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Evaluation of Physiologic Alterations During Prehospital Paramedic-Performed Rapid Sequence Intubation

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Evaluation of Physiologic Alterations During Prehospital Paramedic-Performed Rapid Sequence Intubation Prehospital Emergency Care ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20 Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation Robert G. Walker, Lynn J. White, Geneva N. Whitmore, Alexander Esibov, Michael K. Levy, Gregory C. Cover, Joel D. Edminster & James M. Nania To cite this article: Robert G. Walker, Lynn J. White, Geneva N. Whitmore, Alexander Esibov, Michael K. Levy, Gregory C. Cover, Joel D. Edminster & James M. Nania (2018): Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation, Prehospital Emergency Care, DOI: 10.1080/10903127.2017.1380095 To link to this article: https://doi.org/10.1080/10903127.2017.1380095 © 2017 The Author(s). Published with license by Taylor & Francis© Robert G. Walker, Lynn J. White, Geneva N. Whitmore, Alexander Esibov, Michael K. Levy, Gregory C. Cover, Joel D. Edminster, James M. Nania. Published online: 03 Jan 2018. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipec20 Download by: [104.129.200.76] Date: 03 January 2018, At: 10:18 EVALUATION OF PHYSIOLOGIC ALTERATIONS DURING PREHOSPITAL PARAMEDIC-PERFORMED RAPID SEQUENCE INTUBATION Robert G. Walker, BA ,LynnJ.White,MS , Geneva N. Whitmore, MPH, Alexander Esibov, BS, Michael K. Levy, MD , Gregory C. Cover, MD, Joel D. Edminster, MD, James M. Nania, MD, FACEP ABSTRACT (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not dif- Objective: Physiologic alterations during rapid sequence fer across diagnostic impression categories. Peri-intubation intubation (RSI) have been studied in several emergency air- desaturation (SpO2 decrease to below 90%) occurred in 43% way management settings, but few data exist to describe of cases, and 70% of desaturation episodes occurred on first- physiologic alterations during prehospital RSI performed by attempt success. The incidence of desaturation varied among ground-based paramedics. To address this evidence gap and patient categories, with a respiratory diagnostic impres- provide guidance for future quality improvement initiatives sion associated with more frequent, more severe, and more in our EMS system, we collected electronic monitoring data to prolonged desaturations, as well as a higher incidence of evaluate peri-intubation vital signs changes occurring during accompanying cardiovascular instability. Bradycardia (HR prehospital RSI. Methods: Electronic patient monitor data decrease to below 60 bpm) occurred in 13% of cases, files from cases in which paramedic RSI was attempted were and 60% of bradycardia episodes occurred on first-attempt prospectively collected over a 15-month study period to sup- success. Hypotension (systolic blood pressure decrease to plement the standard EMS patient care documentation. Cases below 90 mmHg) occurred in 7% of cases, and 63% were analyzed to identify peri-intubation changes in oxygen of hypotension episodes occurred on first-attempt suc- saturation, heart rate, and blood pressure. Results: Data from cess. Peri-intubation cardiac arrest occurred in 2 cases, 134 RSI cases were available for analysis. Paramedic-assigned one of which was on first-attempt success. Only 11% prehospital diagnostic impression categories included neu- of desaturations and no instances of bradycardia were rologic (42%), respiratory (26%), toxicologic (22%), trauma reflected in the standard EMS patient care documentation. Conclusions: In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete Received May 8, 2017 from Physio-Control, Inc., Redmond, WA and potentially deceptive measure of intubation quality. (RGW, AE); American Medical Response, Greenwood Village, CO Supplementing the standard patient care documentation (LJW, GNW); University of Alaska Anchorage, College of Health, with electronic monitoring data can identify unrecognized WWAMI School of Medical Education (MKL); American Medi- physiologic instability during prehospital RSI and provide cal Response, Spokane, WA (GCC); City of Spokane Fire Depart- ment, Spokane WA (JDE); Spokane County EMS, Spokane, WA valuable guidance for quality improvement interventions. (JMN). Revision received September 8, 2017; accepted for publication Key words: prehospital; paramedic; rapid-sequence intu- September 11, 2017. bation; airway management; emergency medical services; physiologic monitoring R. G. Walker and A. Esibov are full-time employees of Physio- Downloaded by [104.129.200.76] at 10:18 03 January 2018 Control, Inc. All other