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Three Part Question

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

Clinical Scenario

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.

Search Strategy

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}

Search Outcome

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

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Reid C. et al 2004 May UK	208 RSI's outside theatre, 51 by anaesthetists (A), 82 by non-anaesthetists (NA), 75 by non-anaesthetists supervised by anaesthetists (M)	Prospective, Observational study	Complications (hypotension, arrhythmias & hypoxia)	A 33.3%	Observational study, no power study, no record of duration of hypoxia/hypotension, no comparison of seniority of operator, other complications not included. (When compared with conditions and expected complication rates, no statistical differences between groups)
				NA 34.2%
			(No failed intubations in any groups)	M 49.3%
				(p=0.23)
Graham et al 2004 UK	396 trauma patients in emergency department	Prospective, Observational study	Complications (oesophageal intubation, endobronchial intubation, aspiration, vomit, critical desaturation, cardiac arrest, hypotensive episode)	EP 11/110 (10.0%)	Observational study, no power study
				A 13/123 (10.6%)
				p=1.0
Wong et al 2003 South East Asia	1068 emergency department patients requiring advanced airway management (including cardiac arrests)	Prospective, Observational study	Speciality vs success rate, anaesthetist (A) 16, emergency physician (EP)(equiv. SpR grade or above) 658, medical officer (MO) 392		Observational study, no power study, no breakdown of complications by clinician, not primarily comparing clinician types, large difference in numbers between groups, also included non-RSI cardiac arrest patients
			First attempt	A=87.5%
				EP=93.1%
				MO=85.2%
			Final success rate	A=100%
				EP= 97.3%
				MO=90.5%
Bushra et al 2004 USA	673 trauma patients emergency department, 467 anaesthesia supervised intubations (A), 206 emergency medicine supervised (EM),	Prospective, Observational study	Successful intubations within 2 attempts	A=442/467 (94.6%)	Observational study, no power study, no mention of complications, different numbers between groups. (EM performed most of the intubations and reported EM intubated in 81% of anaesthesia supervised groups and in 98% of EM supervised groups)
				EM=196 (95.1%), odds ratio 1.109
			Intubation failure	A=16/467 (3.4%)
				EM=4 (1.9%), Odds ratio 0.558
Levitan et al 2004 USA	658 trauma patients	ospective, observational study	Number of laryngoscopy attempts;		Observational study, no power study, only major complications, self reported. More numbers in EM groups
			1	EM=394/456 (86.4%),
				A=174/194 (89.7%)
			2	EM=50 (11%)
				=13 (6.7%)
			3	EM=12 (2.6%)
				A=7 (3.6%)
			Success	EM=454/456 (99.6%)
				A=194/194 (100%)
			Cricothyrotomy	EM=2/456 (0.4%)
				A=0
Wong et al 2003 Singapore	142 trauma cases	Retrospective observational study	Number of attempts, (10 not attempted)	113/132 (85.6%) first attempt	Retrospective observational study, No direct comparison between specialities, small numbers
				129 (97.7%)successful
			anaesthetist called (potentially difficult airway),	13 (9.2%)
			complications;
			nil	109 (76.8%)
			hypotension	27 (19%)
			other	6 (4.2%)
Tam et al 2001 Hong Kong	214 patients requiring intubation in the emergency department (87 in cardiac arrest) including 5 children	Prospective observational study	Success rate; Emergency physicians	207/214 (97%) 90% on 1st attempt	Observational study, no power study, no direct comparison between specialities, included paediatric patients, also included non-RSI cardiac arrest patients, small numbers
			Anaesthetists (after failed by EM)	7/214 (3.3%)
			RSI Complications, (none fatal):
			detected oesophageal intubation	8/66 (12%)
			dental trauma	0
			soft tissue injury	6/66 (9%)
			bronchial intubation	1/66 (1.5%)
			desaturation <90%,	2/66 (3%)
			hypotension <90mmHg	2/66 (3%)
			arrhythmia	1/66 (1.5%)
Omert et al 2001 USA	200 trauma intubations, 101 anaesthetics in charge (A), 99 emergency medicine in charge (EM)	Prospective observational study	Demographics	A= higher GCS and RTS P<0.001)	Observational study, no power study, many of the A group intubations were actually carried out by EM residents but no record of numbers, small numbers (*figures confusing for EM staff vs EM residents (~SHO) 'EM staff then intubated 6/7 that the EM residents failed', and anaesthetists intubated 6 of the EM group)
			Intubation success within 3 attempts	A=98%/EM=87.9% *
			First attempt	A=77.2%/EM=73.7%
			Complication rates (%)	A/EM
			Hypoxia	14.9/18.2
			Aspiration	5/0.1
			Main stem intubation	5.9/2
			Bradycardia	2/3
			Oesophageal intubation	7.9/6.7
			Dental trauma	0/2
			Surgical airway	2/0
			TOTAL (no fatalaties)	37.6/33.3
Butler et al 2001 UK	60 RSI's in A&E, 4 aged under 10	Prospective observational study	Speciality of decision maker	A=16 (26%)/EM=44 (73%)	Observational study, no power study, small numbers, no comparison of complications by group.
			Speciality of RSI practitioner	A=35 (58%)/EM=16 (26%)
			Complications, 3 cases =A,3 unrecorded
			Desaturation	2
			Hypotension	3
			Cardiac arrest	1
			Mean Speed to RSI	A=5:42min/EM=3:52min (p=0.17)
			RSI practitioner arrival within 5 mins	A=51%/EM=62%
Dufour et al 1995 Canada	219 RSI's done in emergency department by emergency physicians, including children	Retrospective observational study	Complications;		Observational study, no comparison by grade, no other speciality involved with which to compare, no mention of attempts made.
			Hypotension	24 (10.96%)
			Aspiration	3 (1.37%)
			Bradycardia	3 (1.37%)
			Bigeminy	2 (0.91%)
				(no failed intubations)
Sakles et al 1997 USA	610 intubations, including children, 515 (89.9%) had RSI's	Prospective observational study	Intubations by speciality	EM=569 (93.3%)/A=18 (3%)/Other=23 (3.8%)	Observational study, no mention of attempts made, no comparison by speciality of success or complications
			Intubation by grade;
			EMR-1 (yr1)	15 (2.6%)
			EMR-2 (yr2)	101 (17.8%)
			EMR-3 (yr3)	418 (73.5%)
			Specialists	35 (6.2%)
			Complications;
			Cardiac arrest	3 (0.5%)
			Dental trauma	3 (0.5%)
			Desaturation	20 (3.3%)
			Hypotension	3 (0.5%)
			Mainstem intubation	18 (3%)
			Pneumothorax	0
			Vomiting	10 (1.6%)
			TOTAL	57 (9.3%)
Taryle et al 1979 USA	43 intubations in emergency department	Prospective observational study	Grade intubating	EM=23/A=20	Observational study, small numbers, no comparison of specific complications or attempts by speciality, numbers do not add up
			Complications by speciality (prolonged attempt/aspiration/mainstem bronchus/pneumothorax)	EM=20/23 vs A=14/23 (p=NS)

