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Aragón-Benedí C, Visiedo-Sánchez S, Pascual-Bellosta A, Ortega-Lucea S, Fernández-Liesa R, Martínez-Ubieto J. Study of Rocuronium-Sugammadex as an Alternative to Succinylcholine-Cisatracurium in Microlaryngeal Surgery. Laryngoscope 2020; 131:E212-E218. [PMID: 32324308 DOI: 10.1002/lary.28649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 12/19/2022]
Abstract
Microlaryngeal surgery (ML) is a short procedure that requires a deep neuromuscular blockade to provide optimum surgical conditions. Succinylcholine is a relaxant widely used but involves numerous complications. One valid alternative is rocuronium, with a specific antagonist, sugammadex. The primary objective was to assess the surgical conditions in ML according to the relaxant. The secondary objectives were to assess intubation conditions and intraoperative and immediate postoperative adverse events. STUDY DESIGN Prospective randomized study. METHODS This was a prospective study of patients scheduled for ML randomized into two groups according to relaxant. Neuromuscular blockade was recorded after administration and during ML surgery. Surgical conditions were assessed using the ML Rating Scale, intubation conditions, remifentanil doses, intraoperative complications, surgery time, emergence time, and complications in the postanesthesia care unit. RESULTS Two hundred five patients were included (rocuronium = 103, succinylcholine = 102). Train-of-four values were higher for rocuronium, though the otorhinolaryngology surgical conditions were significantly better in that group (rocuronium = 5.54 ± 1.39 points; succinylcholine = 9.13 ± 1.99 points). Intubation conditions were similar in both groups. Remifentanil doses were higher for succinylcholine (P < .001) (rocuronium = 0.102 ± 0.05 μg/kg/min; succinylcholine = 0.201 ± 0.05 μg/kg/min). There were no differences in the duration of surgery, but the time to awakening was significantly longer for succinylcholine (rocuronium = 3.82 ± 1.38 minutes, succinylcholine = 9.18 ± 2.04 minutes, P < .001). CONCLUSIONS Rocuronium provides better surgical conditions and allows for the use of lower doses of remifentanil as compared to succinylcholine and cisatracurium in ML. This makes it possible to decrease the time to awakening and the complications associated with high doses of remifentanil. LEVEL OF EVIDENCE 1b Laryngoscope, 131:E212-E218, 2021.
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Affiliation(s)
- Cristian Aragón-Benedí
- Department of Anesthesia, Resuscitation and Pain Therapy, Móstoles General University Hospital, Móstoles, Spain
| | - Sara Visiedo-Sánchez
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, Zaragoza, Spain
| | - Ana Pascual-Bellosta
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, Zaragoza, Spain
| | - Sonia Ortega-Lucea
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, Zaragoza, Spain
| | - Rafael Fernández-Liesa
- Head of Department of Otolaryngology-Head and Neck Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Javier Martínez-Ubieto
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, Zaragoza, Spain
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Abstract
The modern version of RSI starts with preoxygenation. General anaesthesia is then induced using a rapid acting intravenous anaesthetic and a rapid acing muscle relaxant. Cricoid pressure is applied by an experienced assistant during induction, which should then be maintained until the trachea of the patient is intubated, correct positioning of the tracheal tube confirmed and the cuff inflated. The patient is conventionally not ventilated during this phase but critically ill patients are exceptions. The patient's tracheal should be intubated when adequately paralysed and its position verified. The assistant can then relieve the cricoid pressure and the tracheal tube fixed.