authors have no conflicts of interest to report. PREHOSPITAL EMERGENCY CARE 2017; Early Online:1–12 The authors alone are responsible for the content and writing of the paper. The authors would like to thank AMR Spokane, City of Spokane Fire NTRODUCTION Department, Cathy St. Amand, Tamara Drapeau, and Nate Cover for I their contributions to this research. Rapid sequence intubation (RSI) of severely ill or Address correspondence to Robert G. Walker, Physio-Control, injured patients is a critical intervention performed Inc., 11811 Willows Road NE, Redmond, WA 98052, USA. in various emergency care settings, including the E-mail: [email protected] out-of-hospital environment. Although RSI facil- © 2017 Robert G. Walker, Lynn J. White, Geneva N. Whitmore, itates definitive airway control to protect against Alexander Esibov, Michael K. Levy, Gregory C. Cover, Joel D. aspiration and establish adequate oxygenation and Edminster, James M. Nania. Published with license by Taylor & ventilation, the procedure also creates a risk for signif- Francis. icant peri-intubation physiologic alterations including This is an Open Access article distributed under the terms of the oxygen desaturation, cardiac dysrhythmias, and sig- Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), nificant hemodynamic changes (1, 2). Such physiologic which permits non-commercial re-use, distribution, and reproduc- derangements have been associated with increased tion in any medium, provided the original work is properly cited, morbidity and mortality in patients with some types and is not altered, transformed, or built upon in any way. of acute pathology (3–8), and can increase the risk of doi: 10.1080/10903127.2017.1380095 peri-intubation cardiac arrest in unstable patients or 1 2 PREHOSPITAL EMERGENCY CARE EARLY ONLINE patients with comorbidities (1,9,10). Consequently, with decreased level of consciousness (GCS ࣘ 8), facial prehospital RSI remains a subject of controversy and is trauma, airway burns, excessive secretions or other presently outside the scope of practice in many North airway compromise, or 2) respiratory failure with American EMS agencies (11). inability to oxygenate or ventilate adequately by less Numerous papers have described the observed invasive means. Online medical direction is avail- incidence of physiologic alterations during emergency able but not required prior to attempting intubation. RSI (9, 10, 12–40). However, due to significant dif- Of roughly 550 prehospital intubations performed ferences in clinical setting, provider level, and case annually, approximately a third are RSIs. mix, a minimal amount of the existing literature is As a part of agency Ongoing Training and Eval- directly applicable to EMS systems with paramedic- uation Programs, all paramedics receive advanced level providers performing RSI in both medical and airway management education and procedural train- trauma patients. Most studies describing physiologic ing annually, comprising computer-based, classroom, alterations during emergency intubation have been and psychomotor instruction. Approximately 180 conducted in an emergency department or in-hospital paramedics are employed across the two participat- setting (9, 10, 12, 15, 17, 21–24, 27, 29–40). The existing ing agencies, and the average paramedic performs prehospital literature largely reflects experience out- three to four prehospital intubations annually. New side the United States where intubation was usually paramedics in the county are required to perform at performed by physicians (18, 19, 25, 26, 28, 31).Thefew least 12 successful prehospital intubations in their first studies reporting on paramedic-performed RSI either 3-year cycle of certification, and must make up any describe air-medical experience or focus exclusively shortfall in the operating room. Thereafter, paramedics on traumatic brain injury (TBI) patients (13, 14, 16, 20). are required to perform at least 6 successful intuba- Thus while the potential physiologic sequelae of emer- tions every 3-year cycle. Prior to each recertification, gency RSI are well established, the existing literature a paramedic must also demonstrate procedural profi- provides minimal insight into the frequency and mag- ciency in a manikin-based simulation to the satisfaction nitude of various physiologic alterations that may be of the Medical Program Director. expected during prehospital RSI performed by ground- RSI is primarily performed using etomidate and suc- based paramedics. To address this evidence gap and cinylcholine for sedation and paralysis, respectively. provide guidance for future RSI quality improvement Midazolam
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