Rapid Sequence Induction
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Supportive (Green)
|
Risk of post-intubation hypotension
|
Patient
|
ED-MD
|
Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022; 26(1):108–13. Medline
|
|
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)
|
First attempt Cormack-Lehane view
|
Process
|
PH-Paramedic
|
Ramsey JT, Pache KM, Sayre MR, Maynard C, Johnson NJ, Counts CR. Comparison of intubating conditions with succinylcholine versus rocuronium in the prehospital setting. Prehosp Emerg Care Nov 2023; 1-11 Medline
|
|
II
|
Supportive (Green)
|
Successful treatment
|
Patient
|
PH-Paramedic & CCT
|
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)
|
Process
|
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)
|
Hemodynamic changes
|
Patient
|
PH-Paramedic & MD
|
Ferguson IMC, Miller MR, Partyka C, Bliss J, Aneman A, et al. The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine. Acta Anaesthesiol Scand Dec 2022. 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
|
PH-Paramedic & CCT
|
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)
|
Haemodynamic changes
|
Patient
|
PH-Paramedic & CCT
|
Stanke L, Nakajima S, Zimmerman LH, Collopy K, Fales C, 4th Powers W. Hemodynamic Effects of Ketamine Versus Etomidate for Prehospital Rapid Sequence Intubation. Air Med J 2021; 40(5):312–6. Medline
|
|
II
|
Neutral (Yellow)
|
Prevalence of ARDS
|
Patient
|
PH-Paramedic
|
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
|
PH-Paramedic
|
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
|
PH-Paramedic & MD
|
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
|
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
|
|
I
|
Supportive (Green)
|
First‐pass intubation success
|
Process
|
PH-Paramedic & CCT
|
Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022; 26(1):108–13. 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)
|
Adverse events
|
Patient
|
PH-Paramedic & MD
|
Hayes-Bradley C, Tarrant M. Rocuronium ≤1.5 mg/kg versus >1.5 mg/kg and inadequate paralysis in prehospital and retrieval intubation: A retrospective study. Emerg Med Australas 2022. 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)
|
Hemodynamic stability
|
Patient
|
PH-Paramedic & MD
|
Kunkel S, Lenz T. Hemodynamics in Helicopter Emergency Medical Services (HEMS) Patients Undergoing Rapid Sequence Intubation With Etomidate or Ketamine. J Emerg Med 2022; 62(2):163–70. 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
|
Supportive (Green)
|
First pass success
|
Patient
|
PH-Paramedic & CCT
|
von Vopelius-Feldt, J., Peddle, M., Lockwood, J. et al. The effect of a multi-faceted quality improvement program on paramedic intubation success in the critical care transport environment: a before-and-after study. Scand J Trauma Resusc Emerg Med 31, 9 (2023). https://doi.org/10.1186/s13049-023-01074-0 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)
|
Blood pressure changes
|
Process
|
PH-Paramedic
|
Fouche PF, Meadley B, St Clair T, Winnall A, Jennings PA, Bernard S, et al. The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out-of-hospital traumatic brain injury. Acad Emerg Med 2021. 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)
|
Adverse events
|
Patient
|
Other
|
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
|
|
II
|
Neutral (Yellow)
|
First Pass success for critical care transport teams
|
Patient
|
PH-Paramedic & MD
|
Ljungqvist H, Pirneskoski J, Saviluoto A, Setälä P, Tommila M, Nurmi J. Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts. Scand J Trauma Resusc Emerg Med Nov 2022; 30(1):61. 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
|
Supportive (Green)
|
Success rate of Endotracheal Intubation
|
Patient
|
PH-MD & CCT
|
Länkimäki S, Spalding M, Saari A, Alahuhta S. Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland. Air Med J 2021; 40(6):385–9. Medline
|
|
III
|
Neutral (Yellow)
|
First-pass success
|
Patient
|
In-Patient
|
Denton G, Green L, Palmera M, Jones A, Quinton S, Simmons A, et al. Advanced airway management and drug-assisted intubation skills in an advanced critical care practitioner team. Br J Nurs 2022; 31(11):564–70. 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
|
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
|