Comment(s)

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.

Clinical Bottom Line

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

References

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. Emergency Medicine Journal 21(3):296-301, 2004 May.
2. Graham CA, Beard D, Henry JM et al. Rapid sequence intubation of trauma patients in Scotland. Journal of Trauma-Injury & Critical care 56(5):1123-6, 2004 May.
3. Wong E, Fong YT, Ho KK. Emergency airway management—experience of a tertiary hospital in South-East Asia. Resuscitation 61(3)349-55, 2004 Jun.
4. Bushra JS, McNeil B, Wald DA et al. A comparison of trauma intubations managed by anesthesiologists and emergency physicians. Academic Emergency Medicine 11(1):66-70, 2004 Jan.
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. Annals of Emergency Medicine 43(1):48-53, 2004 Jan.
6. Wong E, Yong FT. Trauma airway experience by emergency physicians. European Journal of Emergency Medicine 10(3):209-12, 2003 Sep.
7. Tam AY, Lau FL. A prospective study of tracheal intubation in an emergency department in Hong Kong. European Journal of Emergency Medicine 8(4):305-10, 2001 Dec.
8. Omert L, Yeaney W, Mizikowski S et al. Role of emergency medicine physician in airway management of the trauma patient. Journal of Trauma-Injury & Critical care 51(6)1065-8, 2001 Dec.
9. Butler JM, Clancy M, Robinson N et al. An observational survey of emergency department rapid sequence intubation. Emergency Medicine Journal 2001;18;343-348.
10. Dufour DG, Larose DL, Clement SC et al. Rapid sequence intubation in the emergency department. The Journal of Emergency Medicine 1995;13(5);705-710.
11. Sakles JC, Laurin EG, Rantapaa AA et al. Management in the Emergency Department: A One-year Study of 610 Tracheal Intubations. Annals of Emergency Medicine 1998;31;325-332.
12. Taryle DA, Chandler JE, Good JT Jr et al. Room Intubations-Complications and Survival. Chest 1979;75:541-543.