RSI slides for Guardian EMS

16. RSI Equipment Suction Oxygen BVM LMA Working laryngoscope Tubes and stylets Gum Elastic Bougie Bite blocks Tape ETCO2 detectors

34. INCIDENCE OF TRANSIENT HYPOXIA AND PULSE RATE REACTIVITY DURING PARAMEDIC RAPID SEQUENCE INTUBATION Dunford, J.V., et al, Ann Emerg Med 42(6):721, December 2003 BACKGROUND: Cerebral injury is exacerbated by hypotension and hypoxia. Outcome studies of prehospital rapid sequence intubation (RSI) in patients with significant head injuries have yielded conflicting results. METHODS: The authors examined data from a subset of 54 adults with closed head injuries who participated in a larger study of paramedic RSI, to identify episodes of desaturation and pulse rate reactivity during RSI. The larger study was performed within the San Diego EMS System and was terminated after it was found that RSI was associated with worse outcomes. The RSI protocol called for preoxygenation for at least 60 seconds, use of midazolam for sedation if systolic pressure was at least 120mm Hg, weight- based dosing of succinylcholine to achieve neuromuscular blockade, and a maximum of three 30-second intubation attempts. RESULTS: Oxygen desaturation during RSI (to levels below 90%, or any decrease in patients having an initial O2 saturation below 90%) was documented in 57% of the patients, most of whom (84%) had initial SPO2 values of at least 90% before administration of RSI medications. The median decrease in SPO2 during desaturation was 22% and the median duration of the episodes was 160 seconds. Most of the patients had a 20-beat increase (61%) or decrease (29%) in pulse rate during desaturation, and 36% developed significant bradycardia (heart rate below 50). The intubation was considered by paramedics to be "easy" in 26 of the 31 RSI episodes associated with oxygen desaturation. CONCLUSIONS: This study demonstrated a substantial rate of oxygen desaturation during RSI by paramedics in patients with serious closed head injury

35. EFFECT OF OUT-OF-HOSPITAL PEDIATRIC ENDOTRACHEAL INTUBATION ON SURVIVAL AND NEUROLOGIC OUTCOME: A CONTROLLED CLINICAL TRIAL Gausche, M., et al, JAMA 283(6):783, February 9, 2000 METHODS: In this extraordinary controlled clinical trial, from Harbor-UCLA Medical Center in Torrance, CA, outcomes were compared in 410 children below the age of twelve who received bag-valve-mask (BVM) ventilatory support in the prehospital setting and 420 similar children who were assigned to receive endotracheal intubation (ETI). Indications for airway management included traumatic or nontraumatic cardiopulmonary or respiratory arrest respiratory failure, airway obstruction, head trauma with nonpurposeful response, or a perceived need for assisted ventilation. All participating paramedics underwent an initial six-hour training course in pediatric airway management. RESULTS Rates of survival to hospital discharge were similar in the ETI and BVM groups (26% and 30%, respectively), as were rates of discharge with good neurologic outcome (20% and 23%). Survival and/or good neurologic outcome were statistically more likely in the BVM group in subgroups having diagnoses of child abuse, respiratory arrest and foreign body aspiration. Overall, ETI was successful in 57 of children in whom it was attempted. Complications specific to ETI included esophageal intubation (2%), recognized or unrecognized dislodgment of the ET tube (14%), mainstem bronchus intubation (18%), and incorrect tube size (24%). Median scene time and total prehospital time were longer (by 2-3 minutes) in the ETI group BACKGROUND: Although pediatric endotracheal intubation is taught in 97% of paramedic training programs and is widely used in the out-of-hospital setting, findings in this landmark study suggest that (in an urban environment) it is no better than, and may be worse than, pre-hospital use of BVM only.

