- Email: [email protected]
Out-of-hospital rapid sequence intubation
EMERGENCY MEDICAL SERVICES/EDITORIAL
Out-of-Hospital Rapid Sequence Intubation: Are We Helping or Hurting Our Patients? Daniel W. Spaite, MD Elizabeth A. Criss, RN, MEd From the Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ.
See related article, p. 721. [Ann Emerg Med. 2003;42:729-730.]
In this issue, Dunford et al1 present data related to rapid sequence intubation of patients with severe head injuries in the out-of-hospital setting. The application of recording oximeters throughout the process of rapid sequence intubation allowed the evaluation of oxygen saturation and pulse rate. An amazing 57% of these trauma victims demonstrated desaturation during outof-hospital rapid sequence intubation. Among those who experienced desaturation, 84% had initial oxygen saturations in the normal range with the utilization of basic airway skills alone. The median duration of desaturation was 2 minutes and 40 seconds, with 1 patient remaining hypoxemic for 4 minutes and 30 seconds. The median decrease in oxygen saturation was 22%. In addition, nearly 1 in 5 patients experienced marked bradycardia during desaturation. It is also notable that, in 84% of patients who experienced desaturation, the paramedics described the rapid sequence intubation as “easy.” This investigation is a substudy of the San Diego Paramedic RSI Trial. The outcomes from the overall study have recently been published by Davis et al.2 This report demonstrated that paramedic rapid sequence intubation in severely head-injured patients was associated with an increase in mortality and a decrease in “good” outcomes compared with matched historical controls.
Copyright © 2003 by the American College of Emergency Physicians. 0196-0644/2003/$30.00 + 0 doi:10.1016/mem.2003.429
DECEMBER 2003
42:6
ANNALS OF EMERGENCY MEDICINE
Out-of-hospital intubation has been the standard of care in many emergency medical services (EMS) systems for several decades. Unfortunately, the failure to perform controlled studies during the early years of implementation has meant that we do not know the effect of this intervention on patients. Recent reports of the Ontario Prehospital ALS Project (OPALS) have shown a dramatic improvement in survival for patients presenting to the EMS system with respiratory distress after the inception of advanced life support.3-6 Unfortunately, in the OPALS study, the effect of intubation could not be separated out from the other interventions implemented in the “advanced life support package.” However, it is probably reasonable to assume that outof-hospital intubation accounted for at least a portion of the improved survival rates. Despite the absence of proof that out-of-hospital intubation is safe and effective in the out-of-hospital setting, there has been little controversy in the literature about the appropriateness of its use. Scores of reports and vast experience in many systems have documented typical intubation success rates well in excess of 90%. However, much less is known about the safety and effectiveness of out-of-hospital rapid sequence intubation.7-17 One of the most remarkable aspects of the majority of the previous reports of out-of-hospital rapid sequence intubation is the near absence of the reporting of significant complications. The work of Dunford et al1 brings into question the validity of the low complication rates in those reports. The finding detailed in this edition is a profound one: in a busy, metropolitan EMS system with substantial medical oversight and experienced paramedics, a staggering rate of significant desaturation occurs during rapid sequence intubation. It appears that, as with other reports, these complications would have gone unreported if it were not for the technology available to passively, automatically, and reliably record desaturation. The implication of this work goes far beyond just rapid sequence intubation. The reality is, the EMS literature is replete with studies evaluating the implementation of new treatments and procedures that report extremely low complication rates. The vast majority of these studies have been retrospective and relied nearly entirely on EMS personnel identifying and document-
7 2 9
O U T - O F - H O S P I T A L R A P I D S E Q U E N C E I N T U B A T I O N Spaite & Criss
ing complications. The dramatic difference between the results of Dunford et al1 and the previously reported, exceedingly low complication rates for out-of-hospital rapid sequence intubation should bring pause to EMS professionals throughout the country. The fact is, except for defibrillation, essentially no EMS intervention has been prospectively evaluated with robust methodologies that allow us to conclude that safety has been established, let alone effectiveness. The vast majority of systems have taken the “Mount Everest approach” to implementing interventions in EMS. That is, when asked why we are implementing new therapies and procedures in the out-of-hospital setting, our answer is, in essence, “because it’s there.” It is strikingly coincidental that, in Arizona, the Medical Direction Commission has