Should RSI be Performed in the Prehospital Setting?
Author: Donald W. Alves, MD, FACEP, Assistant Professor, Division of Emergency Medicine, Department of Surgery and EMS Fellowship Director, University of Maryland School of Medicine, Baltimore; Benjamin Lawner, DO, EMT-P, Resident Physician, Emergency Medicine Residency Program, University of Maryland School of Medicine, Baltimore
Peer Reviewer: Gary M. Vilke, MD, Professor of Clinical Medicine, Department of Emergency Medicine, University of California, San Diego Medical Center, San Diego
Introduction
Prehospital rapid sequence intubation (abbreviated here as p-RSI) has been described in the emergency medicine and trauma literature for the past two decades. Despite a growing body of increasingly rigorously designed and well-powered studies, the practice of implementing paralytic agents in the field remains controversial. Although increasing numbers of emergency medical services (EMS) systems have embraced p-RSI to facilitate intubation, evidence-based consensus to support its use still does not exist. Consequently, the issue of p-RSI remains the focus of continued and vigorous clinical debate. We reviewed 60 articles to select the most pertinent and representative literature on prehospital neuromuscular blockade to provide clinicians with the grounded perspective necessary to address this complex issue.
It is important to emphasize that this brief review will not provide readers with definitive answers. To pretend to do so would do the entire topic of p-RSI a gross injustice. The endorsement of p-RSI depends upon several key factors including personnel, training, equipment, and jurisdiction-specific issues. Indeed, the articles selected for this review describe EMS systems with varied degrees of procedural competence and ability. Both paramedic ground and aeromedical crews are highlighted in this paper. In an effort to achieve a more in-depth appreciation of this topic's complexity, we will examine related areas including p-RSI pharmacology, rescue, outcomes, and complications associated with prehospital neuromuscular blockade (NMB).
p-RSI: State of the Art
Source: Wang H, et al. Prehospital rapid sequence intubation-What does the evidence show? Proceedings from the 2004 National Association of EMS Physicians Annual Meeting. Prehosp Emerg Care 2004: 8(4):366-373.
This National Association of EMS Physicians (NAEMSP) paper provides some excellent historical and scientific background information and critically dissects the pros and cons of p-RSI. The San Diego RSI (SDRSI) trial was briefly reviewed, and the authors addressed the apparent association between p-RSI and its adverse effect on patient outcome. While intubation success rates are increased with succinylcholine use, the measured increase in mortality cannot be ignored. Fortunately, this NAEMSP paper mentioned the subset of SDRSI trial patients not experiencing increased mortality—patients transported by air medical crews, with additional training and the capability to guide ventilation by end-tidal carbon dioxide (ETCO2). NAEMSP considered a number of factors in the explanation of the SDRSI trial's surprisingly unfavorable results, including operator experience, the lack of universal capnometry, and the possibility of aspiration prior to intubation. These factors are extremely important precisely because they emphasize the many difficulties intrinsic to the development of a prehospital RSI program.
The paper concludes with a verifiable p-RSI success story from Whatcom Medic One (WMO), an integrated BLS/ALS service and is highlighted as an ideal prehospital RSI initiative. Key aspects include vigorous maintenance of skills, continued training, the use of monitoring devices including continuous pulse oximetry and capnometry, and the utilization of rescue devices for failed intubation attempts. In 1999, with 2978 patients, 96.6% were successfully intubated. Utilizing a tube confirmation pathway, only one unrecognized esophageal intubation occurred. Unlike the SDRSI trial, WMO did not observe desaturation and bradycardia. It is hypothesized that the expanded training, with intensive emphasis on pre-oxygenation, served to prevent these untoward events.
Commentary
Fortunately, enough data exist to formulate some conclusions about effective p-RSI strategies. The NAEMSP paper provides an excellent review of p-RSI and recommendations for successful programs. RSI originated in the anesthesia literature to prevent aspiration in unprepped patients undergoing general anesthesia. Physicians working in EDs pioneered paralytic agents outside the operating room, and EMS systems "have quickly jumped on the RSI bandwagon." From the first anecdotal reports of p-RSI in 1972, prehospital intubation has matured into widespread use. The often conflicting outcome data underscored the need to standardize the approach to p-RSI. A successful p-RSI program must embrace several core principles.
