has a
place, but who should be doing it?
↓
A TRAINED AND COMPETENT
TEAM
Physician-paramedic team
• Good medical
experience
• Anaesthetic
experience
• Doctor ≠ pre-hospital
RSI competent!
• Additional pre-hospital
training
• Cost
• Availability
Double Paramedic or paramedic/air
crewman
• At home in the prehospital environment
• Experienced++
• Infrastructure and
governance needed
• Infrequent occurrence
for those purely
working out of hospital;
skill maintenance issue
Do paramedics want to do it?
• 99 London HEMS paramedics were asked if
they felt RSI should be part of experienced UK
paramedic’s practice (courtesy of Prof D Lockey)
• 65% said yes pre-term at London HEMS
• Only 32% said yes on completion of their term working
for HEMS
• Isolated to London HEMS?
Success rates of pre-hospital RSI
• Physician/paramedic team
•
•
•
•
•
99.4% London HEMS (348/350) Mackay CA et al. Emerg Med J 2001
98.8% London HEMS (397/402) Harris T et al. Resuscitation 2010
99.5% GSA-HEMS (185/186) Bloomer R et al. Emerg Med J 2012
99.1% SAMU France (685/691) Adnet F et al. Ann Emerg Med 1998
100% Germany (342/342) Helm M et al. Br J Anaesth 2006
• Paramedic
• 97% MICA Victoria (152/157) Bernard SA et al. Ann Surg 2010
• 96% Auckland rescue helicopter (~280) Tony Smith
• 86.7% San Diego (281/209) Davis DP et al. J Trauma 2003
Are failed intubations an issue?
• Yes, but....
• Can’t Intubate Can’t Oxygenate much worse
• Failure to detect an oesophageal intubation or misplaced
ETT is much worse
• Undetected oesophageal intubations during RSI should
really be a ‘NEVER’ event
• Continuous ETCO2 monitoring reduces UNDETECTED
misplaced intubations from 23.3% to 0%. Silvestri S et al. Ann
Emerg Med 2005
Waveform capnography/ETCO2
•
•
•
•
•
•
•
•
209 RSI, 627 historical controls
Mortality - RSI vs control, 33% vs 24% (p <0.05)
Good outcome – RSI vs control, 57% vs 45% (p <0.01)
High rates of hypotension, hypoxaemia, hypercarbia
Low intubation success
Longer scene times
Training issue?
Use of ETCO2 not universal
•
•
•
•
312 pts RCT
MICA paramedics with ETCO2
Midazolam/Sux
97% success rate, 5 oesophageal intubations
recognised
• Favourable outcome - 51% pre-hospital RSI compared
39% controls (p <0.05)
• 13 lost to follow up, 1 more +ve outcome in control
group would result in NS result
• Prospective RCT by Careflight, awaiting
publication
• Physician/paramedic vs standard care
• 338 recruited over 6yrs, needed 510 pts
• -ve primary outcome (GOSE 6 months)
• High cross over between groups
• When ASNSW physician/paramedic team added
to careflight team data -> improved odds of
survival at discharge (p-0.02)
Pre-hospital RSI is here to stay, so
how do we make it safer?
PRE-HOSPITAL RSI
↓
KEEP IT SIMPLE
↓
STANDARDISE PRACTICE
(equipment, techniques and drugs)
↓
AVOID HUMAN ERROR
↓
IMPROVE CRM
Standard Operating procedures
Standardised pre-hospital drugs
• Pre-drawn drugs
•
•
•
•
Ketamine 200mg/20ml
Suxamethonium 100mg/2ml (x2)
Midazolam 10mg/10ml
Morphine 10mg/10ml
• Spare Ampoules
•
•
•
•
Rocuronium 50mg/5ml (x2)
Fentanyl 500mcg/10ml (x2)
Midazolam 15mg/3ml
Ketamine 200mg/2ml (x5)
In hospital level of monitoring
and Kit dump
Challenge response checklist
Quality assurance and clinical
governance
Training and simulation
Summary
• Pre-hospital RSI is indicated in certain patients
• High risk intervention that needs to be
delivered in a quality assured manner
• Pre-hospital RSI done badly is worse than
standard management
• Some evidence for a morbidity and mortality
benefit
Questions?