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Affiliation(s)
- Hy So
- Alice Ho Miu Ling Nethersole Hospital, Department of Anaesthesiology, Intensive Care & Operating Services, Hong Kong
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Intubation of the Neurologically Injured Patient. J Emerg Med 2015; 49:920-7. [DOI: 10.1016/j.jemermed.2015.06.078] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 04/30/2015] [Accepted: 06/01/2015] [Indexed: 11/17/2022]
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[Sedation and analgesia in emergency structure. Which sedation and/or analgesia for tracheal intubation?]. ACTA ACUST UNITED AC 2012; 31:313-21. [PMID: 22440814 DOI: 10.1016/j.annfar.2012.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fatemeh H, Mojgan R. Comparison of atracurium and "mini-dose" succinylcholine for preventing succinylcholine-induced muscle fasciculations: a randomized, double-blind, placebo-controlled study. ACTA ANAESTHESIOLOGICA TAIWANICA : OFFICIAL JOURNAL OF THE TAIWAN SOCIETY OF ANESTHESIOLOGISTS 2010; 48:28-32. [PMID: 20434110 DOI: 10.1016/s1875-4597(10)60006-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 02/03/2009] [Accepted: 02/06/2009] [Indexed: 10/19/2022]
Abstract
UNLABELLED Several drugs have been used to prevent or attenuate succinylcholine- induced muscle fasciculations. There are possible advantages to succinylcholine pretreatment. We designed the present study to compare the effectiveness of atracurium versus "mini-dose" (5 mg) succinylcholine pretreatment for the prevention of muscle fasciculations. METHODS Under standard monitoring, 79 patients were randomly assigned to three groups after premedication: Group 1 (n = 26) received normal saline as a placebo, Group 2 (n = 27) received 0.03 mg/kg atracurium, and Group 3 (n = 26) received 5 mg succinylcholine. Thiopental (4 mg/kg) was administered intravenously 90 seconds after pretreatment, followed by intravenous administration of 1.5 mg/kg succinylcholine. An anesthesiologist graded fasciculations based on a four-point scale, from 0 (none) to 3 (severe). All patients were evaluated on the first postoperative day for the presence of postoperative myalgia (POM), the severity of which was graded on a four-point scale, from 0 = no myalgia to 3 = generalized, severe discomfort. RESULTS There were no statistical differences among the three groups with respect to sex, weight or age. In Group 1, 3.8% of the patients showed no fasciculations, while 30.8% had mild, 53.8% had moderate and 11.5% had vigorous fasciculations. In Group 2, fasciculations were absent in 74.1% of the patients, while 25.9% of the patients had mild fasciculations. In Group 3, 23.1% patients had no fasciculations, while 42.3%, 30.8% and 3.8% of the patients showed mild, moderate and vigorous fasciculations, respectively, with succinylcholine pretreatment. There was no difference in the presence or severity of myalgia between Groups 1 and 3. Furthermore, the presence of fasciculations was not correlated with POM in Groups 1 and 3, but a significant correlation was found in Group 2. CONCLUSION Our results showed that the incidence and severity of fasciculations were significantly decreased by atracurium pretreatment but not by pretreatment with succinylcholine or placebo (p<0.0001 and p=0.0003 respectively). However, atracurium did not exert significant effects on POM.
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Affiliation(s)
- Hajimohamadi Fatemeh
- Department of Anesthesiology, Amir Alam Hospital, Medical Sciences/University of Tehran, Iran
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Wang HE, Davis DP, Wayne MA, Delbridge T. PREHOSPITALRAPID-SEQUENCEINTUBATION-WHATDOES THEEVIDENCESHOW? PREHOSP EMERG CARE 2009. [DOI: 10.1080/312704000917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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von Elm E, Schoettker P, Henzi I, Osterwalder J, Walder B. Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence. Br J Anaesth 2009; 103:371-86. [PMID: 19648153 DOI: 10.1093/bja/aep202] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). METHODS We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. RESULTS In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. CONCLUSIONS Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.
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Affiliation(s)
- E von Elm
- German Cochrane Centre, Department of Medical Biometry and Statistics, University Medical Centre Freiburg, Stefan-Meier-Strasse 26, Freiburg D-79104, Germany.
