Abstract
A short cut review was carried out to establish whether there are significant differences in the performance of emergency physicians and anaesthetists when carrying out rapid sequence intubation (RSI) in the emergency department. A total of 407 papers were found of which 12 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. The clinical bottom line is that there is little or no difference in the rates of success and complications between emergency department clinicians and anaesthetists performing RSI.
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 computed tomography (CT) scan. The patient needs to be intubated via RSI and you wonder whether you should do this, as you have previous anaesthetic training, or whether you should call the anaesthetist and wait for them to do it for you.
Search strategy
Medline 1966–2 August 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
Of 407 papers found, 304 were irrelevant and one of which was relevant was a review article. This left 12 papers for analysis (table 2).
Table 2.
| Author, date, and country | Patient group | Study type (level of evidence) | Outcomes | Key results | Study weaknesses |
|---|---|---|---|---|---|
| Taryle DA 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 specialty; numbers do not add up |
| Complications by specialty (prolonged attempt/aspiration/mainstem bronchus/pneumothorax) | EM = 20/23 v A = 14/23 (p = NS) | ||||
| Dufour DG et al, 1995, Canada | 219 RSIs, including children done in emergency department by emergency physicians | Retrospective observational study | Complications: | Observational study; no comparison by grade; no other specialty 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 JC et al, 1997, USA | 610 intubations, including children, 515 (89.9%) had RSIs | Prospective observational study | Intubations by specialty | EM = 569 (93.3%)/A = 18 (3%)/Other = 23 (3.8%) | Observational study; no mention of attempts made; no comparison by specialty of success or complications |
| Intubation by grade: | |||||
| EMR‐1 (yr 1) | 15 (2.6%) | ||||
| EMR‐2 (yr 2) | 101 (17.8%) | ||||
| EMR‐3 (yr 3) | 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 | |||||
| Vomiting | 10 (1.6%) | ||||
| Total | 57 (9.3%) | ||||
| Omert L 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 v EM residents (∼SHO) “EM staff then intubated 6/7 that the EM residents failed”; 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 | ||||
| Mainstem intubation | 5.9/2 | ||||
| Bradycardia | 2/3 | ||||
| Oesophageal intubation | 7.9/6.7 | ||||
| Dental trauma | 0/2 | ||||
| Surgical airway | 2/0 | ||||
| Total (no fatalities) | 37.6/33.3 | ||||
| Butler JM et al, 2001, UK | 60 RSIs in A&E, 4 aged under 10 | Prospective observational study | Specialty of decision maker | A = 16 (26%)/EM = 44 (73%) | Observational study; no power study; small numbers; no comparison of complications by group |
| Specialty 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 min | A = 51%/EM = 62% | ||||
| Tam AY 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: | Observational study; no power study; no direct comparison between specialties; included paediatric patients; also included non‐RSI cardiac arrest patients; small numbers | |
| Emergency physicians | 207/214 (97%) 90% on first attempt | ||||
| Anaesthetists (after failed by EM) | 7/214 (3.3%) | ||||
| RSI complications (none fatal): | |||||
| Detected oesophageal intubation | 8/66 (12%) | ||||
| Dental trauma | |||||
| Soft tissue injury | 6/66 (9%) | ||||
| Bronchial intubation | 1/66 (1.5%) | ||||
| Desaturation <90%, | 2/66 (3%) | ||||
| Hypotension <90 mmHg | 2/66 (3%) | ||||
| Arrhythmia | 1/66 (1.5%) | ||||
| Wong E 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 specialties; 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%) | ||||
| Wong E et al, 2003, Southeast Asia | 1068 emergency department patients requiring advanced airway management (including cardiac arrests) | Prospective observational study | Specialty v success rate, anaesthetist (A) 16, emergency physician (EP)(equivalent 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% | |||||
| Levitan RM et al, 2004, USA | 658 trauma patients | Prospective 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%) | ||||
| A = 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 | |||||
| NA 34.2% | |||||
| (No failed intubations in any groups) | M 49.3% | ||||
| (p = 0.23) | |||||
| Bushra JS 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 | |||||
| Graham CA 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 | |||||
| Reid C et al, 2004, UK | 208 RSIs 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, and 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) |
EM, emergency medicine (physician); A, anaesthetist.
Comment(s)
Although many papers looked only at the performance of emergency physicians, there appeared to be ample evidence that emergency physicians can perform RSI and endotracheal intubation at least as well as anaesthetists, and overall there is a high rate of success with a low rate of complications. Emergency physicians themselves must have had training in the field. Among the papers examined in this BET, several mention a trend to call an anaesthetist 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 RSI in the emergency department should be part of an emergency physician's core skill.
Clinical bottom line
There is little or no difference in the rates of success and complications seen between emergency department clinicians and anaesthetists performing RSI.
Addendum
An updated version of this Best evidence topic report is available at http://emj.bmjjournals.com/supplemental
Supplementary Material
References
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