First, medical direction must exhibit constant and ongoing involvement, from initial training to post-intubation debriefing. Ideal paramedic training regimens might include cadaver intubation practice, dedicated operating room experience, and intensive didactic sessions. WMO paramedics, for example, complete a minimum of "20 human ETIs…under the guidance of anesthesiologists." Furthermore, requirements for ongoing procedural competence are outlined. Medics must perform a minimum of 12 intubations per year and complete annual didactic and skill training sessions. Secondly, the WMO program features a simple, effective airway algorithm. The "five P paradigm" involving preparation, preoxygenation, pretreatment, paralysis, and pass-and-confirm the tube helps ensure a systematic approach. Finally, the wide complement of monitoring devices helps minimize human error. The obligatory use of continuous pulse oximetry, waveform capnometry, rescue devices, and backup methods of tube confirmation is a comprehensive strategy that ensures compliance and prevents complications.
Recommendations from other established organizations, such as the Eastern Association for Surgery in Trauma (EAST),1 emphasize that p-RSI is an issue that deserves consideration. Its most recently published clinical management update reaffirms that hypoventilation in trauma patients needs to be urgently corrected while vigilantly avoiding hyperventilation. Furthermore, orotracheal intubation (OTI) emerges as the procedure of choice for securing an airway. EAST's brief review of "drug-assisted" intubation concludes that high success rates are achieved with neuromuscular blockade. EAST calls for the consideration of neuromuscular blockade when urgent OTI is needed and, "the patient's jaws are not flaccid." Paralytic regimens are directed toward the maintenance of hemodynamic stability, prevention of vomiting, the blunting of intracranial hypertension, and providing appropriate procedural sedation.
Hypoxia and Hyperventilation
Source: Dunford J, et al. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med 2003; 42(6):721-727.
Early data from the SDRSI trial revealed that paralytic agents resulted in increased intubation success rates and "excellent…SpO2 data on arrival." However, mortality data during the trial's first two years revealed worsened outcomes and increased mortality. The trial was subsequently halted and analyses undertaken to determine the factors responsible for the poor outcomes. Of the 54 patients with complete records, 31 patients showed evidence of desaturation as defined by "a reduction in SpO2 to less than 90% from a baseline greater than or equal to 90% or any decrease from a baseline SpO2 of less than 90%." Unfortunately, 26 of these patients had acceptable SpO2 readings prior to neuromuscular blockade. Of those suffering hypoxic insult, 19/31 (61%) "experienced a decrease in pulse…of greater than 20 beats/min." The desaturations developed precipitously and were often prolonged. Curiously enough, the introduction of simultaneous capnometry and oximetry was intended to ease the process of tube confirmation. The introduction of these event monitors, however, was responsible for the detection of procedural desaturation in the SDRSI patients.
Commentary
Dunford and Davis acknowledged their results as unexpected and concerning. Although intubation is commonly performed by paramedics, the practice of p-RSI presents providers with unique challenges. The authors offered several explanations for the complications. Although introduced to the concept of pre-oxygenation, with instruction to hyperoxygenate the patient for at least one minute, the training curriculum, however, "did not achieve its goal." Trial paramedics practiced on mannequins rather than on live patients and did not spend time in a controlled environment. Live patients are necessary to replicate the subtle difficulties intrinsic to providing adequate ventilation. Manual ventilation is a difficult skill requiring dedicated practice, but few paramedic training programs mandate training on live patients.
Given that p-RSI was indicated only for patients suffering severe traumatic brain injury, "few if any [paramedics] had the opportunity to participate in a rapid sequence intubation procedure." The issue of a minimum intubation number required to achieve proficiency is addressed later in this review.
Finally, the pre-oxygenation strategy may need more investigation. Victims of serious trauma and shock may have less physiologic reserve and tolerance. Initiation of paralysis on such seriously injured individuals may produce more rapid decompensation due to alterations in perfusion and hemostasis. The authors acknowledged that their protocol for pre-oxygenation may have been inadequate to compensate for such factors.
Spaite and Criss echoed these concerns in their editorial piece.2 Despite an increase in controversy surrounding its implementation, p-RSI is proliferating throughout EMS systems. Clearly, the measure of any p-RSI program must extend far beyond a high first-pass success score. A thorough examination of p-RSI unfortunately reveals underreporting by individual providers and may, therefore, overestimate true success. Belief that techniques result in patient improvement should be solidified by prospective evaluation "with robust methodologies." Medical directors eager to extend the potentially lifesaving practice of RSI into the field must remain aware of complications and commit themselves to accurate data reporting. Spaite's piece succinctly establishes the practice of ongoing quality improvement as vital to any successful p-RSI program.
