rocuronium and Craniocerebral-Trauma

The purpose of this study was to evaluate the effect of paramedic-administered neuromuscular blocking agents as part of a rapid-sequence intubation (RSI) protocol on successful intubation of severely head-injured patients in a large, urban prehospital system.. Adult head-injured patients were prospectively enrolled over 1 year using these inclusion criteria: Glasgow Coma Scale (GCS) score of 3 to 8, transport time > 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. All adult trauma victims with a GCS score of 3 to 8 were identified during the first 12 months of the study as the trial cohort and from the preceding 12 months as the control cohort. The trial and control cohorts were compared with regard to demographic data, mechanism of injury, initial vital signs, and GCS scores. The primary outcome measure was intubation success, defined as insertion of either an endotracheal tube or a Combitube, with patients stratified by GCS score.. The trial cohort (n = 249) and control cohort (n = 189) were similar with regard to demographic data, mechanism of injury, and initial vital signs and GCS scores. Intubation success rates increased significantly during the trial period for all patients and when stratified into GCS score of 3 and GCS score of 4 to 8. The percentage of patients intubated without neuromuscular blocking agents actually increased during the trial period. Although the number of intubations by helicopter flight crews decreased during the trial, the overall use of aeromedical resources did not change.. Paramedic-administered neuromuscular blockade as part of an RSI protocol improves intubation success in a large, urban prehospital system.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Allied Health Personnel; Androstanols; Case-Control Studies; Chi-Square Distribution; Child; Craniocerebral Trauma; Emergency Medical Services; Female; Glasgow Coma Scale; Humans; Intubation, Intratracheal; Male; Midazolam; Middle Aged; Neuromuscular Blockade; Prospective Studies; Rocuronium; Succinylcholine

The safety of out-of-hospital rapid sequence intubation depends on a reliable strategy when orotracheal intubation is unsuccessful. Here we describe our experience with the Combitube (esophageal-tracheal twin-lumen airway device) as a salvage airway device for paramedic rapid sequence intubation.. The San Diego Paramedic Rapid Sequence Intubation Trial was performed to assess the effect of paramedic rapid sequence intubation on outcome in severely head-injured patients. Adults with severe head trauma (Glasgow Coma Scale score 3 to 8) who were unable to be intubated without medications were enrolled. Midazolam and succinylcholine were administered, and paramedics were allowed a maximum of 3 attempts at orotracheal intubation. If the attempts were unsuccessful, Combitube insertion was mandated. After confirmation of tube position, rocuronium was given and standard ventilation protocols were used. The primary outcome measure for this analysis was the success rate for Combitube insertion after unsuccessful orotracheal intubation. In addition, Combitube insertion and orotracheal intubation patients were compared with regard to demographic, clinical, and outcome data.. A total of 426 patients were enrolled in the trial, with 420 meeting inclusion criteria for this analysis. Orotracheal intubation was successful in 355 (84.5%) of 420; Combitube insertion was successful in 58 (95.1%) of 61 attempts, with no reported complications. Patients undergoing Combitube insertion had higher Face Abbreviated Injury Scale scores and were more likely to have oropharyngeal blood or vomitus. Arrival Pco(2) values were higher, and arrival Po(2) values were lower but still supranormal in patients undergoing Combitube insertion. There were no mortality differences between patients undergoing Combitube insertion and those undergoing orotracheal intubation.. The Combitube can be an effective salvage airway device for paramedic rapid sequence intubation in an urban/suburban, high-volume emergency medical services system with paramedics who are experienced in Combitube placement and with stringent protocols for its use. The device should be tested in other sizes and types of systems and under less medical scrutiny than was used in this study.

Topics: Abbreviated Injury Scale; Adult; Androstanols; Anesthetics, Intravenous; Blood Gas Analysis; California; Clinical Competence; Clinical Protocols; Craniocerebral Trauma; Emergency Medical Technicians; Emergency Treatment; Equipment Design; Female; Glasgow Coma Scale; Humans; Intubation, Gastrointestinal; Intubation, Intratracheal; Male; Midazolam; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Prospective Studies; Rocuronium; Salvage Therapy; Succinylcholine; Time Factors; Treatment Outcome

Topics: Adolescent; Adult; Aged; Androstanols; Craniocerebral Trauma; Humans; Intracranial Pressure; Middle Aged; Neuromuscular Blockade; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Rocuronium; Succinylcholine