36. THE EFFECT OF PARAMEDIC RAPID SEQUENCE INTUBATION ON OUTCOME IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY Davis, D.P., et al, J Trauma 54:444 March 2003 METHODS: This prospective study, from the University of California, San Diego, investigated the effect of rapid sequence intubation (RSI) on outcomes in adults with severe traumatic brain injury. Paramedics underwent eight hours of training in RSI, GCS scoring and Combitube (CT insertion. Patients were enrolled if they had a suspected head injury with a GCS of 3-8, an estimated transport time of more than 10 minutes, and could not be intubated without RSI. CT insertion was mandated if RSI was unsuccessful. Each of the 209 study patients was matched to three nonintubated historical controls matched for age, gender, trauma center mechanism of injury and abbreviated injury score (AIS) (total controls 627). RESULTS: When compared with controls, the RSI group had a lower rate of &quot;good outcomes,&quot; defined as discharge to home, jail rehabilitation, a psychiatric facility or leaving against medical advice (45.5% vs. 57.9%, p<0.01) and a higher mortality rate (33% vs. 24.2 p<0.05). The RSI group also had longer scene times (mean, 22.8 vs. 16.4 minutes, p<0.0001) and more frequent inadvertent hyperventilation (15.4 vs. 8.0%, p=0.014). Although the measured mean pO2 on arrival at the ED was higher in the RSI group (315 vs. 216mm Hg in controls, p<0.001 transient hypoxia occurred in more than 50% of the intubated patients in whom pulse oximetry was recorded. CONCLUSIONS: In these patients with severe traumatic brain injury, rapid sequence intubation by paramedics was associated with worse outcomes than those documented in unintubated control patients. Since patients were excluded if intubation was unsuccessful, the detrimental effect of RSI might have been underestimated.

37. COMPARISON OF DIFFERENT AIRWAY MANAGEMENT STRATEGIES TO VENTILATE APNEIC NONPREOXYGENATED PATIENTS Dorges, V., et al, Crit Care Med 31(3):800, 2003 BACKGROUND: Although endotracheal intubation is considered the gold standard for emergency airway management, adjunctive techniques can sometimes be necessary. METHODS: This German study evaluated alternative strategies for emergency ventilation in an apneic patient. Forty-eight ASA I/II non-preoxygenated adults undergoing general anesthesia for a routine surgical procedure were randomized to use of one of four airway devices (bag-valve-mask [BVM], laryngeal mask airway [LMA], cuffed oropharyngeal airway [COPA] or Combitube [CT]). The devices were inserted by an experienced paramedic, and patients were ventilated with 100% oxygen for three minutes, using a self-inflating pediatric bag. RESULTS: The study was terminated due to a decrease in oxygen saturation below 90% during insertion in 3/12 patients in the COPA group, 2/12 in the LMA group and 1/12 CT patients; this complication did not occur in the BVM group Achievement of adequate tidal volumes was also accomplished more rapidly in the BVM group (20 vs. 33-43 seconds). Oxygen saturation decreased statistically during insertion of the CT and LMA, but not with the BVM or COPA. In all patients, however, O2 saturation increased to greater than 98% after one minute of ventilation with 100% oxygen. CONCLUSIONS: Bag valve-mask ventilation with a pediatric self-inflating bag and 100% oxygen appeared to be the most simple and effective of four airway strategies in this series of non-preoxygenated apneic adults ventilated in the operating room by paramedics.

38. COMPARISON OF DIFFERENT AIRWAY MANAGEMENT STRATEGIES TO VENTILATE APNEIC NONPREOXYGENATED PATIENTS Dorges, V., et al, Crit Care Med 31(3):800, 2003 BACKGROUND: Although endotracheal intubation is considered the gold standard for emergency airway management, adjunctive techniques can sometimes be necessary. METHODS: This German study evaluated alternative strategies for emergency ventilation in an apneic patient. Forty-eight ASA I/II non-preoxygenated adults undergoing general anesthesia for a routine surgical procedure were randomized to use of one of four airway devices (bag-valve-mask [BVM], laryngeal mask airway [LMA], cuffed oropharyngeal airway [COPA] or Combitube [CT]). The devices were inserted by an experienced paramedic, and patients were ventilated with 100% oxygen for three minutes, using a self-inflating pediatric bag. RESULTS: The study was terminated due to a decrease in oxygen saturation below 90% during insertion in 3/12 patients in the COPA group, 2/12 in the LMA group and 1/12 CT patients; this complication did not occur in the BVM group Achievement of adequate tidal volumes was also accomplished more rapidly in the BVM group (20 vs. 33-43 seconds). Oxygen saturation decreased statistically during insertion of the CT and LMA, but not with the BVM or COPA. In all patients, however, O2 saturation increased to greater than 98% after one minute of ventilation with 100% oxygen. CONCLUSIONS: Bag valve-mask ventilation with a pediatric self-inflating bag and 100% oxygen appeared to be the most simple and effective of four airway strategies in this series of non-preoxygenated apneic adults ventilated in the operating room by paramedics.