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Medication for Airway Management

Date Last Search Run: Apr 18, 2021
Table last updated: May 02, 2021
Data last added: Mar 31, 2021

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)    
2 (fair evidence exists)
3 (weak evidence exists)  


Interventions

DSI (CCT)
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Hypoxia Patient Other Waack J., Shepherd M., Andrew E., Bernard S., Smith K. Delayed Sequence Intubation by Intensive Care Flight Paramedics in Victoria, Australia. PEC; 22(5) 588-94. Medline

Rapid Sequence Induction
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Successful resuscitation Patient ED-MD Bulger E., Copass M., Sabath D., et al. The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J Trauma 2005; 58: 718-24. Medline
II Supportive (Green) Intubation Success Rate Process PH-Paramedic Davis DP., Ochs M., Hoyt DB., et al. Paramedic-administered neuromuscular blockage improves prehospital intubation success in severely head-injured patients. J Trauma 2003; 55:713-9. Medline
II Supportive (Green) Overall intubation success Process PH-Paramedic Fouche PF., Stein C., Simpson P., Carlson JN., Zverinova KM., Doi SA. Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis. Prehospital emergency care 2017; 22(5):578-87. Medline
II Supportive (Green) Successful treatment  Patient Sloane C., Vilke G., Chan T., et al: Rapid sequence intubation in the field versus hospital in trauma patients. J Emerg Med 2000; 19:259-264. Medline
II Supportive (Green) Use of DFI (drug-facilitated intubation) Patient PH-Paramedic Wang HE., Kupas DF., Paris PM., Yealy DM. Factors associated with the use of pharmacologic agents to facilitate out-of-hospital endotracheal intubation. Prehosp Emerg Care 2004; 8(1):1-9. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic & MD Baekgaard JS, Eskesen TG, Moo Lee J, Ikast Ottosen C, Bennett Gyldenkærne K, Garoussian J, et al. Ketamine for rapid sequence intubation in adult trauma patients: A retrospective observational study. Acta Anaesthesiol Scand 2020; 64(9):1234-42. Medline
II Neutral (Yellow) Prehospital time delay Process PH-Paramedic Cudnik MT., Newgard CD., Wang H., Bangs C., Herrington R. Endotracheal intubation increases out-of-hospital time in trauma patients. Prehosp Emer Care 2007; 11:224-9. Medline
II Neutral (Yellow) Rate of oxygen desaturation/Hypoxia Process PH-Paramedic Davis DP., Hwang JQ., Dunford JV. Rate of decline in O2 saturation at various pulse oximetry values with prehospital RSI. PEC 2008; 12:46-51. Medline
II Neutral (Yellow) Predictors of post-ETI hypotension Patient PH-Paramedic & CCT Elmer J., Brown F., Martin-Gill C., Guyette FX. Prevalence and Predictors of Post-Intubation Hypotension in Prehospital Trauma Care. Prehospital emergency care 2019:1-9. Medline
II Neutral (Yellow) Survival to discharge Patient PH-Paramedic Fouche PF., Jennings PA., Smith K., Boyle M., Blecher G., Knott J., et al. Survival in Out-of-hospital Rapid Sequence Intubation of Non-Traumatic Brain Pathologies. PEC 2017; 21(6):700-8. Medline
II Neutral (Yellow) Success Process Fouche PF., Stein C., Simpson P., Carlson JN., Doi SA. Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis. Ann Emerg Med 2017; 70(4):449-59.e20. Medline
II Neutral (Yellow) Hospital Mortality Patient PH-MD & CCT Gäßler M., Ruppert M., Lefering R., Bouillon B., Wafaisade A. Pre-hospital emergent intubation in trauma patients: the influence of etomidate on mortality, morbidity and healthcare resource utilization. Scandinavian journal of trauma, resuscitation and emergency medicine 2019; 27(1):61 Medline
II Neutral (Yellow) Prevalence of ARDS Patient Warner KJ., Cuschieri J., Jurkovich GJ., Bulger EM. Single-dose etomidate for rapid sequence intubation may impact outcome after severe injury. J Trauma 2009; 67(1):45-50. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Winchell RJ., Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 1997; 132:592-597. Medline
II Opposes (Red) Survival neurologically intact Patient ED-MD Davis DP., Dunford JV., Poste JC., et al. The impact of hypoxia and hyperventilation on outcome after paramedic RSI of severely head-injured patients. J Trauma 2004; 57:1-10. Medline
II Opposes (Red) Mortality, Favourable neuro outcome Patient PH-Paramedic Davis DP., Hoyt DB., Ochs M., et al. The effect of paramedic RSI on outcome in patients with severe traumatic brain injury. J Trauma 2003; 54:444-53. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Poste JC., Davis DP., Ochs M., et al. Air medical transport of severely head-injured patients undergoing paramedic rapid sequence intubation. Air Med J 2004; 23(4):36-40. Medline
III Supportive (Green) ETI success rate Process PH-Paramedic Ochs M., Davis D., Hoyt D., Bailey D., Marshall L., Rosen P. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med 2002; 40(2):159-67. Medline
III Supportive (Green) ETI success rate Process PH-Paramedic Pace S., Fuller F. Out-of-hospital succinylcholine-assisted endotracheal intubation by paramedics. Ann Emerg Med 2000; 35:568-72. Medline
III Supportive (Green) Functional use of succinylcholine: A 20-year review Patient PH-Paramedic Wayne MA., Friedland E. Prehospital use of succinylcholine: A 20-year review. Prehosp Emerg Care 1999; 3:107-109. Medline
III Neutral (Yellow) Proportion that required prehospital intubation Process Ellis DY., Davies GE., Pearn J., Lockey D. Prehospital RSI of patients with trauma with a GCS of 13 or 14 and the subsequent incidence of intracranial pathology. EMJ 2007; 24:139-41. Medline
III Neutral (Yellow) Safety Patient PH-Paramedic Gunning M., Perkins Z., Crilly J., von Rahden R. Paramedic rapid sequence induction (RSI) in a south african emergency medical service: A retrospective observational study. S Afr Med J 2013; 103(9):632-7. Medline
III Neutral (Yellow) Provider by which the AW was obtained Process PH-Paramedic O'Malley RJ., Rhee KJ. Contribution of air medical personnel to the airway management of injured patients. Air Med J 1993; 12(11-12):425-8. Medline
III Neutral (Yellow) ETI success rate Process PH-Paramedic Rhee K., O'Malley R. Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the prehospital care of injured patients. Ann Emerg Med 1994; 23:37-42. Medline
III Opposes (Red) Survival Patient ED-MD Dunford JV., Davis DP., Ochs M., et al. Incidence of transient hypoxia and pulse rate reactivity during paramedic RSI. Ann Emer Med 2003; 42:721-8. Medline

