title: Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia.
abstract: BACKGROUND
  Rapid Sequence Induction of anaesthesia (RSI) is the recommended method to facilitate emergency tracheal intubation in trauma patients. In emergency situations, a simple and standardised RSI protocol may improve the safety and effectiveness of the procedure. A crucial component of developing a standardised protocol is the selection of induction agents. The aim of this study is to compare the safety and effectiveness of a traditional RSI protocol using etomidate and suxamethonium with a modified RSI protocol using fentanyl, ketamine and rocuronium.
  
  
  METHODS
  We performed a comparative cohort study of major trauma patients undergoing pre-hospital RSI by a physician-led Helicopter Emergency Medical Service. Group 1 underwent RSI using etomidate and suxamethonium and Group 2 underwent RSI using fentanyl, ketamine and rocuronium. Apart from the induction agents, the RSI protocol was identical in both groups. Outcomes measured included laryngoscopy view, intubation success, haemodynamic response to laryngoscopy and tracheal intubation, and mortality.
  
  
  RESULTS
  Compared to Group 1 (n = 116), Group 2 RSI (n = 145) produced significantly better laryngoscopy views (p = 0.013) and resulted in significantly higher first-pass intubation success (95% versus 100%; p = 0.007). A hypertensive response to laryngoscopy and tracheal intubation was less frequent following Group 2 RSI (79% versus 37%; p < 0.0001). A hypotensive response was uncommon in both groups (1% versus 6%; p = 0.05). Only one patient in each group developed true hypotension (SBP < 90 mmHg) on induction.
  
  
  CONCLUSIONS
  In a comparative, cohort study, pre-hospital RSI using fentanyl, ketamine and rocuronium produced superior intubating conditions and a more favourable haemodynamic response to laryngoscopy and tracheal intubation. An RSI protocol using fixed ratios of these agents delivers effective pre-hospital trauma anaesthesia.
authors: Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK. RichardL@kssairambulance.org.uk.
authors: Richard M
authors: RM
authors: Lyon
authors: Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK. zane.perkins@nhs.net.|Centre for Trauma Sciences, Queen Mary, University of London, London, E1 2AT, UK. zane.perkins@nhs.net.
authors: Zane B
authors: ZB
authors: Perkins
authors: Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK. djchatterjee@hotmail.com.
authors: Debamoy
authors: D
authors: Chatterjee
authors: School of Clinical Sciences University of Bristol & University of Stavanger Norway, North Bristol NHS Trust, Bristol, BS16 1LE, UK. David.Lockey@nbt.nhs.uk.
authors: David J
authors: DJ
authors: Lockey
authors: Kent, Surrey and Sussex Air Ambulance Trust, Wheelbarrow Park Estate, Pattenden Lane, Marden, Kent, TN12 9QJ, UK. MalcolmRussell@kssairambulance.org.uk.
authors: Malcolm Q
authors: MQ
authors: Russell
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000732:Androstanols / Q000008:administration & dosage; D000758:Anesthesia / Q000379:methods*; D018686:Anesthetics, Intravenous / Q000008:administration & dosage* / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D004632:Emergency Medical Services; D005045:Etomidate / Q000008:administration & dosage; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006801:Humans; D007223:Infant; D007442:Intubation, Intratracheal / Q000379:methods; D007649:Ketamine / Q000008:administration & dosage; D007828:Laryngoscopy; D008297:Male; D008875:Middle Aged; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage; D000077123:Rocuronium; D013390:Succinylcholine / Q000008:administration & dosage; D055815:Young Adult
chemical_list: D000732:Androstanols; D018686:Anesthetics, Intravenous; D003473:Neuromuscular Nondepolarizing Agents; D007649:Ketamine; D013390:Succinylcholine; D005283:Fentanyl; D000077123:Rocuronium; D005045:Etomidate