Selected topics: prehospital careRapid sequence intubation in the field versus hospital in trauma patients1
Introduction
Rapid sequence intubation (RSI) has been used with increasing frequency in the hospital and Emergency Department setting to facilitate endotracheal intubation and airway management on an emergent basis. Although its use in the prehospital arena has also increased, RSI intubation remains controversial in this setting.
Prehospital intubation is complicated by a number of factors including limited equipment and space, poor lighting, and a difficult environment in which to perform advanced procedures 1, 2. Many have argued that prehospital RSI may complicate matters further by paralyzing patients who may have had previously spontaneous airways in the field, as well as delaying hospital transport of critically ill patients. Others have argued that any delay in RSI and intubation in patients who require aggressive airway management in the field (such as those with severe head injuries) places individuals at greater risk (3).
Previous studies have found that endotracheal intubation is a technique that can be safely performed in the prehospital arena and that prehospital RSI has higher success rates and lower complications than other techniques of prehospital airway management and intubation 4, 5, 6. We sought to compare RSI in the prehospital versus hospital setting in adult trauma patients requiring airway management to determine if differences exist in success rates, complications, and patient outcomes.
Section snippets
Materials and methods
We conducted a retrospective review of all adult trauma patients who underwent prehospital RSI by aeromedical crews in transport or on the ground from January 1, 1988 through December 31, 1995, and compared them with those who had RSI upon arrival at a trauma resuscitation suite from January 1, 1992 through December 31, 1995. A longer study period was used for the prehospital RSI patient group to generate a sample size appropriate for comparison. There were no significant changes in practice
Results
During the period from 1993 to 1995, 537 trauma patients were intubated in the hospital during initial trauma resuscitation. Of these patients, 267 were intubated using the RSI method and had complete records for inclusion in the study. Twenty were intubated using RSI, but records were incomplete. The remaining patients were intubated using only one or the other of the RSI agents, no medications at all, nasal intubation, fiberoptic intubation, or surgical airway. During the period from 1988 to
Discussion
We did not find any difference in RSI success rates between the prehospital and hospital groups, and these rates are similar to those reported previously 6, 9. We found no difference in the percentage of patients requiring multiple intubation attempts. Both groups had attempts and success rates comparable to previous work 6, 10. Thus, even though conditions are often less than optimal in the prehospital setting, well trained medical personnel appear to be able to intubate in the field with
Conclusion
From our study, we have shown that RSI intubation can be performed in the field with the same success and complication rates as in the hospital. For patients with isolated head injury, we found no difference in outcome whether they received RSI intubation in the field or hospital. Our results should be verified by a larger, prospective evaluation of prehospital rapid sequence intubation.
Acknowledgements
The authors would like to thank the UCSD Division of Trauma Services for their assistance with the San Diego County Trauma Registry. The authors also acknowledge the assistance of Paul Schragg with the statistical analysis of the study. Statistical support from Grant MO1 RR0087 from the General Clinical Research Center, National Center for Research Resources, National Institutes of Health.
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Selected Topics: Prehospital Care is coordinated by Peter Pons, MD, of Denver General Hospital, Denver, Colorado