RSA
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Successful insertion Process Frascone RJ. Use of King LTS-D with Medication Assisted A/W Management. Prehospital Emerg Care 2009; 13(4):541-5. Medline
III Neutral (Yellow) Time to placement Process SIM Southard A., Braude D., Crandall C. Rapid sequence airway vs rapid sequence intubation in a simulated trauma airway by flight crew. Resuscitation 2010; 81(5):576-578. Medline

RSI (CCT)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Glasgow Outcome Scale at 6 months Patient PH-Paramedic Bernard SA., Nguyen V., Cameron P., Masci K., Fitzgerald M., Cooper DJ., et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg 2010; 252(6):959-65. Medline
II Supportive (Green) Laryngoscopic conditions Process PH-Paramedic Bozeman WP., Kleiner DM., Huggett V. A Comparison of Rapid-Sequence Intubation and Etomidate-Only Intubation in the Prehospital Air Medical Setting. Prehosp Emerg Care 2006; 10(1)8-13. Medline
II Supportive (Green) Successful placement Process PH-Paramedic Brown LH., Hubble MW., Wilfong DA., Hertelendy A., Benner RW. Airway management in the air medical setting. Air Med J 2011; 30(3):140-8. Medline
II Supportive (Green) Success rate Process Other Delorenzo A, St CT, Andrew E, Bernard S, Smith K. Prehospital Rapid Sequence Intubation by Intensive Care Flight Paramedics. Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2018; 22(5):595-601. Medline
II Supportive (Green) Overall intubation success Patient PH-Paramedic & MD Fouche PF., Stein C., Simpson P., Carlson JN., Zverinova KM., Doi SA. Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis. Prehospital emergency care 2017; 22(5):578-87. Medline
II Supportive (Green) Success rate of prehospital ETI Patient PH-Paramedic & MD Gellerfors M., Fevang E., Bäckman A., Krüger A., Mikkelsen S., Nurmi J., et al. Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. Br J Anaesth 2018; 120(5):1103-9. Medline
II Supportive (Green) Death Patient Hiestand B., Cudnik MT., Thomson D., Werman HA. Rocuronium versus succinylcholine in air medical rapid-sequence intubation. Prehosp Emerg Care 2011; 15(4):457-63. Medline
II Supportive (Green) Intubation success rate Process PH-Paramedic Lossius HM., Roislien J., Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: A comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care 2012; 16(1):R24. Medline
II Supportive (Green) Laryngoscopy view Process PH-Paramedic Lyon RM., Perkins ZB., Chatterjee D., Lockey DJ., Russell MQ., Kent, Surrey & Sussex Air Ambulance Trust. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care 2015; 19:134-015-0872-2. Medline
II Supportive (Green) Success rate Process PH-Paramedic Ma OJ., Atchley BR., Hatley T. Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents. Am J Emerg Med 1998; 16:125-7. Medline
II Supportive (Green) Asthma score Patient ED-MD McQueen C., Crombie N., Hulme J., et al. Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: A 12 month review of practice. Emerg Med J 2015; 32(1):65-9. Online Oct 2013. Medline
II Supportive (Green) Success rate of intubation Process Rose WD., Anderson LD., Edmond SA. Analysis of intubations. Before and after establishment of a rapid sequence intubation protocol for air medical use. Air Med J 1994; 13(11-12):475-8. Medline