just approved out-of-hospital rapid sequence intubation to be routinely used statewide. Remarkably, the pilot study showed an endotracheal intubation success rate of considerably less than 90%. In addition, the pilot study reported “essentially no complications.” Clearly, the work from San Diego, CA, brings this conclusion into question because the Arizona study was done using self-reported complications. Nonetheless, it appears that out-of-hospital rapid sequence intubation is destined to be the “standard of care” in our state. Dunford et al1 are to be applauded for the honesty and forthrightness with which they have reported their findings. This investigation should lead EMS professionals to have major concerns about several things: (1) the historic approach of adding advanced life support interventions without any good evidence of safety and effectiveness in the out-of-hospital setting; (2) the assumption that self-reporting and subsequent chart reviews revealing no complications from an intervention actually establishes the existence of a low complication rate; and (3) we have been sloppy for far too long in approving advanced life support interventions without applying the simple discipline of requiring establishment of safety and effectiveness in the out-of-hospital setting. It is as if emergency physicians have forgotten the legendary, overarching theme of medicine, “first do no harm.” In summary, Dunford et al’s1 investigation has several significant implications. It is likely that the EMS literature is riddled with reports asserting that a large number of out-of-hospital interventions have extremely low complication rates. This concept must be loudly and persistently called into question. Second, new technologies and techniques that aid in establishing the true
7 3 0
complication rates of EMS interventions must be developed. Relying on EMS personnel to identify and document complications inevitably leads to underreporting. Finally, the days of implementing new advanced life support interventions without rigorous controlled trials documenting the safety and effectiveness of those interventions in the out-of-hospital setting must be over. We can no longer assume that, because we believe we are improving patient outcomes, this excuses us from verifying that we in fact are improving patient outcomes. The blind, Mount Everest approach to EMS must end. The authors report this study did not receive any outside funding or support. Reprints not available from the authors. Address for correspondence: Daniel W. Spaite, MD, Department of Emergency Medicine, College of Medicine, University of Arizona, 1609 North Warren, Room 122, Tucson, AZ 85719; 520-626-7957; E-mail [email protected].
REFERENCES 1. Dunford JV, Davis DP, Ochs M, et al. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med. 2003;42:721-728. 2. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid-sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;54:444-453. 3. Stiell IG, Wells GA, Spaite DW, et al. The Ontario Prehospital Advanced Life Support (OPALS) Study: rationale and methodology for trauma and respiratory distress patients. Ann Emerg Med. 1999;34:256-262. 4. Stiell IG, Wells GA, DeMaio VJ, et al. Multicenter controlled clinical trial to evaluate the impact of advanced life support on out-of-hospital respiratory distress patients [abstract]. Acad Emerg Med. 2002;9:357. 5. Stiell IG, DeMaio VJ, Nesbitt LP, et al. Predictors of survival for out-of-hospital respiratory distress patients in the OPALS study. Acad Emerg Med. 2003:10;431-432. 6. Nichol G, Stiell IG, Blackburn J, et al. Quality of life outcomes for respiratory distress patients treated by EMS [abstract]. Acad Emerg Med. 2003;10:449. 7. Davis BD, Fowler R, Kupas DF, et al. Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful? Curr Opin Crit Care. 2002;8:571-577. 8. Garner AA, Schoettker P. Efficacy of pre-hospital interventions for the management of severe blunt head injury. Injury. 2002;33:329-337. 9. Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg. 1997;132:592-597. 10. Ochs M, Davis D, Hoyt D, et al. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med. 2002;40:159-167. 11. Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-year review. Prehosp Emerg Care. 1999;3:107-109. 12. Rhee KJ, O’Malley RJ. Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the prehospital care of injured patients. Ann Emerg Med. 1994;23:37-42. 13. Murphy-Macabobby M, Marshall WJ, Schneider C, et al. Neuromuscular blockade in aeromedical airway management. Ann Emerg Med. 1992;21:664-668. 14. Hedges JR, Dronen SC, Feero S, et al. Succinylcholine-assisted intubations in prehospital care. Ann Emerg Med. 1988;17:469-472. 15. Syverud SA, Borron SW, Storer DL, et al. Prehospital use of neuromuscular blocking agents in a helicopter ambulance program. Ann Emerg Med. 1988;17:236-242. 16. Sing RF, Reilly PM, Rotondo MF, et al. Out-of-hospital rapid-sequence induction for intubation of the pediatric patient. Acad Emerg Med. 1996;3:41-45. 17. Sing RF, Rotondo MF, Zonies DH, et al. Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis. Am J Emerg Med. 998;16:598-602.
