Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients.
BACKGROUND
The purpose of this study was to evaluate the effect of paramedic-administered neuromuscular blocking agents as part of a rapid-sequence intubation (RSI) protocol on successful intubation of severely head-injured patients in a large, urban prehospital system.


METHODS
Adult head-injured patients were prospectively enrolled over 1 year using these inclusion criteria: Glasgow Coma Scale (GCS) score of 3 to 8, transport time > 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. All adult trauma victims with a GCS score of 3 to 8 were identified during the first 12 months of the study as the trial cohort and from the preceding 12 months as the control cohort. The trial and control cohorts were compared with regard to demographic data, mechanism of injury, initial vital signs, and GCS scores. The primary outcome measure was intubation success, defined as insertion of either an endotracheal tube or a Combitube, with patients stratified by GCS score.


RESULTS
The trial cohort (n = 249) and control cohort (n = 189) were similar with regard to demographic data, mechanism of injury, and initial vital signs and GCS scores. Intubation success rates increased significantly during the trial period for all patients and when stratified into GCS score of 3 and GCS score of 4 to 8. The percentage of patients intubated without neuromuscular blocking agents actually increased during the trial period. Although the number of intubations by helicopter flight crews decreased during the trial, the overall use of aeromedical resources did not change.


CONCLUSIONS
Paramedic-administered neuromuscular blockade as part of an RSI protocol improves intubation success in a large, urban prehospital system.
Davis
Daniel P
DP
Department of Emergency Medicine, University of California, San Diego, California 92103-8676, USA. davismd@cox.net
Ochs
Mel
M
Hoyt
David B
DB
Bailey
David
D
Marshall
Lawrence K
LK
Rosen
Peter
P
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000488:Allied Health Personnel; D000732:Androstanols / Q000008:administration & dosage; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D002648:Child; D006259:Craniocerebral Trauma / Q000150:complications / Q000628:therapy*; D004632:Emergency Medical Services; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008874:Midazolam / Q000008:administration & dosage; D008875:Middle Aged; D019148:Neuromuscular Blockade; D011446:Prospective Studies; D000077123:Rocuronium; D013390:Succinylcholine / Q000008:administration & dosage
D000732:Androstanols; D013390:Succinylcholine; D008874:Midazolam; D000077123:Rocuronium