A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting.
OBJECTIVE
To compare laryngoscopy conditions produced by etomidate-only intubation (EOI) with those produced by rapid-sequence intubation (RSI) in the prehospital air medical setting.


METHODS
A prospective crossover trial design used two helicopters staffed by the same flight paramedics and nurses. Each aircraft used an EOI protocol (0.3 mg/kg) for six months. An RSI protocol using the same dose of etomidate plus succinylcholine (1.5 mg/kg) was used for the alternate six months. Laryngoscopy conditions were graded by three scales: 1) a formal Laryngoscopy Grading Scale (LGS), 2) the Percentage of Glottic Opening (POGO) score, and 3) subjective overall intubation difficulty using a Likert scale of 1 (very easy) to 5 (very difficult). Orotracheal intubation success was also recorded.


RESULTS
Forty-nine patients were intubated using the EOI (n = 24) and RSI (n = 25) protocols. Mean age was 38 years, 76% were male, and 90% were intubated for trauma. Fifteen (63%) of the 24 EOI patients required additional etomidate (n = 3) or RSI (n = 12) to allow intubation, while one (4%) of the 25 RSI patients required additional medication dosing (p < 0.0001). Laryngoscopy conditions were assessed for all patients. Good or acceptable conditions as assessed by the LGS were seen in 79% of RSI patients and 13% of EOI patients (p < 0.0001). Mean rates of POGO visualization were 60% with RSI and 12% with EOI (p < 0.0001). Mean global intubation difficulty scores were 3.0 (moderate) with RSI and 4.7 (difficult to very difficult) with EOI (p < 0.0001). Ninety-two percent of the patients undergoing RSI and 25% of the EOI patients were successfully orotracheally intubated (p < 0.0001).


CONCLUSIONS
Patients receiving RSI had better laryngoscopy conditions and were easier to intubate than patients receiving EOI. Intubation success rate was higher with RSI.
Bozeman
William P
WP
Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC 27157, USA. wBozeman@wfubmc.edu
Kleiner
Douglas M
DM
Huggett
Vicki
V
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017732:Air Ambulances; D002648:Child; D018592:Cross-Over Studies; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D005045:Etomidate / Q000627:therapeutic use*; D005260:Female; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods*; D007828:Laryngoscopy; D008297:Male; D008875:Middle Aged; D009467:Neuromuscular Depolarizing Agents / Q000627:therapeutic use; D011446:Prospective Studies; D013390:Succinylcholine / Q000627:therapeutic use; D016896:Treatment Outcome
D006993:Hypnotics and Sedatives; D009467:Neuromuscular Depolarizing Agents; D013390:Succinylcholine; D005045:Etomidate