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Wang HE, Davis DP, O'Connor RE, Domeier RM. Drug-Assisted Intubation in the Prehospital Setting (Resource Document to NAEMSP Position Statement). PREHOSP EMERG CARE 2009; 10:261-71. [PMID: 16531387 DOI: 10.1080/10903120500541506] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Dunham CM, Barraco RD, Clark DE, Daley BJ, Davis FE, Gibbs MA, Knuth T, Letarte PB, Luchette FA, Omert L, Weireter LJ, Wiles CE. Guidelines for emergency tracheal intubation immediately after traumatic injury. THE JOURNAL OF TRAUMA 2003; 55:162-79. [PMID: 12855901 DOI: 10.1097/01.ta.0000083335.93868.2c] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Marvez E, Weiss SJ, Houry DE, Ernst AA. Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation. Am J Emerg Med 2003; 21:23-9. [PMID: 12563574 DOI: 10.1053/ajem.2003.50002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Our ED at Louisiana State University developed a unique approach to airway management by having four diagnosis-based protocols for rapid sequence intubation (RSI). This study examines protocol use and outcome from RSI in an academic ED. The study objective was to identify variables that are predictive of adverse outcomes in patients requiring RSI. This was a 4-year prospective, observational, data-gathering study of all intubations in an academic ED setting with >250,000 patient visits per year. Four protocols were established for 1) children <10 years of age, 2) adults with increased intracranial pressure, 3) adults with chronic obstructive pulmonary disease/asthma, and 4) other adults not fitting B or C. A special continuing quality improvement (CQI) committee was established to examine each case of RSI. Prospective data were collected, including age, race, gender, protocol, diagnostic group, intubation indication, and preintubation oxygen saturation. Diagnostic group was categorized as medical, blunt trauma, or penetrating trauma. Adverse outcome was defined as any case with hemodynamic changes, those requiring surgical or bronchoscopic intervention, and those requiring more than three attempts at intubation. Data were analyzed using univariate analysis, logistic regression, and a binomial regression tree analysis with SPSS 9.0 (Chicago, IL) and Answer Tree (SPSS). A total of 1,320 consecutive intubated patients were included. Protocol A was used in 4%, B in 43%, C in 15%, and D in 38%. Significant differences in number of cases with adverse outcome were based on protocol (P =.03) and final diagnosis (P <.03). Protocol C was less likely to be associated with adverse outcome than protocol D (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1-0.7). Penetrating trauma was more likely to be associated with adverse outcome (OR = 1.8, 95%, CI = 1.1-3.2) than blunt trauma. A regression tree analysis yielded the following, all cases using protocol A or C or medical cases using B had an adverse event in 11 of 458 (2.4%), whereas nonmedical cases using protocols B or D and medical cases using D had adverse outcomes in 73 of 862 cases (8.5%). The decision rules lead to a better classification of cases with adverse outcomes (2.4 vs 8.5%, of = 6.1%, 95% CI = 3.7-8.4). Adult trauma patients who fit the protocols B or D or adult medical patients who fit protocol B were at higher risk for adverse outcomes with RSI. This could alert the physician to a population at higher risk for adverse outcomes. Variables available in a diagnosis-based protocol RSI system can be used to predict adverse outcome among patients requiring RSI.
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Affiliation(s)
- Eduardo Marvez
- Louisiana State University/Charity Hospital, New Orleans, LA, USA
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Affiliation(s)
- H E Wang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pennsylvania 15213, USA.
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Affiliation(s)
- D C Cone
- Division of EMS, Yale University School of Medicine, New Haven, Connecticut 06519-1315, USA.
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Quelle est la stratégie de prise en charge d'un multitraumatisé ayant un traumatisme crânien grave? ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s0750-7658(99)80118-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Quelles sont les modalités de prise en charge des traumatismes crâniens graves en phase préhospitalière? ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s0750-7658(99)80110-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Adnet F, Hennequin B, Lapandry C. [Rapid sequence anesthetic induction via prehospital tracheal intubation]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1998; 17:688-98. [PMID: 9750807 DOI: 10.1016/s0750-7658(98)80106-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The choice of sedation for emergency intubation remains controversial. This lack of consensus has led to various sedation protocols used in French prehospital care setting. A review of data from the literature suggests that the association etomidate-suxamethonium is probable the best choice for rapid sequence intubations in the prehospital setting. Its benefits include protection against myocardial and cerebral ischaemia, decreased risk of pulmonary aspiration, and a stable haemodynamic profile. Randomized studies are needed to substantiate the advantages of the association etomidate-suxamethonium for rapid sequences intubation in the prehospital setting.