II Supportive (Green) Intubation success rate on first attempt Process Sato N., Hagiwara Y., Watase H., Hasegawa K. A comparison of emergency airway management between neuromuscular blockades alone and rapid sequence intubation: an analysis of multicenter prospective study. BMC research notes 2017; 10(1):6. Medline
II Supportive (Green) Success rate Process Swanson ER., Fosnocht DE., Jensen SC. Comparison of etomidate and midazolam for prehospital rapid-sequence intubation. Prehosp Emerg Care 2004; 8(3):273-279. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic & MD Baekgaard JS, Eskesen TG, Moo Lee J, Ikast Ottosen C, Bennett Gyldenkærne K, Garoussian J, et al. Ketamine for rapid sequence intubation in adult trauma patients: A retrospective observational study. Acta Anaesthesiol Scand 2020; 64(9):1234-42. Medline
II Neutral (Yellow) Overall success, first pass success and adverse event rate Process PH-Paramedic Fouche PF, Stein C, Simpson P, Carlson JN, Doi SA. Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: AÂ Systematic Review and Meta-Analysis. Ann Emerg Med 2017; 70(4):449-59.e20. Medline
II Neutral (Yellow) stabilization time Process Sonday CJ., Axelband J., Jacoby J., Higgins R., Crider D. Thiopental vs. etomidate for rapid sequence intubation in aeromedicine. Prehosp Disaster Med 2005; 20(5):324-326. Medline
II Neutral (Yellow) Hospital mortality Patient Upchurch CP., Grijalva CG., Russ S., Collins SP., Semler MW., Rice TW., et al. Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients. Ann Emerg Med 2017; 69(1):24-33.e2. Medline
II Neutral (Yellow) Intubation success Patient Werman HA., Schwegman D., Gerard JP. The effect of etomidate on airway management practices of an air medical transport service. Prehosp Emerg Care 2004; 8(2):185-190. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Winchell RJ., Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 1997; 132:592-597. Medline
II Opposes (Red) Incidence of hypotension within 30 minutes of intubation Patient ED-MD Dietrich SK., Mixon MA., Rogoszewski RJ., Delgado SD., Knapp VE., Floren M., et al. Hemodynamic Effects of Propofol for Induction of Rapid Sequence Intubation in Traumatically Injured Patients. Am Surg 2018; 84(9):1504-8. Medline
III Supportive (Green) Survival Patient Bushby N., Fitzgerald M., Cameron P., et al. Prehospital intubation and chest decompression is associated with unexpected survival in major thoracic blunt trauma. Emerg Med Australas 2005; 17(5-6):443-9. Medline
III Neutral (Yellow) Adverse events Patient Newton A., Ratchford A., Khan I. Incidence of adverse events during prehospital rapid sequence intubation: A review of one year on the london helicopter emergency medical service. J Trauma 2008; 64(2):487-92. Medline
III Neutral (Yellow) Provider by which the AW was obtained Process PH-Paramedic O'Malley RJ., Rhee KJ. Contribution of air medical personnel to the airway management of injured patients. Air Med J 1993; 12(11-12):425-8. Medline
III Neutral (Yellow) ETI success rate Process PH-Paramedic Rhee K., O'Malley R. Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the prehospital care of injured patients. Ann Emerg Med 1994; 23:37-42. Medline
X Not Yet Graded (White) - Krebs W, Werman H, Jackson J, Swecker KA, Hutchison H, Rodgers M, et al. Prehospital Ketamine Use for Rapid Sequence Intubation: Are Higher Doses Associated With Adverse Events? Air Med J 2021; 40(1):36-40. Medline

