Rapid Sequence Intubation in Pre-Hospital Care
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1 Rapid Sequence Intubation in Pre-Hospital Care Dr Adam Chesters Specialist Registrar in Emergency Medicine and Pre-Hospital Care London s Air Ambulance
2 CV University of Leicester Medical School Emergency Medicine, Anaesthetics, Critical Care John Radcliffe Hospital Noble s Hospital Northern General Hospital West Suffolk Hospital Addenbrooke s Hospital St Mary s Hospital Pre-Hospital and Retrieval Essex and Herts Air Ambulance East Anglian Air Ambulance Children s Acute Transport Service London s Air Ambulance Oxford Isle of Man Sheffield Bury St Edmunds Cambridge London
3 For the purposes of this talk... Accept that pre-hospital RSI is beneficial to certain seriously injured patients Think about robust systems and safe techniques
4 Things to think about... London s Air Ambulance Description of the process Latest statistics Pre-hospital rapid sequence intubation Who benefits? Do we need drugs? Do we need doctors? Do we need a system?
5 London s Air Ambulance Philosophy for pre-hospital intubation: 1. None of our patients should have to wait to get an anaesthetic if they need one 2. Technique must be safe and reproducible 3. The first attempt at intubation must have the maximum chance of success
6 London s Air Ambulance 25,000 missions since launch in % of all patients seen get RSI Experience of over 6000 pre-hospital RSIs
7 London s Air Ambulance Simple algorithm for RSI: RSI required? If yes, perform standard RSI technique Fail to intubate after failed intubation drills? Surgical airway or supraglottic device EXACTLY THE SAME EVERY TIME
8 The Process 1. Decision 2. Form a team 3. Maximum pre-oxygenation 4. Kit dump and equipment preparation 5. Check list 6. Anaesthetic drugs 7. Intubation 8. Confirmation 9. Maintenance of anaesthesia 10.Journey to hospital 11.Handover to hospital team
9 1. Decision Simple criteria: 1. Unconscious 2. Agitated head injuries 3. Airway compromise 4. Ventilatory failure 5. Anticipated clinical course Traumatic brain injury Pre-hospital mortality In-hospital mortality 6. Humanitarian reasons
10 2. Form a team
11 3. Maximum Pre-oxygenation
12 4. Kit Dump
13
14 Move the patient to the kit... Create a working space to deliver anaesthetic 360 access to patient Shaded from sunlight Lit at night Quiet (engines, phones, radios turned off) Paramedic lays out equipment while doctor finishes patient assessment and briefs team Near to ambulance for loading
15
16 5. RSI Checklist Allows period of oxygenation Equipment present Equipment working Optimise first attempt Back up plan understood
17 6. Anaesthetic drugs
18 Choice of drugs Etomidate Suxamethonium Pancuronium Morphine and Midazolam Pick suitable drugs for the service and make sure all personnel know them in detail EXACTLY THE SAME EVERY TIME
19 7. Intubation
20 Maximising chance of success Preparation Good team work and using a check list Positioning 360 access to the patient Patient at waist height on ambulance trolley Operator kneeling at head of patient Cervical spine collar removed Help Bougie every time Skilled assistant Well rehearsed failed intubation drill
21 8. Confirmation
22 9. Maintain anaesthesia and monitor
23 10. Load and convey
24 11. Handover to the hospital
25 RSI and the anaesthetic package Full monitoring Maximum pre-oxygenation adjuncts and sedation Drugs to induce anaesthesia and paralyse Intubation and confirmation of placement A failed airway drill Maintenance of anaesthesia Appropriate ventilation strategy
26 Failure to intubate 30 second drills Small changes that may make a huge difference Can be read out as a check list Decision: Surgical airway Supraglottic device (igel)
27
28
29
30 Roles in the team? HEMS Doctors Intubation HEMS Paramedics Very unusual for paramedic to intubate Highly skilled assistant Equipment laid out and immediately to hand Passes tube over bougie and attaches anaesthetic circuit Failed intubation drills done together Support, ideas, reminders Retrieves equipment to ensure quick departure
31 Harris T, Lockey D Emergency Medicine Journal 2010 January 2006 May 2007
32 Snapshot of a different system San Diego Paramedic RSI Trial ( ): Paramedic-performed RSI Head injury with GCS <8 209 patients, matched with 627 controls
33 Davis et al. J Trauma. 2002
34 Dunford et al. Annals of Emergency Medicine. 42(6) patients: 31 desaturated to <90% 160 seconds Median decrease in SpO2 was 22%
35 San Diego RSI Trial New system introduced Single Paramedic 8 hours training RSI Medications Failed airway device GCS scoring Ventilation strategies ± Very low dose Midazolam Cricoid pressure for all 60 seconds pre-oxygenation No ETCO2 monitoring Inadvertent hyperventilation standard settings for all London s Air Ambulance >6000 RSIs completed Doctor-Paramedic team Senior doctors At least 6 months anaesthetics Consultants or senior registrars Ongoing training RSIs over 6 months Constant review of outcomes Induction dose Etomidate Low threshold for release Maximum pre-oxygenation Full monitoring ETCO2 key end-point Ventilation titrated
36 Robust systems and safe techniques London s Air Ambulance Description of the process Latest statistics Pre-hospital rapid sequence intubation Who benefits? Do we need drugs? Do we need doctors? Do we need a system?
37
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