ANNALS OF EMERGENCY MEDICINE
42:6
DECEMBER 2003
Out-of-Hospital Rapid Sequence Intubation: Are We Helping or Hurting Our Patients? Daniel W. Spaite, MD Elizabeth A. Criss, RN, MEd From the Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ.
See related article, p. 721. [Ann Emerg Med. 2003;42:729-730.]
In this issue, Dunford et al1 present data related to rapid sequence intubation of patients with severe head injuries in the out-of-hospital setting. The application of recording oximeters throughout the process of rapid sequence intubation allowed the evaluation of oxygen saturation and pulse rate. An amazing 57% of these trauma victims demonstrated desaturation during outof-hospital rapid sequence intubation. Among those who experienced desaturation, 84% had initial oxygen saturations in the normal range with the utilization of basic airway skills alone. The median duration of desaturation was 2 minutes and 40 seconds, with 1 patient remaining hypoxemic for 4 minutes and 30 seconds. The median decrease in oxygen saturation was 22%. In addition, nearly 1 in 5 patients experienced marked bradycardia during desaturation. It is also notable that, in 84% of patients who experienced desaturation, the paramedics described the rapid sequence intubation as “easy.” This investigation is a substudy of the San Diego Paramedic RSI Trial. The outcomes from the overall study have recently been published by Davis et al.2 This report demonstrated that paramedic rapid sequence intubation in severely head-injured patients was associated with an increase in mortality and a decrease in “good” outcomes compared with matched historical controls.
Copyright © 2003 by the American College of Emergency Physicians. 0196-0644/2003/$30.00 + 0 doi:10.1016/mem.2003.429
DECEMBER 2003
42:6
ANNALS OF EMERGENCY MEDICINE
Out-of-hospital intubation has been the standard of care in many emergency medical services (EMS) systems for several decades. Unfortunately, the failure to perform controlled studies during the early years of implementation has meant that we do not know the effect of this intervention on patients. Recent reports of the Ontario Prehospital ALS Project (OPALS) have shown a dramatic improvement in survival for patients presenting to the EMS system with respiratory distress after the inception of advanced life support.3-6 Unfortunately, in the OPALS study, the effect of intubation could not be separated out from the other interventions implemented in the “advanced life support package.” However, it is probably reasonable to assume that outof-hospital intubation accounted for at least a portion of the improved survival rates. Despite the absence of proof that out-of-hospital intubation is safe and effective in the out-of-hospital setting, there has been little controversy in the literature about the appropriateness of its use. Scores of reports and vast experience in many systems have documented typical intubation success rates well in excess of 90%. However, much less is known about the safety and effectiveness of out-of-hospital rapid sequence intubation.7-17 One of the most remarkable aspects of the majority of the previous reports of out-of-hospital rapid sequence intubation is the near absence of the reporting of significant complications. The work of Dunford et al1 brings into question the validity of the low complication rates in those reports. The finding detailed in this edition is a profound one: in a busy, metropolitan EMS system with substantial medical oversight and experienced paramedics, a staggering rate of significant desaturation occurs during rapid sequence intubation. It appears that, as with other reports, these complications would have gone unreported if it were not for the technology available to passively, automatically, and reliably record desaturation. The implication of this work goes far beyond just rapid sequence intubation. The reality is, the EMS literature is replete with studies evaluating the implementation of new treatments and procedures that report extremely low complication rates. The vast majority of these studies have been retrospective and relied nearly entirely on EMS personnel identifying and document-
7 2 9
O U T - O F - H O S P I T A L R A P I D S E Q U E N C E I N T U B A T I O N Spaite & Criss
ing complications. The dramatic difference between the results of Dunford et al1 and the previously reported, exceedingly low complication rates for out-of-hospital rapid sequence intubation should bring pause to EMS professionals throughout the country. The fact is, except for defibrillation, essentially no EMS intervention has been prospectively evaluated with robust methodologies that allow us to conclude that safety has been established, let alone effectiveness. The vast majority of systems have taken the “Mount Everest approach” to implementing interventions in EMS. That is, when asked why we are implementing new therapies and procedures in the out-of-hospital setting, our answer is, in essence, “because it’s there.” It is strikingly coincidental that, in Arizona, the Medical Direction Commission has just approved out-of-hospital rapid sequence intubation