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Pre-hospital RSI

trauma-list@trauma.org trauma-list@trauma.org
Tue, 15 Apr 2003 10:32:32 +0100

i think that the standard of care in the pre-hospital phase should be as near 
as possible to that used in hospital. The same principles should be applied to 
pre-hospital RSI and the same sort of approach used as in hospital.
The approach described in the J Trauma paper does not seem to match these 

Quoting MARK FORREST <atacc.doc@virgin.net>:

> Dear Colleagues,
> I approached the paper on 'paramedic RSI in severe traumatic brain injuries',
> J Trauma, vol 54, March 2003 with great interest. 
> The conclusions are 'Paramedic RSI improves intubation success rates but is
> associated with increase in mortalityand decrease in "good outcomes" when
> compared to hand-matched controls' 
> Various reasons are given for this, but after reading the methods I am
> frankly not surprised.
> I was horrified to read that the RSI is performed with sux and midazolam, but
> sedation is only given if systolic BP is >120mmHg and even when given, the
> maximum dose was 3mg (for the >100Kg group)!
> This does NOT constitute 'anaesthesia' and these patients were paralysed and
> not 'asleep'. No record is made of post-intubation systolic blood pressures,
> which were probably very high. Similarly, no account was made of the effects
> on ICP during such 'awake-intubation'!
> Is this a standard 'RSI' practice in other parts of the world?
> Another area of concern in the methods involves the period of
> de-nitrogenation before starting. 'a minimum of 60 seconds using a
> non-rebreather mask. If oxygen saturation remained below 95%, then bag and
> mask ventilation were instituted before medication...' 
> When I was taught RSI all manual ventilation was avoided to prevent increased
> risk of gastric inflation and increased risk of aspiration!
> Considering these two issues and a number of others including the
> hyperventilation to ETCO2  30-35mmHg and hypoxia 'sufficient to produce
> bradycardia' in many of the cases, I am in no way surprised by the poor
> outcome figures.
> Any comments, especially by paramedics/docs who competently perform RSI on a
> regular basis?
> Regards
> Mark F
> UK