A study in EMJ shows us how safe prehospital RSI can be when really robust operating procedures are in place. In my view it is also more evidence of the superiority of the doctor-paramedic model in prehospital care. During a 16 month period all attempted intubations were successfull.
The study comes out of the East Anglian Air Ambulance,(EAAA) a british HEMS service that relies on the doctor-paramedic model. The doctor is a consultant or senior registrar in either anesthesia or emergency medicine. The study records all intubations performed during a 16 month period after a standard operating procedure was introduced.
The Standard Operating Procedure (SOP) the EAAA introduced is the one developed by London HEMS. The RSI SOP and a whole host of other useful SOPs are open access available here. It is recommended reading. For the electives list anaesthetist/artist/lover the way the SOP is written, and taught, might seem very rigid, but there is a good reason for that.
The SOP is incredibly robust. Their doctrine was to have a RSI SOP where basically a doctor who is having the worst day of his life, working with a paramedic who is also having the worst day of his life, successfully intubates the sickest patients under the worst possible conditions. That SOP is rigidly taught and adhered to.
It seems they got it right. The London HEMS database documents 6000-7000 RSIs where the vast majority of prehospital RSIs were successful.
So, the EAAA adapted that SOP to their rural-suburban conditions with some very minor variations. The study records all prehospital intubations performed during a 16 month period.
Indications for RSI were
(1) actual or impending airway failure
(2) ventilatory failure
(4) humanitarian indications
(5) injured patients who are unmanageable or severely agitated after a head injury and
(6) anticipated clinical course.
Drugs used were etomidate and sux given in standard doses, in a standardised sequence. The tube was always passed over a bougie. In the event of a failed first attempt, a set of rehearsed drills kicks in in order to improve intubating conditions for the second attempt. If the second attempt fails, intubating attempts are abandoned and the next step is a supraglottic airway, BVM or cricothyroidotomy depending on what is appropriate.
A total of 1156 missions were identified.
11,5% percent of missions required RSIs.
78% of missions requiring RSI were trauma. The rest were medical.
All intubations were successful.
No RSI required resorting to a supraglottic or surgical airway.
The numbers are small but this study supports the doctor-paramedic model in prehospital airway management. It is also evidence of the importance of having, and teaching, the right SOP for prehospital airway management.
Hopefully, soon the case will be even stronger. I hear rumours that London HEMS soon will publish data from more than 7000 RSIs with similar impressive outcomes. Add to that the existing studies demonstrating how good some systems have become at intubating in the field.
Prehospital intubations are as safe as theatre intubations if done right.
One of the problems with prehospital intubations seems to be solved. If so, the rest of us should pay close attention and stop improvising and stop basing our RSI of critically ill patients on personal preferences. We should have, teach and adhere to similar SOPs for in hospital use too. Prehospital RSIs done right are as safe, or even safer, than many hospitals’ in-hospital RSIs. That is highly embarrassing.
I recommend reading the paper by Chesters et al. There is a lot more to learn from it in regards to scene times, indications for RSI, consultants vs registrars etc. It lives here:
Emerg Med J. 2014 Jan;31(1):65-8. doi: 10.1136/emermed-2012-201846. Epub 2013 Jan 23. Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Chesters A, Keefe N, Mauger J, Lockey D.