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Affiliation(s)
- F Adnet
- Samu 93 et département d'anesthésie et de réanimation, CHU Avicenne, université Paris XIII, Bobigny, France
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Harvey SC, Roland P, Bailey MK, Tomlin MK, Williams A. A randomized, double-blind comparison of rocuronium, d-tubocurarine, and "mini-dose" succinylcholine for preventing succinylcholine-induced muscle fasciculations. Anesth Analg 1998; 87:719-22. [PMID: 9728861 DOI: 10.1097/00000539-199809000-00044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- S C Harvey
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston 29425-2207, USA
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Harvey SC, Roland P, Bailey MK, Tomlin MK, Williams A. A Randomized, Double-Blind Comparison of Rocuronium, d-Tubocurarine, and "Mini-Dose" Succinylcholine for Preventing Succinylcholine-Induced Muscle Fasciculations. Anesth Analg 1998. [DOI: 10.1213/00000539-199809000-00044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Silber SH. Rapid sequence intubation in adults with elevated intracranial pressure: a survey of emergency medicine residency programs. Am J Emerg Med 1997; 15:263-7. [PMID: 9148982 DOI: 10.1016/s0735-6757(97)90010-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A questionnaire entitled "Survey of Protocols for Rapid Sequence Intubation in Previously Healthy Adults with Elevated Intracranial Pressure" was distributed to the program directors of all 100 emergency medicine residency programs listed in the Directory of Graduate Medical Education Programs in February 1995. The medical literature on rapid sequence intubation in patients with suspected intracranial pressure elevations was reviewed. The findings of the review were compared with the survey responses. Sixty-seven program directors responded to the survey. Sixty-five programs performed rapid sequence intubation in their institution. Five programs performed 0 to 10 procedures annually. Six performed 10 to 30 annually, 19 performed 30 to 50, 17 performed 50 to 100, and 18 performed more than 100. Succinylcholine and vecuronium were the most frequently used neuromuscular blockers. Midazolam and thiopental were the most frequently used sedative induction agents. Most programs use a defasciculating agent prior to succinylcholine administration. The majority of programs do not use a priming agent before the use of a nondepolarizing neuromuscular blocking agent. Intravenous lidocaine was routinely administered prior to neuromuscular blockade. Fentanyl was the most frequently used other pretreatment medication. Rapid sequence intubation is used to facilitate definitive, emergent airway management in patients with suspected intracranial pressure elevations in almost all of the emergency medicine residency programs that responded to the survey. Most of these programs follow the guidelines recommended in the medical literature. The majority of these guidelines, however, are based on statistical data performed in the laboratory or nonemergency environments. Further clinical studies in an emergency medicine environment must be performed to determine the optimal drug regimen for rapid sequence intubation in patients with elevated intracranial pressure.
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Affiliation(s)
- S H Silber
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY 11215, USA
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Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 1996; 334:438-44. [PMID: 8552147 DOI: 10.1056/nejm199602153340706] [Citation(s) in RCA: 252] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- C H Schultz
- Department of Emergency Medicine, Los Angeles County Harbor-UCLA Medical Center 90509-2910, USA
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Abstract
Rapid sequence intubation (RSI) has recently gained wide acceptance among emergency physicians (EP). The debate regarding the safety of neuromuscular blocking (NMB) agents in the hands of EPs nonetheless remains open, as objective studies are few, and all data available so far come from tertiary care centers. This retrospective study was done to review our experience with RSI and assess the related morbidity and mortality. Two hundred and nineteen intubations were done using an RSI protocol during the study period. Hypotension occurred in 24 patients. Two patients had a short run of bigeminy and 3 had bradycardia. One patient went into cardiac arrest unrelated to the use of a NMB agent. Aspiration was documented in 3 patients. All patients were successfully intubated. No mortality was attributed to the use of muscle relaxants. Our results support the safety and effectiveness of RSI in the hands of emergency physicians.
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Affiliation(s)
- D G Dufour
- Emergency Department, Hôpital du Haut-Richelieu, St-Jean-sur-le-Richelieu, Quebec, Canada
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Rose WD, Anderson LD, Edmond SA. Analysis of intubations. Before and after establishment of a rapid sequence intubation protocol for air medical use. Air Med J 1994; 13:475-8. [PMID: 10137495 DOI: 10.1016/s1067-991x(05)80289-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION After finding the success rate of intubations in our air medical program to be less than optimal (with a success rate of only 73%), a protocol for increased doses of sedatives and neuromuscular blocking (NMB) agents was developed for field use by flight nurses and paramedics. METHODS A retrospective chart review was performed for 100 intubations before and 100 intubations after establishment of this protocol. RESULTS Success rate of intubation increased from 73% to 96%, which was statistically significant (p < 0.01). No difference existed between the two groups with regard to age, gender, Glasgow Coma Scale scores, nature of injury, route of intubation, number of attempts or percent intubated. Two patients (2%) became bradycardic using the new protocol. CONCLUSIONS Our results suggest that protocols including sedatives and NMB agents can be used safely and effectively by an appropriately trained air medical team of nurses and paramedics and may improve patient care.
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Affiliation(s)
- W D Rose
- West Virginia University Health Sciences Center, Morgantown 26506
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Affiliation(s)
- B Simon
- Highland Hospital Emergency Department, Oakland, Ca 94602, USA
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