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Comparative Study
. 2015 Apr 1;19(1):134.
doi: 10.1186/s13054-015-0872-2.

Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia

Richard M Lyon  1 , Zane B Perkins  2   3 , Debamoy Chatterjee  4 , David J Lockey  5 , Malcolm Q Russell  6 ; Kent, Surrey & Sussex Air Ambulance Trust
Affiliations
Comparative Study

Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia

Richard M Lyon et al. Crit Care. .

Abstract

Introduction: Rapid Sequence Induction of anaesthesia (RSI) is the recommended method to facilitate emergency tracheal intubation in trauma patients. In emergency situations, a simple and standardised RSI protocol may improve the safety and effectiveness of the procedure. A crucial component of developing a standardised protocol is the selection of induction agents. The aim of this study is to compare the safety and effectiveness of a traditional RSI protocol using etomidate and suxamethonium with a modified RSI protocol using fentanyl, ketamine and rocuronium.

Methods: We performed a comparative cohort study of major trauma patients undergoing pre-hospital RSI by a physician-led Helicopter Emergency Medical Service. Group 1 underwent RSI using etomidate and suxamethonium and Group 2 underwent RSI using fentanyl, ketamine and rocuronium. Apart from the induction agents, the RSI protocol was identical in both groups. Outcomes measured included laryngoscopy view, intubation success, haemodynamic response to laryngoscopy and tracheal intubation, and mortality.

Results: Compared to Group 1 (n = 116), Group 2 RSI (n = 145) produced significantly better laryngoscopy views (p = 0.013) and resulted in significantly higher first-pass intubation success (95% versus 100%; p = 0.007). A hypertensive response to laryngoscopy and tracheal intubation was less frequent following Group 2 RSI (79% versus 37%; p < 0.0001). A hypotensive response was uncommon in both groups (1% versus 6%; p = 0.05). Only one patient in each group developed true hypotension (SBP < 90 mmHg) on induction.

Conclusions: In a comparative, cohort study, pre-hospital RSI using fentanyl, ketamine and rocuronium produced superior intubating conditions and a more favourable haemodynamic response to laryngoscopy and tracheal intubation. An RSI protocol using fixed ratios of these agents delivers effective pre-hospital trauma anaesthesia.

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Figures

Figure 1
Figure 1
Cormack-Lehane grade at laryngoscopy by rapid sequence intubation (RSI) group. Data presented as proportion with 95% CI. There was a significant difference between groups in the proportions (P = 0.013, chi-square).
Figure 2
Figure 2
Relative change in a) systolic blood pressure (SBP) and b) mean arterial pressure (MAP) following a full-dose rapid sequence induction of anaesthesia. Group 1 were administered etomidate and suxamethonium and Group 2 were administered fentanyl, ketamine and rocuronium. Grey shaded area indicates an acceptable haemodynamic response (within 20% of baseline measurement).
Figure 3
Figure 3
Baseline and procedural systolic blood pressure (SBP) in the eight Group 2 patients who had a hypotensive response. The median (IQR) baseline SBP was 140 (127 to 154) mmHg and median (IQR) procedural SBP was 104 (93 to 118) mmHg.
Figure 4
Figure 4
Relative change in a) systolic blood pressure (SBP) and b) mean arterial pressure (MAP) following a reduced-dose rapid sequence induction of anaesthesia. Group 1 was administered etomidate and suxamethonium and group 2 was administered fentanyl, ketamine and rocuronium. Grey shaded area indicates an acceptable haemodynamic response (within 20% of baseline measurement).
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References

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