Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation

doi:10.1016/S0196-0644(03)00660-7

Annals of Emergency Medicine

Volume 42, Issue 6, December 2003, Pages 721-728

https://doi.org/10.1016/S0196-0644(03)00660-7 Get rights and content

Abstract

Study objective

We determine the incidence of desaturation and pulse rate reactivity during paramedic rapid sequence intubation of patients with severe head injuries (Glasgow Coma Scale score ≤8).

Methods

Adult patients with severe head injuries had recording oximeter-capnometers applied before rapid sequence intubation. Desaturation was defined as a reduction in oxygen saturation (Spo₂) to less than 90% from an initial Spo₂ of greater than or equal to 90% or a decrease from a baseline of less than 90%. Event records were analyzed with emergency medical services (EMS) run sheets and debriefing reports.

Results

Thirty-one (57%) of 54 patients demonstrated desaturation during rapid sequence intubation. Twenty-six (84%) of these 31 events occurred in patients whose initial Spo₂ value with basic airway skills was greater than or equal to 90%. The median duration of desaturation was 160 seconds (interquartile range 48 to 272 seconds), and the median decrease in Spo₂ was 22%. Six (19%) patients experienced marked bradycardia (pulse rate <50 beats/min) during desaturation events. Paramedics described rapid sequence intubation as “easy” in 26 (84%) of 31 patients with desaturation.

Conclusion

Out-of-hospital rapid sequence intubation by paramedics was complicated by a concerning incidence of desaturation and bradycardia. Paramedic reports did not reflect the presence of these concerning derangements. Most patients had acceptable Spo₂ values before rapid sequence intubation. An effective strategy for preoxygenation is needed before it can be concluded that rapid sequence intubation is of value in the out-of-hospital care of patients with serious closed head injury.

Introduction

Outcomes from severe closed head injury are related to primary and secondary injury. Immediate damage to neurologic structures can be compounded by a cascade of events resulting in delayed neuronal death. The central nervous system has a high rate of oxygen consumption and lacks alternate energy reserves. Hypotension and hypoxia have been linked to worsened outcomes, and preservation of cerebral perfusion and oxygenation is essential.1, 2, 3, 4, 5

Capsule Summary

What is already known on this topic

Primarily on the basis of retrospective chart reviews, it is claimed that complications associated with rapid sequence intubation in the out-of-hospital setting are rare.

What question this study addressed

The incidence of desaturation below 90% and alterations in pulse rate during paramedic rapid sequence intubation of severely head-injured patients were prospectively recorded.

What this study adds to our knowledge

Fifty-seven percent of patients demonstrated desaturation lasting, on average, 2 minutes and 40 seconds during intubations mostly described as “easy” by paramedics. Eleven percent experienced bradycardia below 50 beats/min.

How this might change clinical practice

Most studies claiming the safety of rapid sequence intubation in emergency medical services have been retrospective chart reviews. This prospective study suggests significant complications and that rapid sequence intubation in the out-of-hospital setting should not be implemented until more is known of its risk.

Although rapid sequence intubation has been recommended as the preferred method for securing the airways of combative patients with closed head injury,6, 7 its role in out-of-hospital airway management is debated.8, 9 Advanced life support care, including intubation, has been correlated with improved survival in some studies10, 11 but not others.12, 13, 14, 15, 16, 17 Davis et al¹⁸ recently demonstrated in the San Diego Paramedic RSI Trial that a paramedic rapid sequence intubation protocol to facilitate the intubation of head-injured patients was associated with an increase in mortality and decrease in good outcomes compared with matched historical control subjects.

One agency participating in the San Diego trial implemented recording oximetry-capnometry devices midway through the study. The goal of this analysis was to define the incidence of desaturation and pulse rate reactivity documented with this equipment during paramedic-performed rapid sequence intubation. It is important to understand whether the out-of-hospital use of neuromuscular blocking agents can adversely affect oxygenation and hemodynamic parameters when used to facilitate the intubation of patients with closed head injury.

