References
Rapid sequence airway not rapid sequence intubation
Abstract
There has been a focus when managing traumatic brain injury patients on achieving the gold standard of airway management in the field. This has been often quoted as being rapid sequence intubation. This article looks at the evidence to support this notion and attempts to justify consideration to maintaining an adequate airway with the use of a drug assisted (paralysis) supraglottic airway device insertion (intubating laryngeal mask (ILMA). The focus being on adequate ventilation rather than intubation at all costs. Avoidance of hypoxaemia and hypotension, causing secondary brain injury, should be paramount. The article is of relevance to paramedic services considering the introduction of paralysis assisted intubations. In Australia, the remoteness of locations had originally led to upskilling of retrieval paramedics in some regions which has now been transferred to non–rural paramedics. The introduction of paralysis assisted intubation in paramedics has raised the issue of competencies and continuing maintenance of skills programmes. There are, in addition, many training issues and cost implications to maintain paramedic competency in a skill seldom performed. Australia, like many nations, is suffering from an under supply of medical graduates.
There has been much controversy over the management of the prehospital airway and the issue of who should intubate a patient
requiring sedation. In Australia, each state has its own ambulance service and there is no agreement on this issue. In some states, there are retrieval doctors who attend the cases where intubation may be required, especially in the setting of trauma.
In one state, road and helicopter intensive care paramedics are authorized to give sedation and paralysis to facilitate rapid sequence intubation.
Most states do not allow paramedics to paralyze patients in the field—leading to the potential for large doses of narcotic to be administered in combative brain trauma patients, in order to perform laryngoscopy. Hypotension and hypoxaemia are often the result.
Current literature confirms that there is still a great deal of debate around the issue of prehospital intubation, especially in the setting of acute traumatic brain injury. A failure to intubate rate of 31% in patients who had an attempted prehospital intubation by paramedics prior to arrival at a level 1 trauma centre, has recently been reported (Cobas et al, 2009).
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