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Three Part Question

In [patients requiring emergency RSI in the ED] does [prophylactic administration of an IV anti-emetic] [reduce the incidence of aspiration related complications]?

Clinical Scenario

A 50yr old male is 'blue-lighted" into your ED resus in status epilepticus. Despite IV lorazepam and phenytoin, the patient continues to fit and a decision is made to intubate and sedate him, to control his seizures. As the team is preparing to intubate him, you wonder if there is any evidence to support giving him a prophylactic dose of an IV anti-emetic as you are concerned about the potential risks of aspiration and related complications during an RSI?

Search Strategy

MEDLINE via OVID interface
Embase
Cochrane
CINHAL
exp Antiemetics/ or exp Metoclopramide/ or metoclopromide.mp or cyclizine.mp. or exp Cyclizine/ or ondansetron.mp. or exp Ondansetron/ AND {rapid sequence intubation.mp. or intubation.mp. or exp Intubation/ or RSI.mp}

Search Outcome

No relevant articles were found

Comment(s)

In patients presenting to the ED with acutely reduced levels of conciseness or those that need rapid sequence intubation for other reason such as poly trauma or head injury patients requiring CT scanning, etc, there is a significant risk of aspiration. The is a wide variation in current practice regarding the use of 'prophylactic' anti-emetics to reduce the risk of vomiting and therefore aspiration. While it would seem logical, that premedication with anti-emitics in patients at high risk of aspiration is a good idea, one must remember that that all drugs come with the risk of potential serious adverse effects. These patients present a constant challenge for EM physicians and more research into this question would be valuable

Clinical Bottom Line

There is currently no evidence to support the routine use of anti-emetics prior to RSI in the ED. The decision to use an anti-emeitc and the choice of the drug should take on an individual case basis, weighing the risks and benefits.