to be routinely used statewide. Remarkably, the pilot study showed an endotracheal intubation success rate of considerably less than 90%. In addition, the pilot study reported “essentially no complications.” Clearly, the work from San Diego, CA, brings this conclusion into question because the Arizona study was done using self-reported complications. Nonetheless, it appears that out-of-hospital rapid sequence intubation is destined to be the “standard of care” in our state. Dunford et al1 are to be applauded for the honesty and forthrightness with which they have reported their findings. This investigation should lead EMS professionals to have major concerns about several things: (1) the historic approach of adding advanced life support interventions without any good evidence of safety and effectiveness in the out-of-hospital setting; (2) the assumption that self-reporting and subsequent chart reviews revealing no complications from an intervention actually establishes the existence of a low complication rate; and (3) we have been sloppy for far too long in approving advanced life support interventions without applying the simple discipline of requiring establishment of safety and effectiveness in the out-of-hospital setting. It is as if emergency physicians have forgotten the legendary, overarching theme of medicine, “first do no harm.” In summary, Dunford et al’s1 investigation has several significant implications. It is likely that the EMS literature is riddled with reports asserting that a large number of out-of-hospital interventions have extremely low complication rates. This concept must be loudly and persistently called into question. Second, new technologies and techniques that aid in establishing the true
7 3 0
complication rates of EMS interventions must be developed. Relying on EMS personnel to identify and document complications inevitably leads to underreporting. Finally, the days of implementing new advanced life support interventions without rigorous controlled trials documenting the safety and effectiveness of those interventions in the out-of-hospital setting must be over. We can no longer assume that, because we believe we are improving patient outcomes, this excuses us from verifying that we in fact are improving patient outcomes. The blind, Mount Everest approach to EMS must end. The authors report this study did not receive any outside funding or support. Reprints not available from the authors. Address for correspondence: Daniel W. Spaite, MD, Department of Emergency Medicine, College of Medicine, University of Arizona, 1609 North Warren, Room 122, Tucson, AZ 85719; 520-626-7957; E-mail [email protected].
REFERENCES 1. Dunford JV, Davis DP, Ochs M, et al. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med. 2003;42:721-728. 2. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid-sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;54:444-453. 3. Stiell IG, Wells GA, Spaite DW, et al. The Ontario Prehospital Advanced Life Support (OPALS) Study: rationale and methodology for trauma and respiratory distress patients. Ann Emerg Med. 1999;34:256-262. 4. Stiell IG, Wells GA, DeMaio VJ, et al. Multicenter controlled clinical trial to evaluate the impact of advanced life support on out-of-hospital respiratory distress patients [abstract]. Acad Emerg Med. 2002;9:357. 5. Stiell IG, DeMaio VJ, Nesbitt LP, et al. Predictors of survival for out-of-hospital respiratory distress patients in the OPALS study. Acad Emerg Med. 2003:10;431-432. 6. Nichol G, Stiell IG, Blackburn J, et al. Quality of life outcomes for respiratory distress patients treated by EMS [abstract]. Acad Emerg Med. 2003;10:449. 7. Davis BD, Fowler R, Kupas DF, et al. Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful? Curr Opin Crit Care. 2002;8:571-577. 8. Garner AA, Schoettker P. Efficacy of pre-hospital interventions for the management of severe blunt head injury. Injury. 2002;33:329-337. 9. Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg. 1997;132:592-597. 10. Ochs M, Davis D, Hoyt D, et al. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med. 2002;40:159-167. 11. Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-year review. Prehosp Emerg Care. 1999;3:107-109. 12. Rhee KJ, O’Malley RJ. Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the prehospital care of injured patients. Ann Emerg Med. 1994;23:37-42. 13. Murphy-Macabobby M, Marshall WJ, Schneider C, et al. Neuromuscular blockade in aeromedical airway management. Ann Emerg Med. 1992;21:664-668. 14. Hedges JR, Dronen SC, Feero S, et al. Succinylcholine-assisted intubations in prehospital care. Ann Emerg Med. 1988;17:469-472. 15. Syverud SA, Borron SW, Storer DL, et al. Prehospital use of neuromuscular blocking agents in a helicopter ambulance program. Ann Emerg Med. 1988;17:236-242. 16. Sing RF, Reilly PM, Rotondo MF, et al. Out-of-hospital rapid-sequence induction for intubation of the pediatric patient. Acad Emerg Med. 1996;3:41-45. 17. Sing RF, Rotondo MF, Zonies DH, et al. Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis. Am J Emerg Med. 998;16:598-602.
ANNALS OF EMERGENCY MEDICINE
42:6
DECEMBER 2003