Contents:

The Research Question Potential audiences Useful evidence and hierarchy Method Appraising Evidence Two part question Question 1
Searches Supporting Evidence Summary

Question 2
Searches Supporting evidence Summary

Conclusions

Can the use of Pre-hospital RSI be safely and effectively instituted in the South African Emergency Medical care system as a supplement to current practice of sedation assisted intubation for patients requiring advanced airway management?

Potential Audiences
Key audience: Health Professions Council of South Africa: Professional Board of Emergency Care; as policy makers and as head of Emergency Care in South Africa.
Other relevant audiences: South African Department of Health: As policy makers for the provision of optimal health care for all South Africans South African Medical Research Council: As a health care research group Emergency Medical Care Training Collages: As trainers of future Health Care Practitioners Current Medical Care Practitioners: As health care providers with the potential to practice such protocol Emergency Medical Services: As health care providers in the pre-hospital settings and employers of professionals with the skills for such protocol

 Secondary research only:

Useful Evidence and Hierarchy

Empirical: Both observational and experimental research studying the use of RSI in the Pre-hospital or in hospital settings in contrast to sedation assisted intubation Quantitative: Meta analyses of trials involving the use of pre hospital RSI, its effectiveness and outcomes, safety and efficiency Qualitative: Pre-hospital usage of RSI protocol, and the outcome and attitude experienced by the practitioner administering such protocol Theoretical: an analysis of research resulting in the theory of whether or not RSI in the pre-hospital, South African setting is likely to work Experiential: views and interviews from both pre-hospital and in hospital medical staff on the acceptability of such practice Contextual: This study, as far as possible would be centered on pre-hospital emergency services in South Africa, however international Pre-Hospital settings will also feature.

The hierarchy of preferred evidence:

Research secondary quantitative Research secondary contextual Research secondary qualitative Research secondary theoretical

Method:
Various internet database searches were done in order to answer the above question under two sub questions References were then found under each sub question They were ranked according to relevance and reliability Exclusion criteria ranged form relevance to the question to availability of text The references were then summarized and used to conclude an answer to each question

Appraising Evidence
Relevance:
To the question:
1 quantitative research on use of RSI in the prehospital environment by paramedics in South Africa 2 quantitative research on RSI in the prehospital setting by paramedics or other medical staff; 3 quantitative or qualitative studies on RSI , 4 theoretical foundations to the use and practice of RSI (hospital or prehospital)

To the topic:
1 Prehospital Rapid Sequence Intubation, 2 Success rate of paramedic RSI, 3 Reliability of paramedic intubation (RSI or other); 4 - Emergency department RSI

To the Context:
1 - South African Pre-hospital context (Empirical - quantitative), 2 international pre-hospital context (Empirical - quantitative), 3 hospital context

 Reliability: Sample (papers selected for this topic):

1 control trials and observational studies assessing Prehospital RSI 2 controlled trials and observational studies assessing prehospital intubation (RSI or Other), 3 large random studies done over longer periods of time focusing on success rate of paramedic initiated RSI (quantitative, qualitative), 4 Met analyses and Studies involving any aspect of Rapid sequence intubation (in or out-of-hospital), 5 theoretical evaluation and implementation of hospital or prehospital rapid sequence intubation (theoretical, contextual)

 Unbiased/biased: Author:
1 No prior expectation or preference for outcome, 2 prior expectation and/outcome of trial, 3 Attempt to prove theoretical expected outcome,

The Two-Part Question:

[Can the use of Pre-hospital RSI be safely and effectively instituted] in the South African Emergency Medical care system as a [supplement to current practice of sedation assisted intubation] for patients requiring advanced airway management?

Question 1: Can prehospital RSI be used safely and effectively? Searches: The search phrases included:
[Rapid sequence intubation OR induction] [Prehospital Rapid Sequence Intubation AND Safety and effectiveness] [Safety of] AND [Prehospital RSI] [Rapid sequence intubation] + [out-of-hospital] OR [prehospital] OR [paramedic] AND [safety]

Databases searched included Google and metalib health and wellness sciences

Supporting evidence: 6/48 - The strongest supporting evidence according to the ranking system
1. 2. Mackey CA, Terris J, Coats TJ; Prehospital rapid sequence induction by emergency physicians: Is it safe?; Emergency Medical Journal Issue 18: pp 20 24; 2001; http://emj.bmj.com/cgi/reprint/18/1/20; Accessed April 4, 2009 Dunford JV, Davis DP, Ochs M, Doney M, Hoyt D; Incidents of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation; Annals of Emergency Medicine Issue 42 number 6; ISSN 0196-0644; Elsivier New York; www.annemergmed.com/article/S0196-0644(03)00660-7; December 2003 Accessed May 2009 Wang H, Yearly DM, Out-of-Hospital Rapid sequence intubation: Is This really the success we envisioned?; Annals of emergency medicine; Vol.40 pp168 171; ISSN 0196-0644; American College of Emergency Physicians; August 2002 Spaite DW, Criss EA; Out-of-hospital rapid sequence intubation-Are we helping or hurting our patients?; Annals of Emergency medicine; Elsivier New York; Vol 42 issue 6, pp729-730; Arizona; December 2003 Barnard A, Handel D, Locasto D, Prehospital Rapid sequence Intubation, A review of literature; Emergency Medical Service Magazine; January Issue 2006, updated July 2008; Cincinnati; http://publicsafety.com/article/article.jsp?id=2716&siteSection=12; accessed May 2009 Wang HE, Lave JR, Sirio CA, Yearly DM; Paramedic Intubation Errors: Isolated Events or Symptoms of Larger Problems?; Health Affairs Volume 25 number 2, pp 501 509; Pennsylvania; People to people Health Foundation Inc. 2006; http://content.healthaffairs.org/cgi/reprint/25/2/501; Accessed 5 May 2009

3.

