Annals of Emergency Medicine
Volume 31, Issue 3 , Pages 398-400, March 1998

Rapid Sequence Intubation Revisited☆☆☆

Emergency Department, Regions Hospital, St. Paul, MN

Article Outline

Abstract 

[Knopp RK: Rapid sequence intubation revisited. Ann Emerg Med March 1998;31:398-400.]

 

See related article, p 325.

In this issue of Annals, Sakles et al1 report a 1-year descriptive study of patients who required emergency airway management in a busy urban emergency department. The publication of this study serves as an opportunity to address two issues: the change in emergency airway management over the last 15 years from nasotracheal to rapid-sequence intubation (RSI) and the current problem of gaining and maintaining competency in surgical airway management.

In the late 1970s and early 1980s, nasotracheal intubation was often considered the method of choice for emergency airway management in spontaneously breathing patients. At that time nasotracheal intubation was described as “a frequently used and most often successful method for tracheal intubation.”2 Although some emergency physicians used RSI, it was used infrequently. In 1982 Thompson et al3 reported that emergency physicians at an urban teaching hospital used neuromuscular blocking agents in only 5.9% (48/810) of patients requiring tracheal intubation during a 1-year period.

By the late 1980s and early 1990s, emergency physicians used RSI with increasing frequency. There were several reasons for this increase. First, RSI resulted in higher success rates and fewer complications than nasotracheal intubation.4 Second, with greater experience and refinement of the technique, more emergency medicine residency programs trained residents in RSI.

In 1995 a survey of emergency medicine residency programs reported that 95% of residencies routinely used neuromuscular blocking agents.5 However, 7% (8/114) of institutions associated with the residencies mandated an anesthesiologist's presence during the administration of neuromuscular blocking agents, and 5% (6/114) did not allow the administration of these agents by emergency physicians. Despite the advantages of RSI, hospital politics and local interpretations of Joint Commission on Accreditation of Healthcare Organizations standards at a few institutions continued to restrict RSI use.

Community hospitals also noted an increase in the use of RSI. Dufour et al6 reported the intubation experience of one Canadian community hospital ED during a 28-month period (1991–1993). Excluding the 156 intubations for cardiac arrest, physicians used RSI in 62% (219/349) of patients, whereas only 2.6% (9/349) had nasotracheal intubation.

Emergency medicine was not alone in the slow transition to RSI. In 1993 the American College of Surgeons (ACS) published a new edition of the Advanced Trauma Life Support (ATLS) manual.7 The ACS recommended “nasotracheal or orotracheal intubation with in-line manual cervical immobilization” for immediate airway control in spontaneously breathing patients. RSI was not discussed. A new ATLS manual published in 1997 includes a discussion of RSI and the use of neuromuscular blocking agents.8

In the article in this issue by Sakles et al, RSI was the initial method of choice for tracheal intubation in 83% (509/610) of cases. However, 14% (85/610) of patients had orotracheal intubation without RSI. A certain number of those patients had a cardiac arrest and would not need RSI. It is unclear, however, why the remaining patients did not have RSI. The authors report an overall immediate complication rate of 8%, and slightly more than 1% of patients required cricothyrotomy for definitive airway control.

Although RSI should produce fewer complications than nasotracheal intubation, the frequency of complications depends not only on the physician's technical facility with orotracheal intubation but also on his or her knowledge and understanding of other essential components of the procedure: the indications, contraindications, complications, and pharmacology of the various induction agents and neuromuscular blocking agents; appropriate application of cricoid pressure; and availability of trained personnel to assist with the procedure. In trauma patients, RSI often may require five individuals with specific roles: the physician intubator who determines medications and dosages, a team member who immobilizes the cervical spine, a team member to apply cricoid pressure, a respiratory therapist to preoxygenate with 100% oxygen (and ventilate the patient's lungs when indicated), and a nurse to administer the medications in appropriate dosages and sequence while monitoring vital signs, cardiac rhythm, and oxygen saturation.

