Prehospital rapid sequence intubation for head trauma: Conditions for a successful program

Background: Recent reports have questioned the safety and efficacy of prehospital rapid sequence intubation (RSI) for patients with head trauma. The purpose of this study is to determine the rate of successful prehospital RSI, associated complications, and delays in transport of critically injured trauma patients treated by a select, well-trained group of paramedics with frequent exposure to this procedure and a rigorous quality control system. Methods: A helicopter paramedic group's database of patient flight records (1999 to 2003) was merged with registry data of a suburban Level I trauma center. Both databases included comprehensive performance improvement data. After Institutional Review Board approval, data were analyzed to determine RSI success rate, impact. on oxygenation, delays in transport and complications associated with attempted RSI. Attempted RSI was defined as any insertion of the laryngoscope into the oropharynx. Results: In all, 1,117 trauma patients were transported. One hundred and seventy-five had attempted RSI (74% male, mean age 31.1 +/- 19.2 years, 91% blunt trauma, 88% with Head/Neck AIS >= 2, mean Injury Severity Score 25.6, mean scene Glasgow Coma Scale score 4.8 +/- 2.4). One hundred and sixty-nine patients (96.6%) had successful scene RSI. Seventy percent were intubated on the first attempt, 89% by the second attempt, and 96% by the third attempt. Of the six patients (3.4% overall) who failed RSI, (2.3% overall) had scene cricothyroidotomy and two (1.1% overall) were managed by bag-valve mask. Complications included five (2.9%) right mainstem intubations and 2 (1.2%) endotracheal tube dislodgments en route. There were no esophageal intubations. Four patients in extremis (2.3%) had arterial desaturations associated with RSL Arterial blood gas analyzed upon arrival revealed (mean pCO(2) 36.6 +/- 8, median 37). Attempted RSI was associated with a mean of 6 minutes of added scene time. Conclusion: Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport. This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure. This is particularly important given the high rates of traumatic brain injury encountered.