Out-of-hospital rapid sequence intubation: Are we helping or hurting our patients?

In this issue, Dunford et al1 present data related to rapid sequence intubation of patients with severe head injuries in the out-of-hospital setting. The application of recording oximeters throughout the process of rapid sequence intubation allowed the evaluation of oxygen saturation and pulse rate. An amazing 57% of these trauma victims demonstrated desaturation during outof-hospital rapid sequence intubation. Among those who experienced desaturation, 84% had initial oxygen saturations in the normal range with the utilization of basic airway skills alone. The median duration of desaturation was 2 minutes and 40 seconds, with 1 patient remaining hypoxemic for 4 minutes and 30 seconds. The median decrease in oxygen saturation was 22%. In addition, nearly 1 in 5 patients experienced marked bradycardia during desaturation. It is also notable that, in 84% of patients who experienced desaturation, the paramedics described the rapid sequence intubation as “easy.” This investigation is a substudy of the San Diego Paramedic RSI Trial. The outcomes from the overall study have recently been published by Davis et al.2 This report demonstrated that paramedic rapid sequence intubation in severely head-injured patients was associated with an increase in mortality and a decrease in “good” outcomes compared with matched historical controls. Out-of-hospital intubation has been the standard of care in many emergency medical services (EMS) systems for several decades. Unfortunately, the failure to perform controlled studies during the early years of implementation has meant that we do not know the effect of this intervention on patients. Recent reports of the Ontario Prehospital ALS Project (OPALS) have shown a dramatic improvement in survival for patients presenting to the EMS system with respiratory distress after the inception of advanced life support.3-6 Unfortunately, in the OPALS study, the effect of intubation could not be separated out from the other interventions implemented in the “advanced life support package.” However, it is probably reasonable to assume that outof-hospital intubation accounted for at least a portion of the improved survival rates. Despite the absence of proof that out-of-hospital intubation is safe and effective in the out-of-hospital setting, there has been little controversy in the literature about the appropriateness of its use. Scores of reports and vast experience in many systems have documented typical intubation success rates well in excess of 90%. However, much less is known about the safety and effectiveness of out-of-hospital rapid sequence intubation.7-17 One of the most remarkable aspects of the majority of the previous reports of out-of-hospital rapid sequence intubation is the near absence of the reporting of significant complications. The work of Dunford et al1 brings into question the validity of the low complication rates in those reports. The finding detailed in this edition is a profound one: in a busy, metropolitan EMS system with substantial medical oversight and experienced paramedics, a staggering rate of significant desaturation occurs during rapid sequence intubation. It appears that, as with other reports, these complications would have gone unreported if it were not for the technology available to passively, automatically, and reliably record desaturation. The implication of this work goes far beyond just rapid sequence intubation. The reality is, the EMS literature is replete with studies evaluating the implementation of new treatments and procedures that report extremely low complication rates. The vast majority of these studies have been retrospective and relied nearly entirely on EMS personnel identifying and documentE M E R G E N C Y M E D I C A L S E R V I C E S / E D I T O R I A L