Emergency Medicine

Guidelines can help paramedics select which drugs to use to facilitate prehospital endotracheal intubation

Paramedics sometimes have to use medication to facilitate endotracheal intubation (ETI) of awake or unrelaxed patients. ETI is difficult in these patients either due to the gag reflex, resistance, seizures, or other problems. Drug-assisted intubation (DAI) encompasses rapid-sequence intubation (RSI), the use of neuromuscular blocking with or without sedative agents to rapidly facilitate ETI, as well as other techniques. Properly trained and prepared emergency medical service (EMS) rescuers may use DAI to facilitate ETI in selected patients. However, they should follow standard protocols, suggest Henry E. Wang, M.D., M.P.H., of the University of Pittsburgh, and colleagues in a new resource document on the topic.

They recommend that prehospital RSI programs receive medical direction from physicians who have substantial clinical experience with RSI. Paramedics generally cannot perform prehospital RSI safely in circumstances that don't allow adequate access to the patient's airway, patients with contraindications to RSI medications, and, depending on operator skill and experience, patients with difficult airway anatomy (for example, severe facial trauma, short neck, or morbid obesity).

As an alternative to RSI, many EMS services use single or combination benzodiazepines, opioids, or induction agents, without the use of neuromuscular blocking agents. This technique is widely used because these agents are commonly carried by EMS services for other applications. However, benzodiazepines and opioids are not ideal agents for facilitating prehospital ETI, because they may dangerously lower a patient's blood pressure. ETI facilitated by topical anesthesia is also not recommended. This study was supported by the Agency for Healthcare Research and Quality (HS13628).

See "Drug-assisted intubation in the prehospital setting (Resource document to NAEMSP position statement)," by Dr. Wang, Daniel P. Davis, M.D., Robert E. O'Connor, M.D., and Robert M. Domeier, M.D., in the April 2006 Prehospital Emergency Care 10(2), pp. 261-271.

Editor's Note: A related AHRQ-supported study concludes that the operating room ETI training available to paramedic students is limited compared with that available to other ETI providers. Paramedics from one-third of programs reported a recent reduction in operating room access. For more details, see Johnston, B.D., Seitz, R., and Wang, H.E. (2006, October). "Limited opportunities for paramedic student endotracheal intubation training in the operating room." (AHRQ grant HS13628) Academic Emergency Medicine 13(10), pp. 1051-1055.

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