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

Objectives Why? Who? How? Evidence

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?

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

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

Solution = Rapid Sequence intubation (RSI)?

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

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

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

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

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

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

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

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

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

So we think pre-hospital RSI has a place, but who should be doing it? ↓ A TRAINED AND COMPETENT TEAM

Physician-paramedic team Good medical experience Anaesthetic experience Doctor ≠ pre-hospital RSI competent! Additional pre-hospital training Cost Availability

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

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?

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

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

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

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

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)

Pre-hospital RSI is here to stay, so how do we make it safer?

PRE-HOSPITAL RSI ↓ KEEP IT SIMPLE ↓ STANDARDISE PRACTICE (equipment, techniques and drugs) ↓ AVOID HUMAN ERROR ↓ IMPROVE CRM

Standard Operating procedures

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)

In hospital level of monitoring and Kit dump

Challenge response checklist

Quality assurance and clinical governance

Training and simulation

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

Questions?