SUX and Etomidate
Source: Bozeman W, et al. Etomidate as a sole agent for endotracheal intubation in the prehospital air medical setting. Air Med J 2002;21(4):32-6.
Just as flight programs pioneered the extension of RSI into the prehospital arena, they also have taken the lead in examining the role of etomidate as a sole intubation agent. Bozeman and Young reviewed the records of patients receiving etomidate at 0.3 mg/kg prior to endotracheal intubation. The study's exclusion criteria allowed one repeat dose of etomidate if relaxation was deemed insufficient for effective endotracheal intubation. Benzodiazepines were used at the flight crew's discretion. The 44 patients included in the review suffered from a variety of conditions including motor vehicle accidents, falls, gunshot wounds, and seizures; 39 (89%) were successfully intubated, and flight crews reported difficult intubation in 7 (16%). Barriers to intubation included "orofacial muscle spasm" and "clenched jaws." Bozeman's published etomidate-only intubation (EOI) success rate of 89% is respectable but nevertheless lower than other p-RSI trials allowing concomitant neuromuscular blockade.
Limitations—including a lack of an objective airway difficulty assessment and retrospective design — were addressed in a subsequent trial of EOI. In 2006, Bozeman and colleagues again examined the role of etomidate in the air medical setting but prospectively compared the drug against patients receiving etomidate plus succinylcholine (SUX).3 Flight crews implementing the p-RSI protocol consisted of veteran nurses and paramedics. Intubation difficulty was objectively assessed with three scoring systems: 1) POGO, or percentage of glottic opening score, 2) LGS, a standardized laryngoscopic grading scale, and 3) a subjective examiner assessment of intubation difficulty employing a Likert scale. Seventy-two patients were enrolled in the study. Like Bozeman's previous patient population, medical and trauma patients were included. Of 24 patients assigned to the etomidate-only (EOI) protocol, 15 (63%) required additional medication: 3 received additional etomidate, and 12 received succinylcholine as a rescue strategy. Of the 25 patients in the etomidate-plus-succinylcholine arm, only 1 (4%) required re-dosing. Laryngoscopic conditions in the EOI group were significantly more difficult than in the traditional RSI subgroup. Bozeman concluded that EOI is associated with inferior glottic visualization and lower success rates.
Commentary
Most studies focusing on p-RSI utilize a succinylcholine-based regimen for neuromuscular blockade even though other agents may have more favorable pharmacologic and physiologic profiles. Intubation success rates from such strategies have approached 95%. Debate about the most suitable RSI agents is beyond the scope of this review. However, recent papers have examined the role of etomidate for facilitation of endotracheal intubation. Although not a paralytic agent, a loading dose of etomidate may achieve the sedation necessary to facilitate intubation in a previously awake patient. Further inciting the EMS community's interest in etomidate is its favorable side effect profile. EOI is more properly classified as facilitated intubation because it does not involve neuromuscular blockade.
These small studies do not constitute a definitive argument for the elimination of an EOI protocol. Bozeman's study cautions readers not to completely dismiss EOI because there are situations in which paralysis might not be feasible. Bozeman's study utilized veteran flight nurses and paramedics, prehospital professionals best suited to execute field intubation. These providers, despite experience in airway management, encountered difficulties when attempting intubation without paralytic agents. It seems reasonable to conclude that less trained prehospital providers would experience similar challenges. Because prehospital RSI remains so controversial, EMS systems looking to optimize outcomes and patient safety may want to avoid an EOI protocol. It is imperative that any drug regimen to facilitate intubation maximize first-pass success rates. Although the traditional succinylcholine-based regimen has been the subject of recent scrutiny, these data reinforce its position as a superior method of achieving success.
Also of note are studies using midazolam alone to facilitate intubation. Complications identified with midazolam include hypotension and clenched teeth. In one study conducted by Wang, success rates were inferior to those reported in other p-RSI studies.4 It is important to maintain the distinction between facilitated intubation and neuromuscular blockade; p-RSI refers to the administration of paralytic agents. Etomidate, midazolam, or other benzodiazepine-based regimens should not be considered equivalent to the more aggressively studied succinylcholine airway protocols.