RSI is the method of choice for emergency airway management in most patients. However, facility with other approaches is essential when RSI cannot be used (eg, no intravenous access), is contraindicated, or is unsuccessful. Nasotracheal intubation is still a viable alternative in spontaneously breathing patients who have no intravenous access or appear to have anatomic variations that may make oral intubation difficult or impossible. However, because of its infrequent use, it is more difficult for emergency medicine residents to gain and maintain expertise with this approach.

Emergency physicians should also be familiar with other methods and adjuncts for managing difficult airways. However, when RSI is unsuccessful, emergency physicians must possess the ability to establish a surgical airway if needed. Regardless of how facile a physician is with tracheal intubation, Sakles et al and other investigators9 report that approximately 1% to 2% of patients will require a cricothyrotomy. During the past decade, emergency physician experience with cricothyrotomy has decreased.10 The reasons for this decrease are varied but include the decision not to transport blunt traumatic arrest victims to the ED, higher success rates with RSI, and the possible effect of emergency medicine residency training on the frequency of cricothyrotomies.10

In the highly charged setting of a failed RSI, it is unrealistic to expect an emergency physician to establish a surgical airway successfully and without complications in a paralyzed patient if that physician has not performed a cricothyrotomy for a number of years. Yet this is the situation that currently exists. With the number of cricothyrotomies decreasing, an increasing number of residents complete their training without ever performing a cricothryotomy on a patient. To guarantee competency in this skill, we should develop measures that ensure emergency physicians will not only be able to establish a surgical airway safely and effectively but also maintain that skill. In a number of emergency medicine residency programs, residency directors have initiated procedure laboratories to allow residents to develop competency with certain infrequently used skills such as cricothyrotomy. In Minnesota, Dr Ernie Ruiz developed such a procedure laboratory for emergency medicine residents and medical students a number of years ago. He has expanded this program to provide such training and retraining for physicians who provide emergency care throughout the state. This or a similar model is one that our specialty should embrace for all practicing emergency physicians.

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References 

  1. Sakles JC, Laurin EG, Rantapaa AA, et al.  Airway management in the emergency department: A one-year study of 610 tracheal intubations. Ann Emerg Med. 1998;31:325–332
  2. Tintinnali JE, Claffery J. Complications of nasotracheal intubation. Ann Emerg Med. 1981;10:142–144
  3. Thompson JD, Fish S, Ruiz E. Succinylcholine for endotracheal intubation. Ann Emerg Med. 1982;11:526–529
  4. Dronen S, Merigian KS, Hedges JR, et al.  A comparison of blind nasotracheal intubation and succinylcholine-assisted intubation in the poisoned patient. Ann Emerg Med. 1987;16:650–652
  5. Ma OJ, Bentley B, Debehnke DJ. Airway management practices in emergency medicine residencies. Am J Emerg Med. 1995;13:501–504
  6. Dufour DG, Larose DL, Clement SC. Rapid sequence intubation in the emergency department. J Emerg Med. 1995;5:705–710
  7. American College of Surgeons Committee on Trauma . ATLS Instructor Manual. In: Chicago: : American College of Surgeons; 1997;p. 57
  8. American College of Surgeons Committee on Trauma . ATLS 1997: Compendium of Changes. Chicago: : American College of Surgeons; 1997;
  9. Erlandson MJ, Clinton JE, Ruiz E, et al.  Cricothyrotomy in the ED emergency department revisited. J Emerg Med. 1989;7:115–118
  10. Chang RS, Hamilton RJ, Carter WA. Influence of an emergency medicine residency on the role of cricothyrotomy [abstract]. Acad Emerg Med. 1996;3:534

☆ Address for reprints: Robert K Knopp, MD, Department of Emergency Medicine, Regions Hospital, St Paul, MN 55101, Fax 612-221-8756

☆☆ Reprint no. 47/1/88590

PII: S0196-0644(98)70353-1

Annals of Emergency Medicine
Volume 31, Issue 3 , Pages 398-400, March 1998

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