Section snippets

Materials and methods

The San Diego Paramedic RSI Trial was conducted between November 1998 and April 2002. It was designed to measure the effect of paramedic-performed rapid sequence intubation on outcome of adult major trauma victims with severe closed head injury. Twelve emergency medical services (EMS) agencies participated in the trial, which was halted once an analysis of patients enrolled during the first 2 years demonstrated worsened outcomes in patients undergoing rapid sequence intubation than those seen

Results

Between November 1998 and April 2002, San Diego Medical Services Enterprise enrolled 152 (36%) of the 426 patients in the San Diego Paramedic RSI Trial. San Diego Medical Services Enterprise enrolled 102 (67%) of these 152 patients after the implementation of recording oximetry-capnometry equipment in March 2000. Of these 102 patients, only 54 (53%) had complete event data available for analysis. Reasons for incomplete data in the remaining 48 patients included the following: Spo₂ monitor not

Limitations

There are several limitations to this study. The study group was small in comparison with the 426 patients enrolled in the entire San Diego Paramedic RSI trial. Only 54 (53%) of the 102 City of San Diego patients who were eligible for oximetry-capnometry had complete data for analysis. Missing data occurred primarily because of detached Spo₂ probes, dead batteries, and (in 5 cases) severe hypotension. Although loss of such a large number of patients could introduce selection bias, there were no

Discussion

In this study, 1 of the 12 EMS agencies participating in the San Diego Paramedic RSI Trial demonstrated that 31 (57%) of 54 patients undergoing rapid sequence intubation for serious closed head injury experienced significant desaturation during the procedure. Twenty-six (84%) of these 31 patients were not hypoxic before the administration of neuromuscular blocking agents. For these 26 patients, basic airway management, including supplemental oxygen with bag-valve-mask assist, was effective in

Acknowledgements

We thank San Diego Fire-Rescue Department Quality Management Coordinator Ginger Ochs, RN; Quality Improvement Manager Roger Fisher; and Captain-paramedic Dan Saner for their assistance in training, collating data, and maintaining accurate records. We also thank the San Diego Fire-Rescue Department, the San Diego Medical Services Enterprise, Rural/Metro of San Diego, and the San Diego County Emergency Medical Services Agency for their support.

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Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement.
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In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO₂ values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.
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Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.
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Critically ill patients suffer arterial desaturation more rapidly than healthy patients during intubation and the resulting hypoxaemia has been shown to put patients at risk of haemodynamic instability and death. Apnoeic oxygenation improves oxygen saturation and prolongs the duration of safe apnoea in anaesthesia. There is controversy around its usefulness and efficiency in critically ill patients. A non-structured search was carried out in PubMed, EBSCO, Medline, SciELO, and Scopus databases. Although this intervention can be seen as an alternative method to reduce episodes of severe hypoxaemia during intubation, few clinical studies support its routine use. Apnoeic oxygenation did not lead to any differences in desaturation rates, intubation success without hypoxaemia, adverse events, days of hospital admission, and mortality. Apnoeic oxygenation in the critically ill patient did not prevent oxygen desaturation. Its routine use cannot be recommended.
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^☆

Author contributions: DPD participated in training, data review, statistical analysis, and review of the draft document. MO participated in training and performed all paramedic debriefing interviews. MD performed interim analysis of the data. DBH reviewed the draft document and provided access to the trauma data bank. JVD planned the study, obtained the oximetry-capnometry equipment, participated in the training, performed the data review, and was the primary writer of the document. JVD takes responsibility for the paper as a whole.

Presented at the National Association of EMS Physicians annual meeting, Panama City, FL, January 2003.

The authors report this study did not receive any outside funding or support.

Reprints not available from the authors.

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Emergency Medical ServicesIncidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation☆

Abstract

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Limitations

Discussion

Acknowledgements

J Pediatr Surg

J Pediatr Surg

Emerg Med Clin North Am

Injury

J Emerg Med

Semin Pediatr Surg

Ann Emerg Med

Ann Emerg Med

Br J Anaesth

Prehosp Emerg Care

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

J Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Am J Emerg Med

The role of secondary brain injury in determining outcome from severe head injury

J Trauma

Hypoxia and arterial hypotension at the accident scene in head injury

J Trauma

Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia and hypoperfusion

J Trauma

Intubating trauma patients before reaching hospital—revisited

Crit Care

Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful?

Curr Opin Crit Care

Endotracheal intubation in the field improves survival in patients with severe head injury

Arch Surg

Emergency Medical Services
Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation☆