Essential Equipment
Source: Davis D, et al. The use of quantitative end tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. J Trauma 2004;56(4):808-814.
Further analysis of the San Diego p-RSI trial by Davis and colleagues highlighted the necessity of controlling factors such as hypoxia and hyperventilation. Although hyperventilation has been clearly associated with poorer outcomes in patients with substantial head injury, data indicate that this problem persists. Measurement of ETCO2 is the method of choice for confirmation of tube placement. In addition, quantitative ETCO2 detectors function to guide ventilation. The San Diego trial implemented devices that permitted paramedics to target ventilation to 30-35 mmHg CO2. Although 417 patients were enrolled, objective data on hyperventilation were available for only a subset of 144 patients. Severe hyperventilation was classified as an arrival arterial PCO2 reading of less than 25 mm Hg. Of the 144 patients transported with quantitative CO2, severe hyperventilation was observed in 8 (5.6%). Conversely, 20 patients of 149 (13.4%) transported without the use of quantitative CO2 measurement exhibited severe hyperventilation upon hospital arrival (OR, 2.64; 95% CI, 1.12-6.20; p = 0.035). The researchers concluded that patients who were inadvertently hyperventilated showed higher mortality rates.
Commentary
Cerebral perfusion suffers when the partial pressure of carbon dioxide in the blood is decreased. Davis' study showed that continuous CO2 waveform monitoring can help decrease the incidence of hyperventilation. Any EMS system considering an RSI protocol should embrace both qualitative and quantitative measurement of ETCO2.
Do NMBA's Affect Outcome?
Source: Bulger E, et al. The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J Trauma 2005;58(4):718-724.
Tackling the controversy surrounding the perceived association between p-RSI and mortality, Bulger studied a select group of patients in Washington state. Seattle Fire and King County EMS have been utilizing neuromuscular blocking agents (NMBA's) for 30 years. This system comprises highly trained ALS ground units as well as an aeromedical service. Patients suffering from traumatic brain injury were subclassified into mild, moderate, or severe categories. Patients transferred from outside facilities were excluded from analysis. Overall, 72% of 1077 patients underwent p-RSI for traumatic brain injury. Bulger concluded that p-RSI did not adversely affect mortality. Furthermore, patients receiving NMBA's benefited with regard to both survival and outcome: "The unadjusted mortality for [intubation] with NMBA's was 25% versus 37%." These analyses were at least partially inspired by the unexpected termination of the much-cited San Diego RSI Trial (SDRSI). These two groups had differing presentation complications: CPR (2.8% vs 7.3%) and hypotension (23% vs 37%), respectively, raising concerns about the similarity of patient groups.
Commentary
Although this study's conclusion differs from those of the SDRSI trial, it is important to emphasize some specific contrasts. Paramedics in the Seattle EMS system have the advantage of experience over their San Diego counterparts. While San Diego paramedics underwent didactic and practical training prior to implementation of the NMBA protocol, the Seattle cohort already had been practicing with paralytic agents for more than two decades. Furthermore, 50% of the ground ALS units in Bulger's trial were equipped with continuous, ETCO2 waveform monitoring. The lack of such devices was cited as a potential reason for adverse outcomes — specifically inadvertent and severe hyperventilation — in the SDRSI study. Bulger's study group was well aware of this documented complication risk and instructed their paramedics to "maintain normal respiratory rates at 12 breaths/min with a goal PCO2 [value] on hospital arrival of 35 mm Hg." Unfortunately, initial hospital blood gases values were not available from the Seattle trauma registry, and incidence of severe hyperventilation could not be determined. It is inferred that more meticulous attention to ventilation, coupled with the wider availability of ETCO2 monitors, is at least partially responsible for the mortality benefit.
Prior to accepting this study as proof that p-RSI does not adversely affect outcome, it is important to consider some other limitations. First, the retrospective format may lend itself to selection bias. Although Bulger's study might have selected "less severely injured" patients to receive RSI, there was no difference in mean injury severity score between patient groups (NMBA vs non-NMBA.) Patients receiving NMBA's, however, did experience a "lower incidence of prehospital hypotension and prehospital CPR."
There currently is not a definitive answer to the question: Does p-RSI adversely affect patient outcome? The stream of data that has poured from the SDRSI trial, in addition to subsequent studies, suggests that the answers are, at best, complicated.
Does Air Transport Affect Outcome?
