Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers

doi:10.5847/wjem.j.1920-8642.2019.01.003

Abstract

Abstract:

BACKGROUND: We aimed to describe the current practice of emergency physicians and anaesthesiologists in the selection of drugs for rapid-sequence induction (RSI) among trauma patients.
METHODS: A prospective survey audit was conducted based on a self-administered questionnaire among two intubating specialties. The preferred type and dose of hypnotics, opioids, and muscle relaxants used for RSI in trauma patients were sought in the questionnaire. Data were compared for the use of induction agent, opioid use and muscle relaxant among stable and unstable trauma patients by the intubating specialties.
RESULTS: A total of 102 participants were included; 47 were anaesthetists and 55 were emergency physicians. Propofol (74.5%) and Etomidate (50.0%) were the most frequently used induction agents. Significantly higher proportion of anesthesiologist used Propofol whereas, Etomidate was commonly used by emergency physicians in stable patients (P=0.001). Emergency physicians preferred Etomidate (63.6%) and Ketamine (20.0%) in unstable patients. The two groups were comparable for opioid use for stable patients. In unstable patients, use of opioid differed significantly by intubating specialties. The relation between rocuronium and suxamethonium use did change among the anaesthetists. Emergency physicians used more suxamethonium (55.6% vs. 27.7%, P=0.01) in stable as well as unstable (43.4 % vs. 27.7%, P=0.08) patients.
CONCLUSION: There is variability in the use of drugs for RSI in trauma patients amongst emergency physicians and anaesthesiologists. There is a need to develop an RSI protocol using standardized types and dose of these agents to deliver an effective airway management for trauma patients.

Key words: Rapid-sequence induction, Trauma, Emergency physicians, Anaesthetists, Drugs

Bianca M. Wahlen, Ayman El-Menyar, Mohammad Asim, Hassan Al-Thani. Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers[J]. World Journal of Emergency Medicine, 2019, 10(1): 19-26.

Figures/Tables 4

Table 1

Table 2

Table 3

Table 4

Sedative agents for RSI

Parameters	Etomidate	Midazolam	Ketamine	Propofol
Mechanism	Imidazole-derived, it acts directly on the GABA receptor complex, blocking neuroexcitation and producing anesthesia.	Benzodiazepines act on the GABA receptor complex.	It acts at many receptors causing a range of effects. It may stimulate the N-methyl-D-aspartate receptor at the GABA receptor complex, causing neuroinhibition and anesthesia.	It is a highly lipid-soluble, alkylphenol derivative that acts at the GABA receptor causing sedation and amnesia.
Induction dose	IV push in a dose of 0.3 mg/kg	0.1 to 0.3 mg/kg IV push	1 to 2 mg/kg	1.5 to 3 mg/kg IV
Time to effect	15 to 45 seconds	Approximately 30 to 60 seconds	45 to 60 seconds	Approximately 15 to 45 seconds
Duration of action	3 to 12 minutes	15 to 30 minutes	10 to 20 minutes	5 to 10 minutes
Hemodynamic effect	As the most hemodynamically neutral of the sedative agents, it does not stimulate histamine release.	Midazolam (0.2 mg/kg) causes moderate hypotension, with an average drop in MAP 10% to 25%.	It stimulates catecholamine receptors and release of catecholamines causing increases in HR, contractility, MAP and cerebral blood flow.	It suppresses sympathetic activity, causing myocardial depression and peripheral vasodilation (drops MAP of≈ 10 mmHg)
Analgesia	No analgesic effect. It does not blunt the noxious stimulation of the upper airway during laryngoscopy and intubation.	It does not provide analgesia but does possess anticonvulsant effects, making it an effective agent for RSI in patients with status epilepticus.	It excites opioid receptors within the insular cortex, putamen, and thalamus, producing analgesia.	No
Effects	It decreases cerebral blood flow and cerebral metabolic oxygen demand, while preserving cerebral perfusion pressure. It is a sedative-hypnotic agent. It should not be used as an infusion or in repeated bolus doses for maintenance of sedation after intubation. Neuroexcitation can be reduced by postintubation sedation with propofol or a benzodiazepine In CVD or elevated intracranial pressure, it is often given during the pretreatment phase of RSI.	It causes sedation and amnesia.	It is a dissociative anesthetic agent. It provides analgesia along with its amnestic and sedative effects. It decreases the production of vascular nitric oxide, diminishing its vasodilatory effect, and inhibits nicotinic acetylcholine receptor. Ketamine may cause bronchodilation by stimulating the release of catecholamines. It preserves respiratory drive and has both a quick onset of action and analgesic properties. Use for "awake" intubation attempts, but not in paralyzed patients.	It reduces airway resistance. It does not prolong cardiac QT interval. It causes sedation and amnesia, but it does not cause analgesia. Its neuroinhibitory effects allows its use for patients with intracranial pathology (in hemodynamically stable cases).
Side effects	It is a reversible inhibitor of 11-beta-hydroxylase, which converts 11-deoxycortisol to cortisol. It causes adrenal suppression, myoclonus, and evidence of regional cerebral excitation after intubation.	It induces hypotension.	In patients with hypertension and suspected ICP elevation, ketamine should be avoided. When ketamine is used with a GABA agonist, this rise in ICP may not occur.
Use in shock	Yes	No	Yes	No
Use in bronchospasm			Yes	Yes
Use in significant CVD	Yes
Use in head injury or stroke	Yes		Yes
GABA: gamma amino butyric acid; MAP: mean arterial pressure, HR: heart rate; CVD: cardiovascular disease; Data adopted from [ref 34].

