Rapid Sequence Intubation in the Pre-Hospital Setting – Difference Between Trauma and Nontrauma Patients
1Center for Emergency Medicine Ljubljanska,Medical Faculty University of Maribor
2University of Maribor
DOI: 10.22514/SV51.042010.5 Vol.5,Issue 1,April 2010 pp.34-39
Published: 27 April 2010
Aim. To determine, in a prospective observational study, whether there are differences in the practice of rapid sequence intubation (RSI) and to ascertain the characteristics between trauma and non-trauma patients that were intubated in a prehospital setting. Methods. Included were patients (18 years and over) who were not in cardiac arrest and who underwent RSI and were transported to hospital. From January 2000 to December 2006 we intubated 636 patients in cardiac arrest, 159 critically ill non-trauma patients and 142 trauma patients. Placement of an endotracheal tube was confirmed by capnography. We compared medical and trauma groups of intubated patients. We used the two-independent sample t-test, Chi-square test and Wilcoxon-Mann Whitney test for statistical analysis. Results. Statistical differences between groups (medical vs. trauma): initial main arterial pressure (104.9 +/- 34.6 vs. 90.7 +/- 24.8; p=0.01), blood glucose levels (9.2 +/- 3.5 vs. 5.9 +/- 1.9; p=0.011), administration of colloids (13,1 % vs. 70,2; p=0.003) and Hyperhaes (2.5 % vs.17.6 %; p=0.001), male gender (62.3 vs 81.6; p=0.014), rate of RSI (71.1 % vs. 96.4 %; p<0.001), initial GCS distribution 3-4/5-8/9-15 (30.9 % /61.6 % /7.5 % vs 11.7 % /60,2 % /28,1 %; p<0.001), initial pet CO2 (49,5 +/- 8,4 mmHg vs. 32,8 +/- 5.4 mmHg; p=0.007), APACHE II first day of hospitalization (25,9 +/- 4.9 vs. 20,8 +/- 3.6; p=0.002) and hospital mortality (78/159 (49.1 %) vs. 44/142 (30.1 %); p=0.023). We also analyzed the number of intubation attempts, intubation success rate, perceived difficulty of intubation and side effects with complications. The hospital survival analysis showed that survivors are younger (54.2 +/- 19.9 vs. 62.3 +/-18.8; p=0.019), have a higher rate of RSI (175/179(97.7 %) vs. 75/122(61.6 %); p=0.002) and have a better (lower) APACHE II score (19.9 +/-3.6 vs.28.3 +/- 4.6; p=0.002). We found the highest mortality rate in the subgroup of patients with non-traumatic intracranial hemorrhage (58.8 %, 60/102). Conclusion. In non-trauma, critically ill patients we found a lower rate of RSI, more patients with an initial GCS of 3-4, higher APACHE II first day, higher initial pet CO2 and higher hospital mortality than in trauma patients.
rapid sequence intubation,pre-hospital setting, injured patients,critically ill patients, prognosis
KATJA LAH ,MILJENKO KRIŽMARIĆ,ŠTEFEK GRMEC. Rapid Sequence Intubation in the Pre-Hospital Setting – Difference Between Trauma and Nontrauma Patients. Signa Vitae. 2010. 5(1);34-39.
1. Ummenhofer W, Scheidegger D. Role of the physician in prehospital management of trauma: European perspective. Curr Opin Crit Care 2002;8:559–65.
2. Klemen P, Grmec Š. Effect of prehospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury. Acta Anaesthesiol Scand 2006;50:1250–4.
3. Lewis RJ. Prehospital care of the multiply injured patient-The challenge of figuring out what works. JAMA 2004;291(11):1382–4.
4. Davis DP, Kene M, Vilke GM, Sise MJ, Kennedy F, Eastman AB, et al. Head – injured patients who“ talk and die“: the San Diego perspec-tive. J Trauma 2007;62:277–81.
5. Di Bartolomeo S, Sanson G, Nardi G, Michelutto V, Scian E. Inadequate ventilation of patients with severe brain injury: a possible drawback to prehospital advanced trauma care? Eur J Emerg Med 2003;10:268-71.
6. Fakhry SM, Scanlon JM, Robinson L, Askari R, Watenpaugh RL, Fata P, et al. Prehospital rapid sequence intubation for head trauma: conditions for a successful program. J Trauma 2006;60(5):997-1001.
7. Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest 2005;127:1397–412.
8. Kraus JJ, Metzler MD, Coplin WM. Critical care issues in stroke and subarachnoid hemorrhage. Neurol Res 2002;24(suppl 1):S47-57.
9. Ricard-Hibon A, Chollet C, Leroy C, Marty J. Succinylcholine improves the time of performance of a tracheal intubation in prehospital critical care medicine. Eur J Anaesthesiol 2002;19:361–7.
10. Adnet F, Minadeo JP, Finot MA, Borron SW, Fauconnier V, Lapandry C, et al. A survey of sedation protocols used for emergency endotra-cheal intubation in poisoned patients in the French prehospital medical system. Eur J Emerg Med 1998;5(4):415–9.
11. Marvez-Valls E, Houry D, Ernst AA, Weiss SJ, Killen J. Protocol for rapid sequence intubation in pediatric patients – a four-year study. Med Sci Monit 2002;8:CR229–34.
12. Marvez E, Weiss SJ, Houry DE, Ernst AA. Predicting adverse outcomes in a diagnosis based protocol system for rapid sequence intubation. Am J Emerg Med 2003;21(1):23-9.
13. Simpson J, Munro PT, Graham CA. Rapid sequence intubation in the emergency department: 5 year trends. Emerg Med J 2006;23(1):54-6.