Source: Poste J, et al. Air medical transport of severely head injured patients undergoing paramedic rapid sequence intubation. Air Med J 2004; 23(4):36-40.
In yet another incarnation of data from the SDRSI trial, Poste and colleagues sought to further qualify the relationship between prehospital intubation and mortality. Adult patients suffering traumatic brain injury were considered for enrollment. This particular analysis limited its inquiry to patients transported by aeromedical crews. The decision to activate air medical responders is solely at the discretion of the ALS ground crew. Capabilities of air transport providers beyond those of the San Diego ground units include advanced monitoring and mannitol administration. Poste and Davis reminded readers that ALS ground crews consist of two paramedic trained providers. Conversely, the air medical complement consists of a flight nurse paired with any of the following personnel: flight paramedic, flight nurse, or flight physician. The main purpose of enlisting aeromedical assistance was to expedite patient arrival to a trauma center. Interestingly, patients included in the current sub-analysis were those successfully intubated (Combitube vs endotracheal tube) by ground paramedics and subsequently turned over to their flight counterparts. Using 11 criteria, study subjects were matched against two historical, non-intubated controls. Patients transported by air showed improved mortality and an "improved differential survival coefficient." Poste and Davis described this measurement as a means to demonstrate a statistically significant trend toward survival "in favor of the air medical transport cohort."
Commentary
The idea that experienced providers achieve superior results has been postulated in a number of previous papers. Air medical crews often are viewed as the top tier of prehospital providers because they represent a cohort with expanded expertise and skill sets. The SDRSI trial was exciting because it showed an increase in intubation success rates after administration of neuromuscular blockade. Unfortunately, subgroup analysis revealed that patients undergoing p-RSI experienced unexpected incidents of hypoxia and hyperventilation. Mortality data showing unfavorable outcomes from p-RSI soon followed, and the "bubble" of excitement surrounding paramedic-administered neuromuscular blockade appeared to have ruptured. Subsequently, several dedicated EMS physicians have undertaken intensive investigations to attempt to discern the etiology of poor p-RSI outcomes. This study demonstrated that patient outcomes are at least partially transport-dependent. Patients in this most recent analysis fared better when transported by aeromedical crews: "discordant group analysis revealed an independent effect of transport personnel on relative survival versus matched controls." This conclusion suggests that there are factors other than the actual intubation event that contribute to ultimate patient outcome. As previously mentioned, ETCO2 monitoring, coupled with more training and experience, may play a pivotal role in the survival of patients undergoing p-RSI.
Training Needed?
Source: Swanson E, et al. Air medical rapid sequence intubation: How can we achieve success? Air Med J 2005; 24(1):40-46.
Any discussion about optimizing p-RSI is incomplete without considering the necessary specialized training. Although outcome data are often conflicting, several studies have shown an association between provider experience and patient survival. Air medical crews, often represented as the elite prehospital provider cohort, boast excellent intubation success rates and improved patient outcomes. Swanson's paper functions as a virtual blueprint for EMS agencies interested in implementing a successful RSI program. The paper mentions NAEMSP guidelines and outlines important steps in the ongoing quality improvement program, which must necessarily be linked to any p-RSI initiative.
Swanson maintained that paramedic success rates must be comparable to those of their inhospital counterparts. Furthermore, he proposed that multiple intubation attempts should be limited and affirms the benefits of close patient monitoring in an effort to avoid hypoxia and hyperventilation. Efforts at extending complicated techniques into the field arena must be guided by principles of speed, simplicity, and ease of use. In other words, prehospital providers ideally should be furnished with an algorithmic approach to management of the difficult airway. There should be no question regarding the proposed medication regimen, and paramedics should routinely anticipate the possibilities of complications and failure. Therefore, a rescue airway pathway needs to be readily accessible and understood by every member of the intubating crew.
The authors concluded that successful elements of the successful p-RSI program should encompass: "strong medical oversight, excellent…techniques…quality improvement…a planned stepwise approach to RSI, adequate backup methods… procedures to confirm endotracheal tube placement…and ongoing… monitoring."
Commentary
Numerous sources underscore the importance of provider training. Although no consensus exists as to the requisite number of didactic sessions or intubations necessary to achieve proficiency, it is probably accurate to suggest that more intubations equal improved likelihood of success. In contrast to the 12 intubations sometimes cited as the minimum necessary for maintenance of paramedic p-RSI skills (Bulger's article), Mizelle and colleagues stated that emergency medicine residents complete an average of 146 intubations prior to graduation from their training program and operating independently as board eligible physicians.5 If we are to expect a success rate similar to that of inhospital-performed RSI, then paramedics may be deficient in their procedural numbers. The low prevalence of patients requiring prehospital RSI makes it challenging to maintain a high level of expertise, but the numeric discrepancy is nevertheless profound.