Table 4

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Induction agent	Total (n=102)	Emergency physicians (n=55)	Anaesthesiologists (n=47)	P value
Stable patients
Propofol	76 (74.5)	31 (56.4)	45 (95.7)	0.001 for all
Etomidate	21 (20.6)	20 (36.4)	1 (2.1)
Ketamine	3 (2.9)	2 (3.6)	1 (2.1)
Midazolam	2 (2.0)	2 (3.6)	0 (0.0)
Unstable patients
Etomidate	51 (50)	35 (63.6)	16 (34.0)	0.023 for all
Ketamine	25 (24.5)	11 (20.0)	14 (29.8)
Propofol	22 (21.6)	8 (14.5)	14 (29.8)
Midazolam	4 (3.9)	1 (1.8)	3 (6.4)

Opioid	Total (n=102)	Emergency physicians (n=55)	Anesthesiologist (n=47)	P value
Stable patients				0.093 for all
Fentanyl	94 (93.1)	49 (89.1)	45 (97.8)
Morphine	5 (5.0)	5 (9.1)	0 (0.0)
Remifentanil	1 (1.0)	0 (0.0)	1 (2.2)
No opioid	1 (1.0)	1 (1.8)	0 (0.0)
Unstable patients				0.005 for all
Fentanyl	80 (81.6)	40 (72.7)	40 (93.0)
Morphine	2 (2.0)	2 (3.6)	0 (0.0)
Remifentanil	2 (2.0)	0 (0.0)	2 (4.7)
No opioid	14 (14.3)	13 (23.6)	1 (2.3)

Muscle relaxant	Total (n=102)	Emergency physicians (n=55)	Anesthesiologist (n=47)	P value
Stable patients
Rocuronium	57 (56.4)	24 (44.4)	33 (70.2)	0.013 for all
Suxamethonium	43 (42.6)	30 (55.6)	13 (27.7)
Cis-Atracurium	1 (1.0)	0 (0.00)	1 (2.1)
Unstable patients
Rocuronium	62 (62)	28 (52.8)	34 (72.3)	0.081 for all
Suxamethonium	36 (36)	23 (43.4)	13 (27.7)
Cis-Atracurium	2 (2/0)	2 (3.8)	0 (0.0)

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