Sedation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Improved survival Patient Hoffmann M., Czorlich P., Lehmann W., Spiro AS., Rueger JM., Lefering R., et al. The Impact of Prehospital Intubation With and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less. J Neurosurg Anesthesiol 2017; 29(2):161-167. Medline
II Neutral (Yellow) To describe prehospital use of ketamine (frequency, dose, intubation). Process Hollis GJ., Keene TM., Ardlie RM., Caldicott DG., Stapleton SG. Prehospital ketamine use by paramedics in the Australian Capital Territory: A 12 month retrospective analysis. Emergency medicine Australasia : EMA 2017; 29(1):89-95. Medline
II Neutral (Yellow) Adverse events Patient Michetti CP., Maguire JF., Kaushik A., et al. Single-drug sedation with fentanyl for prehospital postintubation sedation in trauma patients. J Trauma Acute Care Surg 2012; 72(4):924-9. Medline
II Neutral (Yellow) Use of DFI (drug-facilitated intubation) Patient PH-Paramedic Wang HE., Kupas DF., Paris PM., Yealy DM. Factors associated with the use of pharmacologic agents to facilitate out-of-hospital endotracheal intubation. Prehosp Emerg Care 2004; 8(1):1-9. Medline
III Neutral (Yellow) Successful endotracheal intubation Process PH-Paramedic Dickinson ET., Cohen JE., Mechem CC. The effectiveness of midazolam as a single pharmacologic agent to facilitate endotracheal intubation by paramedics. Prehosp Emerg Care 1999; 3:191-3. Medline
III Neutral (Yellow) - Patient Driver BE., Reardon RF. Apnea After Low-Dose Ketamine Sedation During Attempted Delayed Sequence Intubation. Ann Emerg Med 2017; 69(1):34-5. Medline
III Neutral (Yellow) Successful intubation Process PH-Paramedic Jacoby J., Heller M., Nicholas J., Patel N., et al. Etomidate versus midazolam for out-of-hospital intubation: a prospective, randomized trial. Ann Emerg Med 2006; 47(6)525-30. Medline
III Neutral (Yellow) ETI success rate Process PH-Paramedic Reed DB., Snyder G., Hogue TD. Regional EMS experience with etomidate for facilitated intubation. Prehosp Emerg Care 2002; 6(1):50-3. Medline
III Neutral (Yellow) Efficacy Patient PH-Paramedic Wang H., O'Connor R., Megargel R., et al. The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care 2000; 4:14-18. Medline

Sedation (CCT)
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Successful placement Process PH-Paramedic Brown LH., Hubble MW., Wilfong DA., Hertelendy A., Benner RW. Airway management in the air medical setting. Air Med J 2011; 30(3):140-8. Medline
II Opposes (Red) Laryngoscopic conditions Process PH-Paramedic Bozeman WP., Kleiner DM., Huggett V. A Comparison of Rapid-Sequence Intubation and Etomidate-Only Intubation in the Prehospital Air Medical Setting. Prehosp Emerg Care 2006; 10(1)8-13. Medline

Topical anaesthetic
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Sore throat Patient OR Keller C., Sparr HJ., Brimacombe JR. Laryngeal Mask Lubrication. A comparative study of saline vs 2% lignocaine gel with cuff pressure control. Anaesthesia 1997; 52(6)592-7. Medline
III Supportive (Green) Attenuation of airway circulatory reflexes Patient OR Jee D., Park SY. Lidocaine sprayed down the endotracheal tube attenuates the airway-circulatory reflexes by local anesthesia during emergence and extubation. Anesth Analg 2003; 96(1):293-7. Medline
III Supportive (Green) Success rate Process PH-Paramedic Kenny JF., Molloy K., Pollack M., Ortiz MT. Nebulized lidocaine as an adjunct to endotracheal intubation in the prehospital setting. Prehosp Disast Med 1996; 11(4)312-3. Medline


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