Original Contribution
Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service

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Abstract

Background

Hypoxemia may occur during rapid sequence intubation (RSI). This study establishes the incidence of this adverse event in patients intubated by physicians in a helicopter emergency service in Norway.

Methods

This was a prospective, observational study of all RSIs performed by helicopter emergency service physicians during a 12-month period. Hypoxemia was defined as a decrease in Spo2 values to below 90% or a decrease of more than 10% if the initial Spo2 was less than 90%.

Results

A total of 122 prehospital intubations were performed during the study period. Spo2 data were available for 101 (82.8%) patients. Hypoxemia was present in 11 (10.9%) patients.

Conclusions

Prehospital, RSI-related hypoxemia rates in this study are lower than reported rates in similar studies and are comparable with in-hospital rates. Prehospital RSI may accordingly be considered a safe procedure when performed by experienced physicians with appropriate field training.

Introduction

Rapid establishment of a patent airway in the seriously ill or injured patient is a priority for prehospital health care providers. Endotracheal intubation (ETI) has, for years, been the criterion standard in advanced airway management, although the introduction of various supraglottic devices may challenge this notion in the future [1], [2]. Especially in patients with head injury, it is controversial whether prehospital rapid sequence intubation (RSI) is beneficial. The literature is inconclusive, with some studies indicating benefits in survival, whereas others show increased mortality [3], [4], [5]. It has been suggested that the potential increase in morbidity and mortality associated with prehospital RSI may be attributed to hypoxemia during the procedure [6], [7]. Transportation to definitive surgical intervention may be delayed by intubation attempts at the scene of the accident. Repeated intubation attempts in the inadequately anesthetized patient can result in a detrimental increase of intracranial pressure. The most serious complication, however, is unrecognized esophageal intubation, which has been shown to occur with a significant incidence (0.4%-16.7%) in some prehospital systems [8], [9], [10], [11].

Many studies on prehospital advanced airway management focus on the ETI procedure itself, paying less attention to the patient's physiologic parameters [12], [13], [14]. Reports from prehospital services with physician-performed RSIs are scarce. This study investigates in detail the effects of prehospital RSI on oxygen saturation in medical and trauma cases attended by physicians affiliated with the Oslo University Hospital Helicopter Emergency Medicine Service (HEMS) in Norway.

Section snippets

Study design and participants

Prospective, observational data concerning prehospital RSI performed by HEMS physicians were collected during a 12-month period (April 1, 2008 to March 31, 2009). Only cases requiring drug-assisted intubation were included in the study. Patients with cardiac arrest, independent of etiology, were therefore excluded from the study.

The HEMS operates an EC-135 and an EC-145 helicopter 24/7/365, serving a population of 2.1 million within a flight radius of approximately 200 km from the base at

Patient description and incident characteristics

A total of 2621 patients were investigated, resulting in 122 (4.7%) prehospital RSI attempts, with trauma being the most common indication (Table 1, Table 2). The mean age of trauma patients undergoing RSI (36.1 years) was significantly lower than that of patients intubated for medical reasons (43.8 years, P = .049) (Table 3). There was no significant difference in sex, with men dominating both groups. There were complete Spo2 recordings for 101 (82.8%) of the 122 intubation procedures. There

Discussion

Hypoxemia contributes to poor outcome after injury, especially in head-injured patients [19]. It is also imperative to avoid hypoxemia in nontraumatic cases such as spontaneous subarachnoidal hemorrhage and circulatory disorders. There are only few reports focusing on advanced prehospital airway management in patients experiencing the latter kind of disorders [12]. Recent reports indicate that hypoxemia occurs with relatively high frequency during prehospital RSI in trauma patients. Dunford et

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