Pre-hospital Rapid Sequence Induction and Intubation

Pre-hospital Rapid Sequence Intubation

Dr Peter SherrenSenior registrar Anaesthesia, Intensive Care and Pre-hospital care The Royal London Hospital and Greater Sydney Area HEMS

ObjectivesWhy?Who?How?Evidence

IntroductionControversial/Territorial/Evocative topic!Early appropriate airway control central to good trauma careWhy not bring a hospital level of care to the roadside?

Why?Like haemorrhage, airway compromise is a significant cause of preventable deathsHypoxia common on scene in trauma. Stochetti et al. J Trauma 1997Hypoxia and hypercarbia associated with increased morbidity and mortality in TBI. Sherren PB et al. Curr Opin Anesthesiol 2012ETI is gold standard in hospitalPatient and pathology have no respect for geography

How? - Intubation without drugs or sedation onlySuccessful 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 sedationStill a low success rateSecondary brain injuryMortality

SOLUTION = RAPID SEQUENCE INTUBATION (RSI)?

Components of RSIPreoxygenationPremedicationRapid induction of AnaesthesiaMILS CricoidRapid onset neuromuscular relaxationIdeally no BVM ventilationETI and confirmationMaintenance of Anaesthesia and paralysis

Components of RSIPreoxygenationPremedicationRapid induction of AnaesthesiaMILS CricoidRapid onset neuromuscular relaxationIdeally no BVM ventilationETI and confirmationMaintenance of Anaesthesia and paralysis

Drug assisted definitive airway control

Minimising time from induction to ETI

Decreased gastric insufflation

Decreased risk of hypoxia and aspiration

Controversies Optional Premedictions Sedate to preoxygenate (midazolam vs ketamine)Opioid (Fentanyl 1-3mcg/kg) to obtund hypertensive response to laryngoscopy and ICP spikesFluid/blood bolus in hypovolaemicAtropine in paedsInduction agent? (much lower doses in hypovolaemic)Midazolam (0.3mg/kg)Propofol (1.5-2.5mg/kg)Thiopentone (3-5mg/kg) Reconstitution, SVR issuesEtomidate (0.3mg/kg) 11/17 hydroxylase inhibitionKetamine (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 spikesFluid/blood bolus in hypovolaemicAtropine in paedsInduction agent? (much lower doses in hypovolaemic)Midazolam (0.3mg/kg)Propofol (1.5-2.5mg/kg)Thiopentone (3-5mg/kg) Reconstitution, SVR issuesEtomidate (0.3mg/kg) 11/17 hydroxylase inhibitionKetamine (1-2mg/kg) CLOSE TO IDEAL AGENT

ControversiesNeuromuscular blockadeSuxamethonium (1.5-2mg/kg) Rapid, familiarity and obvious fasciculation end point but dirty drugRocuronium (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 lineGenerally 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 controversialPre-hospital environment is no excuse for low standards of careRigorous training, simulation, assessment and currenciesTrained operator and assistantAAGBI standard of monitoring (ECG, NiBP, SpO2, waveform ETCO2)Quality control/assurance as part of good clinical governance PreoxygenationNon-rebreath mask or BVM PEEP valveNasal cannula oxygen 15L/min. PreO2 + DAOConsider OPA/NPAx2/SGA

Still not controversialMILS - remove C-collarMaximise 1st pass intubation success

Control your environment 360 degree accessOptimise position Use bougie for all casesStandardised equipment and techniquesFormalised failed intubation and oxygenation drills

Who?Impending or actual failure of airway patencyFailure of airway protectionOxygenation or ventilation failureInjured patients who are unmanageable or severely agitated after head injuryHumanitarian indicationsAnticipated clinical course

So we think pre-hospital RSI has a place, but who should be doing it?

A TRAINED AND COMPETENT TEAM

Physician-paramedic teamGood medical experienceAnaesthetic experienceDoctor pre-hospital RSI competent!Additional pre-hospital training CostAvailability

Double Paramedic or paramedic/air crewmanAt home in the pre-hospital environmentExperienced++Infrastructure and governance neededInfrequent 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 paramedics practice (courtesy of Prof D Lockey)65% said yes pre-term at London HEMSOnly 32% said yes on completion of their term working for HEMS

Isolated to London HEMS?

Success rates of pre-hospital RSIPhysician/paramedic team

99.4% London HEMS (348/350) Mackay CA et al. Emerg Med J 200198.8% London HEMS (397/402) Harris T et al. Resuscitation 201099.5% GSA-HEMS (185/186) Bloomer R et al. Emerg Med J 201299.1% SAMU France (685/691) Adnet F et al. Ann Emerg Med 1998100% Germany (342/342) Helm M et al. Br J Anaesth 2006Paramedic

97% MICA Victoria (152/157) Bernard SA et al. Ann Surg 201096% Auckland rescue helicopter (~280) Tony Smith86.7% San Diego (281/209) Davis DP et al. J Trauma 2003

Are failed intubations an issue?Yes, but....

Cant Intubate Cant Oxygenate much worseFailure to detect an oesophageal intubation or misplaced ETT is much worseUndetected oesophageal intubations during RSI should really be a NEVER eventContinuous 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 controlsMortality - RSI vs control, 33% vs 24% (p