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Pre hospital rapid sequence intubation

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Pre-hospital rapid sequence intubation (RSI) can provide a higher level of care to trauma patients in the pre-hospital setting. While controversial, RSI has the potential to reduce preventable deaths from airway compromise and hypoxia if performed by a trained team using standardized procedures. The key components of pre-hospital RSI include preoxygenation, rapid induction of anesthesia, neuromuscular blockade, endotracheal intubation, and utilization of capnography to confirm proper tube placement. When done by experienced physician-paramedic teams with rigorous training and quality assurance, success rates of over 95% have been reported. However, RSI also carries risks and must only be undertaken following strict standardized protocols to

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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 賊 Cricoid Rapid onset neuromuscular relaxation Ideally no BVM ventilation ETI and confirmation Maintenance of Anaesthesia and paralysis
Components of RSI Preoxygenation definitive airway control Drug assisted Premedication Rapid induction of Anaesthesia Minimising time from induction to ETI MILS 賊 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) 11硫/17留 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) 11硫/17留 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 賊 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
Pre hospital rapid sequence intubation
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 pre- hospital 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 paramedics 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.... Cant Intubate Cant 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 rapid sequence intubation
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?

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Pre hospital rapid sequence intubation

  • 1. 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
  • 2. Objectives Why? Who? How? Evidence
  • 3. 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?
  • 4. 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
  • 5. 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
  • 6. SOLUTION = RAPID SEQUENCE INTUBATION (RSI)?
  • 7. Components of RSI Preoxygenation Premedication Rapid induction of Anaesthesia MILS 賊 Cricoid Rapid onset neuromuscular relaxation Ideally no BVM ventilation ETI and confirmation Maintenance of Anaesthesia and paralysis
  • 8. Components of RSI Preoxygenation definitive airway control Drug assisted Premedication Rapid induction of Anaesthesia Minimising time from induction to ETI MILS 賊 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
  • 9. 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) 11硫/17留 hydroxylase inhibition Ketamine (1-2mg/kg) CLOSE TO IDEAL AGENT
  • 10. 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) 11硫/17留 hydroxylase inhibition Ketamine (1-2mg/kg) CLOSE TO IDEAL AGENT
  • 11. 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
  • 12. 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
  • 13. 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 賊 PEEP valve Nasal cannula oxygen 15L/min. PreO2 + DAO Consider OPA/NPAx2/SGA
  • 14. 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
  • 15. 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
  • 17. So we think pre-hospital RSI has a place, but who should be doing it? A TRAINED AND COMPETENT TEAM
  • 18. Physician-paramedic team Good medical experience Anaesthetic experience Doctor pre-hospital RSI competent! Additional pre-hospital training Cost Availability
  • 19. Double Paramedic or paramedic/air crewman At home in the pre- hospital environment Experienced++ Infrastructure and governance needed Infrequent occurrence for those purely working out of hospital; skill maintenance issue
  • 20. 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 HEMS Only 32% said yes on completion of their term working for HEMS Isolated to London HEMS?
  • 21. 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
  • 22. Are failed intubations an issue? Yes, but.... Cant Intubate Cant 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
  • 23. 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
  • 24. 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
  • 25. 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)
  • 26. Pre-hospital RSI is here to stay, so how do we make it safer?
  • 28. PRE-HOSPITAL RSI KEEP IT SIMPLE STANDARDISE PRACTICE (equipment, techniques and drugs) AVOID HUMAN ERROR IMPROVE CRM
  • 30. 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)
  • 31. In hospital level of monitoring and Kit dump
  • 33. Quality assurance and clinical governance
  • 35. 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