![]() ![]() ![]() 2, 3, 5, 6, 8, 17– 19 Standardizing the approach to RSI in the ED is associated with reducing the attempt number and complication incidence. ![]() ![]() 16 Because coordination of numerous tasks is critical for successful intubation, previous quality improvement (QI) initiatives focused on system and team factors such as team member roles, equipment preparation, and optimizing patient oxygenation. Multiple intubation attempts increase complication and mortality risk 6, 10– 15 with >2 attempts being significantly more associated with severe hypoxia. Based on current literature, some investigators estimate that 16-61% of cases 1– 3 have complications including hypoxia and associated cardiac arrest. Furthermore, the ED setting is inherently high risk because a quickly assembled team must manage the airway while providing simultaneous resuscitation efforts. However, because these patients are already compromised, they are at risk of further deterioration. When done correctly, RSI in the PED saves lives. This procedure includes sedating and paralyzing a child to protect the airway and manage respiratory distress. © 2019 by the Society for Academic Emergency Medicine.Rapid sequence intubation (RSI) provides definitive airway management for severely ill and injured patients presenting to the pediatric emergency department (PED). If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec).Īdministration of either the neuromuscular blocking or the sedative agent first are both acceptable. Of 757 original trial patients, 562 patients (74%) met criteria for analysis 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. We performed a multivariable analysis using a mixed-effects generalized linear model. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated. The optimal order of drug administration (sedative first vs. ![]()
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