RSI: The First Two Years

      It is 17:30 on a sunny fall day when a BLS engine from the Wilmington (DE) Fire Department, a BLS ambulance from Wilmington EMS, and a paramedic response unit from New Castle County EMS are dispatched to a "pedestrian struck." All three units arrive at about the same time to find a 15-year-old male face down in the roadway, not moving. The patient responds only to pain, is breathing irregularly and has contusions on his head. The crew immediately takes C-spine precautions and rolls him onto his back. One paramedic easily manipulates his jaw forward while an EMT applies oxygen via non-rebreather mask.

   After he is moved onto the backboard, the patient becomes combative. Several providers attempt to restrain him, but he continues to move his head and strike it against the backboard. His teeth are now clenched and the oxygen mask will not stay on his face.

   The region's level 1 trauma center is Christiana Hospital in Newark, DE. Ground transport in normal traffic conditions is about 15 minutes, but it is now rush hour and could take up to 30 minutes. The paramedics are concerned that the patient does not have a patent airway and his combativeness could worsen a head or neck injury. For these reasons they decide that this patient is a candidate for rapid sequence intubation (RSI), which was implemented three weeks earlier for New Castle County EMS.

   The patient continues to be combative after he is moved to the back of the ambulance. His pulse is 150 and the monitor shows sinus tachycardia, RR 36 and irregular, BP 160 systolic, and a pulse ox reading of 100% with the non-rebreather mask as close as he will allow it to be from his face. One of the paramedics calls Christiana to request orders for RSI while the other starts an IV in the patient's left arm.

   The paramedic requests permission to administer lidocaine, etomidate and succinylcholine to intubate the patient. He also requests orders to administer midazolam and vecuronium after intubation for longer-lasting sedation and paralysis. The base physician agrees and confirms doses for the medications.

   One paramedic draws up the medications and applies labels to the syringes while the other paramedic prepares an 8.0 ET tube with a stylette and syringe, turns on the suction unit, and places an open Thomas Tube Holder and end-tidal CO₂ circuit next to the patient's head.

   The paramedic who is positioned at the head reports that his equipment is ready, and the paramedic at the patient's side administers the medications in the correct order. Cricoid pressure is applied immediately after they are given. The collar is removed and manual C-spine precautions are taken by one of the EMTs. The patient is successfully intubated on the first attempt approximately 45 seconds later, during which his pulse ox reading remains above 96%. The ambulance then starts for the hospital after being on scene for 14 minutes.

   After the run the paramedics are debriefed by their associate medical director. They discuss the decision process leading up to RSI, how the intubation went smoothly and any problems that may have been encountered.

INTRODUCTION

   RSI is routinely used for emergency airway management in hospitals, but there is a great deal of controversy about its safety in the prehospital environment. This article is not intended to advocate for or against the procedure, but instead discuss why EMS and trauma system leaders determined that certain patients could benefit from RSI in one county's EMS system. It also discusses how the program was implemented, the safeguards that were built into the procedure and paramedic airway performance since implementation.