14. Stevenson AG, Graham CA, Hall R, Korsah P, McGuffie AC. Tracheal intubation in the emergency department: the Scottish district hospital perspective. Emerg Med J 2007; 24(6):394–7.
15. Alanoglu Z, Ates Y, Yilmaz AA, Tüzüner F. Is there an ideal approach for rapid-sequence induction in hypertensive patients? J Clin Anesth 2006;18(1):34-40.
16. Jeremie N, Seltzer S, Lenfant F, Ricard-Hibon A, Facon A, Cabrita B, et al. Rapid sequence induction: a survey of practices in three French prehospital and mobile emergency units. Eur J Emerg Med 2006;13(3):148-55.
17. Bochicchio GV, Scalea TM. Is field intubation useful? Curr Opin Crit Care 2003;9(6):524-9.
18. Di Bartolomeo S, Sanson G, Nardi G, Scian F, Michelutto V, Lattuada L. Effects of 2 patterns of prehospital care on the outcome of patients with severe head injury. Arch Surg 2001;136(11):1293-300.
19. Combes X, Jabre P, Jbeili C, Leroux B, Bastuji-Garin S, Margenet A, et al. Prehospital standardization of medical airway management: incidence and risk factors of difficult airway. Acad Emerg Med 2006;13(8):823-34.
20. Kill C, Wranze E, Wulf H, Geldner G. Rapid sequence induction in prehospital emergency medicine: it is safe? Anaesthesiol Intensivmed Notfallmed Schmertzher2004;39(11):668-71.
21. Ricard Hibon A, Chollet C, Belpomme V, Duchateau FX, Marty J. Epidemiology of adverse effects of prehospital sedation analgesia. Am J Emerg Med 2003;21(6):461-6.
22. Mackay CA, Terris J, Coats TJ. Prehospital rapid sequence induction by emergency physicians: is it safe? Emerg Med J 2002;19(4):374.
23. Davis BD, Fowler R, Kupas DF, Roppolo LP. Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful?Curr Opin Crit Care 2002;8(6):571–7.
24. Sloane C, Vilke GM, Chan TC, Hayden SR, Hoyt DB, Rosen P. Rapid sequence intubation in the field versus hospital in trauma patients. J Emerg Med 2000;19(3):259-64.
25. Sing RF, Rotondo MF, Zonies DH, Schwab CW, Kauder DR, Ross SE, et al. Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis. Am J Emerg Med 1998;16(6):598–602.
26. Grmec Š, Mally Š. Prehospital determination of tracheal tube placement in severe head injury. Emerg Med J 2004;21:518 -52.
27. Davis DP, Vadeboncoeur TF, Ochs M, Poste JC, Vilke GM, Hoyt DB. The association between field Glasgow Coma Scale score and out-come in patients undergoing paramedic rapid sequence intubation. J Emerg Med 2005;2984:391-7.
28. Bernard SA. Paramedic intubation of patients with severe head injury: a review of current Australian parctice and recommendation for change. Emerg Med Australas 2006; 18(3):221-8.
29. Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of factors associated with head-injury mortality after paramedic rapid sequence intubation. J Trauma 2005;59(2): 486-90.
30. Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, et all. Advanced life support for out-of-hospital respiratory distress. N Engl J Med 2007;356:2156-64.
31. Grmec Š, Lah K, Tusek –Bunc K. Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventri-cular tachycardia cardiac arrest in the prehospital setting. Crit Care 2003;7:R139-44.
32. Grmec Š, Gašparovi V. Comparison of APACHE II, MEES and Glasgow Coma Scale in patients with non-traumatic coma for prediction of mortality. Crit Care 2001;5:19-23.
33. Wang HE, Yealy DM. How many attempts are required to accomplish out-of-hospital endotracheal intubation. Acad Emerg Med 2006;13(4):372-7.
34. Jennet Me, Kendal KM, Fourre MW, Burton JH. Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad emerg Med 2003;10(9):961-5.
35. Timmermann A, Russo SG, Eich C, Roessler M, Braun U, Rosenblatt WH, Quintel M. The out-of-hospital esophageal and endobronchial intubations performed be emergency physicians. Anesth Analg 2007;104:619-23.
36. Dibble C Maloba M. Rapid sequence induction in the emergency department by emergency personnel. Emerg Med J 2006;23:62-4.
37. Reid C, Chan L, Tweeddale M. The who, where and what of rapid sequence intubation prospective observational study of emergency RSI outside the operating theatre. Emerg Med J 2004,2:296-301.
38. Levitan RM, Dominici P, O’Malley G. Hypoxia during emergency department intubation: relationship to repeat laryngoscopy and time to intubation. Acad Emerg Med 2006;13(Suppl 1):166.
39. Davis DP, Ochs M, Hoyt DB, Marshall LK, Rosen P. The San Diego paramedic rapid sequence intubation trial: a three-year experience. Acad Emerg Med 2003;10(5):446.
40. Isserles Sa, Bree Ph. Can changes in end-tidal pCO2 measure changes in cardiac output Anest Analg 1991;73:808-14.
41. Shibutani K, Muraoki M, Shirasaki S, Kubal K, Sanchala VT, Gupte P. Do changes in end tidal pCO2 quantitatively reflect changes in cardiac output. Anesth Analg 1994;79:829-33.
42. Grmec Š, Križmari M, Mally S, Koželj A, Špindler M, Lešnik B. Utstein-style analysis of out-of-hospital cardiac arrest –bystander CPR and end-expired carbon dioxide. Resuscitation 2007;72:404-14.
43. Deakin CD, Sado DM, Coats TJ, Davies G. Prehospital end-tidal carbon dioxide concentration and outcome in major trauma. J Trauma 2004;57:65-8.
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