Rapid sequence induction in the emergency department by emergency medicine personnel

August 2, 2005

September 22, 2005

Colin Dibble, Specialist Registrar in Emergency Medicine (North Manchester General Hospital)

Margaret Maloba, North Manchester General Hospital

[In an emergency department RSI] are [emergency medicine clinicians as effective as anaesthetists] with regard to [complications and success rates]

You are in the resuscitation room and are faced with a combative head injury requiring a CT scan. He needs to be intubated via a rapid sequence induction and you wonder whether you should do this, as you have previous anaeasthetic training or call the anaesthetists down to do it for you.

Medline 1966 to August 2 2005 via Ovid interface

{exp Intubation, Intratracheal/ OR (rapid sequence induction).mp OR rsi.mp OR intubation.mp OR (crash induction).mp OR airway management.mp} AND {exp Medical Staff, Hospital/ or exp Emergency Medical Services/ or exp Emergency Service, Hospital/ or (emergency department).mp OR A&E.mp OR (accident and emergency).mp OR casualty.mp} AND {safety.mp. or exp SAFETY/ OR efficacy.mp OR complications.mp OR success.mp}

407 papers were found of which 304 were irrelevent and 1 of which was relevent but was a review article. This left 12 papers for analysis

Although many papers look only at the performance of emergency physicians, there appears to be ample evidence that emergency physicians can perform rapid sequence induction and endotracheal intubation at least as well as anaesthetists, and there is overall a high success rate with a low complication rate. Emergency Physicians themselves must have had training in the field. Among the papers examined in this BET, several mention a trend to call anaesthetists when a difficult airway is anticipated. In our experience the use of anaesthetists is variable between departments and is often influenced by the skills available within the emergency department. It would appear that the absolute need for anaesthetists in the resuscitation room is diminishing. It is our belief that endotracheal intubation and rapid sequence induction in the emergency department should be part of an emergency physicians core skills.

There is little or no difference in the success and complication rates seen between emergency department clinicians and anaesthetists performing RSI.

1. Reid C, Chan L, Tweeddale M.. The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre.
2. Graham CA, Beard D, Henry JM et al.. Rapid sequence intubation of trauma patients in Scotland.
3. Wong E, Fong YT, Ho KK.. Emergency airway management—experience of a tertiary hospital in South-East Asia.
4. Bushra JS, McNeil B, Wald DA et al.. A comparison of trauma intubations managed by anesthesiologists and emergency physicians.
5. Levitan RM, Rosenblatt B, Meiner EM et al.. Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success.
6. Wong E, Yong FT.. Trauma airway experience by emergency physicians.
7. Tam AY, Lau FL.. A prospective study of tracheal intubation in an emergency department in Hong Kong.
8. Omert L, Yeaney W, Mizikowski S et al.. Role of emergency medicine physician in airway management of the trauma patient.
9. Butler JM, Clancy M, Robinson N et al.. An observational survey of emergency department rapid sequence intubation.
10. Dufour DG, Larose DL, Clement SC et al.. Rapid sequence intubation in the emergency department.
11. Sakles JC, Laurin EG, Rantapaa AA et al.. Management in the Emergency Department: A One-year Study of 610 Tracheal Intubations.
12. Taryle DA, Chandler JE, Good JT Jr et al.. Room Intubations-Complications and Survival.