Walker Robert G, White Lynn J, Whitmore Geneva N, Esibov Alexander, Levy Michael K, Cover Gregory C, Edminster Joel D, Nania James M
Prehosp Emerg Care. 2018 May-Jun;22(3):300-311. doi: 10.1080/10903127.2017.1380095. Epub 2018 Jan 3.
Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI.
Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure.
Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation.
In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.
在多种急诊气道管理场景中已对快速顺序诱导插管（RSI）期间的生理改变进行了研究，但关于地面护理人员在院前进行RSI期间生理改变的数据却很少。为填补这一证据空白并为我们急救医疗服务（EMS）系统未来的质量改进举措提供指导，我们收集了电子监测数据以评估院前RSI期间插管前后生命体征的变化。
在15个月的研究期间前瞻性收集了尝试进行护理人员RSI的病例的电子患者监测数据文件，以补充标准的EMS患者护理记录。对病例进行分析，以确定插管前后血氧饱和度、心率和血压的变化。
有134例RSI病例的数据可供分析。护理人员指定的院前诊断印象类别包括神经科（42%）、呼吸科（26%）、毒理学（22%）、创伤（9%）和心脏科（1%）。不同诊断印象类别之间的总体插管成功率（95%）和首次尝试成功率（82%）无差异。43%的病例出现插管期间血氧饱和度下降（SpO₂降至90%以下），70%的血氧饱和度下降事件发生在首次尝试成功时。血氧饱和度下降的发生率在不同患者类别中有所不同，呼吸诊断印象与更频繁、更严重和更持久的血氧饱和度下降以及更高的伴随心血管不稳定发生率相关。13%的病例出现心动过缓（心率降至60次/分以下），60%的心动过缓事件发生在首次尝试成功时。7%的病例出现低血压（收缩压降至90 mmHg以下），63%的低血压事件发生在首次尝试成功时。插管期间心脏骤停发生2例，其中1例发生在首次尝试成功时。标准的EMS患者护理记录中仅反映了11%的血氧饱和度下降情况，且未记录任何心动过缓事件。
在本研究中，大多数插管期间的生理改变发生在首次尝试成功时，这突出表明首次尝试成功是插管质量的一个不完整且可能具有欺骗性的指标。用电子监测数据补充标准的患者护理记录可以识别院前RSI期间未被认识到的生理不稳定情况，并为质量改进干预提供有价值的指导。
