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 ± Cricoid • Rapid onset neuromuscular relaxation • Ideally no BVM ventilation • ETI and confirmation • Maintenance of Anaesthesia and paralysis

8. Components of RSI Drug assisted definitive airway control Minimising time from induction to ETI Decreased gastric insufflation Decreased risk of hypoxia and aspiration • Preoxygenation • Premedication • Rapid induction of Anaesthesia • MILS ± Cricoid • Rapid onset neuromuscular relaxation • Ideally no BVM ventilation • ETI and confirmation • 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) 11β/17α 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) 11β/17α 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 ± 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 paramedic’s 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.... • Can’t Intubate Can’t 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

29. Standard Operating procedures

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

32. Challenge response checklist

33. Quality assurance and clinical governance

34. Training and simulation

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

36. Questions?