Is pre-hospital Rapid Sequence Intubation (RSI) performed by paramedics safe?

From the Guidelines

Pre-hospital rapid sequence intubation (RSI) performed by paramedics can be safe when conducted by properly trained personnel within appropriate systems of care. The safety profile depends heavily on several factors including comprehensive training, ongoing skill maintenance, proper equipment, clear protocols, and medical oversight 1. Medications commonly used in pre-hospital RSI include sedatives like etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg), and paralytics such as succinylcholine (1-1.5 mg/kg) or rocuronium (1-1.2 mg/kg) 1. For successful implementation, paramedics need regular simulation training, direct supervision during initial cases, and continuous quality improvement processes.

Key Considerations

• Capnography is essential for confirming tube placement, and backup airway devices (supraglottic airways, video laryngoscopy) should be immediately available.
• The risk-benefit ratio must be carefully considered for each patient, as complications can include failed intubation, hypoxia, hypotension, and aspiration.
• Systems implementing pre-hospital RSI should track success rates, complications, and patient outcomes to ensure safety standards are maintained 1.
• Ketamine is frequently used in PHEA in patients with head injury, and its relative haemodynamic stability makes it an attractive induction drug for pre-hospital trauma care.

Training and Competence

The training required for undertaking pre-hospital anaesthesia safely and competently has been described by the Intercollegiate Board for Training in Pre-hospital Emergency Medicine (IBTPHEM) 1. Skills in both anaesthesia and the ability to work safely in the pre-hospital environment are required. Competence should be defined by these skills, rather than by the primary specialty of the individual.

When these conditions are met, paramedic-performed RSI can provide critical airway management for severely compromised patients before hospital arrival. It is crucial to weigh the benefits of pre-hospital RSI against the potential risks and to ensure that paramedics are adequately trained and equipped to perform this procedure safely 1.

From the Research

Safety of Pre-Hospital Rapid Sequence Intubation (RSI) by Paramedics

• The safety of pre-hospital RSI performed by paramedics has been evaluated in several studies 2, 3.
• A study published in 2018 found that intensive care flight paramedics in Victoria, Australia, had a high success rate of RSI, with a first pass success rate of 89.4% and an overall success rate of 99.4% 2.
• The study also reported that the majority of cases involved trauma (71.7%) and that neurological pathologies were the most common clinical indication for RSI (68.3%) 2.
• Another study published in 2012 found that physicians had significantly fewer pre-hospital ETI failures overall than non-physicians, including paramedics 3.
• However, the study also noted that the use of drug-assisted intubation significantly increased the success rates of non-physicians, including paramedics 3.

Complications and Adverse Events

• The 2018 study reported that transient cases of hypotension (5.2%), hypoxemia (1.3%), or both (0.1%) occurred in 6.6% of cases during the RSI procedure 2.
• The study also found that all patients who experienced failed intubations (0.6%) were safely returned to spontaneous respiration, with no surgical airways required 2.
• A 2021 study compared the success and complications of different intubation approaches, including ketamine-only, topical anesthesia, and RSI, and found that RSI had the highest first attempt success rate (90%) and the lowest rate of adverse events (14%) 4.

Training and Experience

• A 2010 review emphasized the importance of clinical training in increasing airway management skills and recommended that only experienced healthcare providers attempt prehospital anaesthesia induction 5.
• The review also suggested that moderately experienced healthcare providers should optimize oxygenation, fasten hospital transfer, and only attempt intubation in extremis, while lesser experienced providers should completely refrain from intubation 5.

Comparison of Intubation Agents

• A 2008 meta-analysis compared the effectiveness of rocuronium and succinylcholine for rapid sequence induction intubation and found that succinylcholine created superior intubation conditions, particularly when used with propofol for induction 6.