Perhaps systems embracing p-RSI may consider increasing the minimum number of intubations per paramedic prior to completion of RSI training. Mizelle and Rothrock proposed a cut-off number of 90 intubations per paramedic. With the introduction of more lifelike human simulators, programs may develop newer and more efficient ways of increasing paramedic opportunities for intubation. Besides formal didactic sessions, committed medical direction and ongoing quality improvement are keys to any p-RSI program's success.
Recommendations
Prehospital rapid sequence intubation (p-RSI), despite ongoing controversy, is continuing to gain acceptance. While it is clear that prehospital providers can perform tracheal intubation, the need for further education in patient management is of extreme importance.
Specifically, paramedic personnel must understand the importance of proper pre-oxygenation. After intubation, RSI-capable medics must target ventilation to a pre-determined ETCO2 level to avoid inadvertent hyperventilation. Al-though complications confront even the most experienced provider, efforts should focus on preparation, education, and anticipation of potential pitfalls. Furthermore, a vigorous quality improvement strategy should complement any RSI program. Medical directors must be willing to critically analyze failed intubations, commit to maintenance of paramedic skills, and ensure accurate data collection of patients undergoing p-RSI.
The "Planned Stepwise Approach" to paramedic intubation, outlined by Swanson, emerges as a common theme within the p-RSI literature. Differences may exist with individualized drug dosing regimens, but agencies permitting the use of paralytic agents must understand the importance of standardization. Preoxygenation with 100% oxygen is an almost universally cited prerequisite and can be accomplished with a non-rebreather face mask or a BVM in the absence of spontaneous respirations. Included in the stepwise approach is the administration of drugs necessary to effect sedation and paralysis. Other key intervals in the performance of p-RSI include the actual intubation event, confirmation of tube placement, and post-intubation management. It is clear from the SDRSI outcome data that emphasis should be placed on each step. Paramedics should be trained in several methods of tube confirmation including direct visualization and qualitative/ colorimetric ETCO2 measurement.
Undetected esophageal intubations have disastrous consequences, and many inexpensive devices are available to help minimize this deadly complication. Thus, direct visualization, coupled with ETCO2 detection, is considered ideal. As previously mentioned, survival depends upon far more than just passing the tube through the cords.
Structured p-RSI education programs should emphasize the use of continuous CO2 monitoring as a means to protect against inadvertent hyperventilation and extubation. A comprehensive approach to the education of p-RSI-capable medics includes an overview of the several rescue devices available. Failed airway algorithms should be readily available and well rehearsed. Difficult airway algorithm adjuncts should take an exhaustive approach to airway salvage, including education in the use of the Combitube, jet ventilation, and exceptional BVM skills, in addition to surgical airway skills such as cricothyroidotomy. Although EMS agencies employ paramedics of varying skill and ability, a comprehensive prehospital education program represents an attractive method for achieving and sustaining success. Education initiatives focused on practical skills, pharmacology, quality improvement, and post-intubation ventilatory management can help bridge the gap between ground providers and their air medical counterparts.
The increased availability of waveform CO2 monitoring and lower cost transport ventilators will further narrow the survival gap, and future generations of p-RSI-capable paramedics ideally should receive instruction in these new technologies.
References
1. Dunham CM, et al. Guidelines for emergency tracheal intubation immediately after traumatic injury. J Trauma 2002;55(1):162-79.
2. Spaite DW, et al. Out-of-hospital rapid sequence intubation: Are we helping or hurting our patients? Ann Emerg Med 2003; 42(6):729-30.
3. Bozeman WP, et al. A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care 2006; 10(1):8-13.
4. Wang HE, et al. The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care 2000;4(1):14-8.
5. Mizelle HL, et al. Preventable morbidity and mortality from prehospital paralytic assisted intubation: Can we expect outcomes comparable to hospital-based practice? Prehosp Emerg Care 2002;6(4):472-5.
Prehospital rapid sequence intubation (abbreviated here as p-RSI) has been described in the emergency medicine and trauma literature for the past two decades.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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