4. 5.

6.

 Summary
Intubation problems encountered by paramedics: Trismis, combative patients GCS greater then 3 less then 8, intact gag reflex, vocal chord spasm, difficult anatomy (Barnard:2006; Wang:2006) RSI methods can mitigate these problems (barring anatomical difficulties) (Barnard:2006; Wang:2006; So:2001; Walls:2009) Training and skills retention are the most important aspects of RSI (Wang:2006; Dunford:2003; Wang:2007; Sutphen; 2006) Paramedics must be proficient enough to:
Avoid producing hypoxia Avoid hyperventilation Select the correct drug: avoid adverse effects Recognize dislodged/misplaced tube Avoid prolonged sedation to tube time (multiple attempts) Alternative airway devices (Wang et al:2006; Yearly et al:2002; Braude:2007; Davis:2003) Recognized as a failed airway (Barnard:2006; Davis et al:2003)

Be able to recognize whether RSI is the best rout for the patient (Basic airways) All of which is obtainable in the South African prehospital context with extensive training (Btech)

Trials by Barnard:2006 were considered successful prehospital RSI trials

Paramedics had at least one intubation every 3 months to stay current with the protocol Some paramedics did not reach this goal 1 intubation annually (Wang:2007) Experientially, this is not the case in South Africa Skills retention Errors of intubation are lower in services with a higher intubation rate and greater patient contact rates (Wang:2007)

Increase in mortality rates?

Desaturation, Heart rate changes Most references with these outcomes deal with TBI (Barnard:2006; Dunford:2003; Davis:2003; Stuphen:2006; Hoyt:2003; Wang:2002) The criteria: Inability to intubate without RSI Trials not focused on TBI have more positive outcome (Barnard:2006) None are South African based studies

Question 2: What are the benefits of RSI compared to current practice of sedation assisted intubation?

Searches: the following search phrases were used on google database:

[succinycholine pharmacology] [Veccuronium pharmacology] [Midazolam pharmacology] [Etomidate pharmacology] [Ketamine Pharmacology]

Supporting evidence

RxList; The internet Drug Index; Ketamine Hydrochloride (Ketamine HCl) Drug information; Electronic data source; RxList Inc. 2009 http://www.rxlist.com/anectine-drug.htm; accessed May 2009 Bedford Laboritories Div-ETMP02; Etomidate injection Rx Only; Bedforf Laboritories, Bedford; 2004; www.bedfordlabs.com/products/inserts/etomidate_pi.pdf; Accessed May 2009 DrugLib.com: Drug information portal; Midazolam Side Effects and Adverse Reactions; 2007; Electronic data source; www.druglib.com/druginfo/midazolam/side-effects_adversereactions/; Accessed May 2009 Drugs.com: Drug information on line; Vecuronium Official FDA information, side effects and uses;2006; www.drugs.com/pro/vecuronium.html; Accessed May 2009 RxList; The internet Drug Index; Anectin (Succinylcholine Chloride) Drug information; Electronic data source; RxList Inc. 2009 http://www.rxlist.com/anectine-drug.htm; accessed May 2009

 Summary
System Ketamine Midazolam Etomidate Vecuronium Suxamethonium Blood Pressure
Hypertension Hypotension Hypertension Minimal changes Minimal changes

Heart Rate

Tachycardia

Bradycardia

Brady/ Tachycardia

None

none

Respiratory Laryngospasm Emisis Other

Stimulation Yes Yes

Depression No Possible

Either Yes Yes

Depression No No

Depression No No Malignant Hyperthermia and Hyperkalemia

Contraindications Hypersensitivity

Hypersensitivity

Hypersensitivity

Hypersensitivity, potential difficult airway

Hypersensitivity, potential difficult airway

(Bedford Laboritories :2004; DrugLib.com:2007; Drugs.com:2006; RxList2009)

 Midazolam is not without its potential problems Hypotensive patients, with or without bradycardia stand a greater risk midazolam and morphine only Midazolam
good induction agent, only with the use of a neuromuscular blocking agent (DrugLib.com:2007) Respiratory depression at high doses or rapid administration gag reflex, trismis, laryngospam not reduced Unable to intubate hypoxia, asphyxia, death

 With Neuromuscular Blocking agents: Gag reflex, laryngospasm, trismis, GCS all eliminated (RxList:2009; Drugs.com:2009) Elimination of most of the problems encountered by paramedics (Barnard:2006; Wang:2006; So:2001; Walls:2009) Neither way is without risk Both methods require adequate practice and skill retention

Conclusion:
RSI used for placement of endotracheal tube for patients in need of advanced airway management Controversy in use of RSI in prehospital setting by paramedics Greater risks for patients with TBI Hypoxia, heart rate changes, inability to pass the tube (Barnard:2006; Dunford:2003; Davis:2003; Stuphen:2006; Hoyt:2003; Wang:2002)

 Prehospital RSI no greater risk than in hospital RSI (Dunford et al:2003; Wang et al:2006; Yearly:2007; Stuphen et al:2006) Finally it can be concluded:
Useful addition to the current sedation only technique High number of patients needing intubation in SA prehospital skill retention

Thank you
Any Questions?